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| author | Fudgerboy <91767657+Fudgerboy@users.noreply.github.com> | 2024-04-14 05:02:38 +0000 |
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| committer | Fudgerboy <91767657+Fudgerboy@users.noreply.github.com> | 2024-04-14 05:02:38 +0000 |
| commit | 248d296234dc7ce76294c677bf2ca5e76c2f50d1 (patch) | |
| tree | 5a38d5a5eb4cd6075e10de1583fde289c144cc91 /wk5/pset/speller/texts/aca.txt | |
| parent | ba93a5dca5f93fe7b5761c251037d4f1860f9a43 (diff) | |
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diff --git a/wk5/pset/speller/texts/aca.txt b/wk5/pset/speller/texts/aca.txt new file mode 100644 index 0000000..229c84a --- /dev/null +++ b/wk5/pset/speller/texts/aca.txt @@ -0,0 +1,58485 @@ +[111th Congress Public Law 148] +[From the U.S. Government Printing Office] + + + +[[Page 124 STAT. 119]] + +Public Law 111-148 +111th Congress + + An Act + + + + Entitled The Patient Protection and Affordable Care Act. <<NOTE: Mar. + 23, 2010 - [H.R. 3590]>> + + Be it enacted by the Senate and House of Representatives of the +United States of America in Congress assembled, <<NOTE: Patient +Protection and Affordable Care Act.>> + +SECTION 1. SHORT TITLE; TABLE OF CONTENTS. + + (a) Short <<NOTE: 42 USC 18001 note.>> Title.--This Act may be cited +as the ``Patient Protection and Affordable Care Act''. + + (b) Table of Contents.--The table of contents of this Act is as +follows: + +Sec. 1. Short title; table of contents. + + TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS + + Subtitle A--Immediate Improvements in Health Care Coverage for All + Americans + +Sec. 1001. Amendments to the Public Health Service Act. + + ``PART A--Individual and Group Market Reforms + + ``subpart ii--improving coverage + + ``Sec. 2711. No lifetime or annual limits. + ``Sec. 2712. Prohibition on rescissions. + ``Sec. 2713. Coverage of preventive health services. + ``Sec. 2714. Extension of dependent coverage. + ``Sec. 2715. Development and utilization of uniform explanation + of coverage documents and standardized + definitions. + ``Sec. 2716. Prohibition of discrimination based on salary. + ``Sec. 2717. Ensuring the quality of care. + ``Sec. 2718. Bringing down the cost of health care coverage. + ``Sec. 2719. Appeals process. +Sec. 1002. Health insurance consumer information. +Sec. 1003. Ensuring that consumers get value for their dollars. +Sec. 1004. Effective dates. + + Subtitle B--Immediate Actions to Preserve and Expand Coverage + +Sec. 1101. Immediate access to insurance for uninsured individuals with + a preexisting condition. +Sec. 1102. Reinsurance for early retirees. +Sec. 1103. Immediate information that allows consumers to identify + affordable coverage options. +Sec. 1104. Administrative simplification. +Sec. 1105. Effective date. + + Subtitle C--Quality Health Insurance Coverage for All Americans + + PART I--Health Insurance Market Reforms + +Sec. 1201. Amendment to the Public Health Service Act. + + ``subpart i--general reform + + ``Sec. 2704. Prohibition of preexisting condition exclusions or + other discrimination based on health status. + ``Sec. 2701. Fair health insurance premiums. + ``Sec. 2702. Guaranteed availability of coverage. + +[[Page 124 STAT. 120]] + + ``Sec. 2703. Guaranteed renewability of coverage. + ``Sec. 2705. Prohibiting discrimination against individual + participants and beneficiaries based on + health status. + ``Sec. 2706. Non-discrimination in health care. + ``Sec. 2707. Comprehensive health insurance coverage. + ``Sec. 2708. Prohibition on excessive waiting periods. + + PART II--Other Provisions + +Sec. 1251. Preservation of right to maintain existing coverage. +Sec. 1252. Rating reforms must apply uniformly to all health insurance + issuers and group health plans. +Sec. 1253. Effective dates. + + Subtitle D--Available Coverage Choices for All Americans + + PART I--Establishment of Qualified Health Plans + +Sec. 1301. Qualified health plan defined. +Sec. 1302. Essential health benefits requirements. +Sec. 1303. Special rules. +Sec. 1304. Related definitions. + + PART II--Consumer Choices and Insurance Competition Through Health + Benefit Exchanges + +Sec. 1311. Affordable choices of health benefit plans. +Sec. 1312. Consumer choice. +Sec. 1313. Financial integrity. + + PART III--State Flexibility Relating to Exchanges + +Sec. 1321. State flexibility in operation and enforcement of Exchanges + and related requirements. +Sec. 1322. Federal program to assist establishment and operation of + nonprofit, member-run health insurance issuers. +Sec. 1323. Community health insurance option. +Sec. 1324. Level playing field. + + PART IV--State Flexibility to Establish Alternative Programs + +Sec. 1331. State flexibility to establish basic health programs for low- + income individuals not eligible for Medicaid. +Sec. 1332. Waiver for State innovation. +Sec. 1333. Provisions relating to offering of plans in more than one + State. + + PART V--Reinsurance and Risk Adjustment + +Sec. 1341. Transitional reinsurance program for individual and small + group markets in each State. +Sec. 1342. Establishment of risk corridors for plans in individual and + small group markets. +Sec. 1343. Risk adjustment. + + Subtitle E--Affordable Coverage Choices for All Americans + + PART I--Premium Tax Credits and Cost-sharing Reductions + + subpart a--premium tax credits and cost-sharing reductions + +Sec. 1401. Refundable tax credit providing premium assistance for + coverage under a qualified health plan. +Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified + health plans. + + subpart b--eligibility determinations + +Sec. 1411. Procedures for determining eligibility for Exchange + participation, premium tax credits and reduced cost-sharing, + and individual responsibility exemptions. +Sec. 1412. Advance determination and payment of premium tax credits and + cost-sharing reductions. +Sec. 1413. Streamlining of procedures for enrollment through an exchange + and State Medicaid, CHIP, and health subsidy programs. +Sec. 1414. Disclosures to carry out eligibility requirements for certain + programs. +Sec. 1415. Premium tax credit and cost-sharing reduction payments + disregarded for Federal and Federally-assisted programs. + + PART II--Small Business Tax Credit + +Sec. 1421. Credit for employee health insurance expenses of small + businesses. + +[[Page 124 STAT. 121]] + + Subtitle F--Shared Responsibility for Health Care + + PART I--Individual Responsibility + +Sec. 1501. Requirement to maintain minimum essential coverage. +Sec. 1502. Reporting of health insurance coverage. + + PART II--Employer Responsibilities + +Sec. 1511. Automatic enrollment for employees of large employers. +Sec. 1512. Employer requirement to inform employees of coverage options. +Sec. 1513. Shared responsibility for employers. +Sec. 1514. Reporting of employer health insurance coverage. +Sec. 1515. Offering of Exchange-participating qualified health plans + through cafeteria plans. + + Subtitle G--Miscellaneous Provisions + +Sec. 1551. Definitions. +Sec. 1552. Transparency in government. +Sec. 1553. Prohibition against discrimination on assisted suicide. +Sec. 1554. Access to therapies. +Sec. 1555. Freedom not to participate in Federal health insurance + programs. +Sec. 1556. Equity for certain eligible survivors. +Sec. 1557. Nondiscrimination. +Sec. 1558. Protections for employees. +Sec. 1559. Oversight. +Sec. 1560. Rules of construction. +Sec. 1561. Health information technology enrollment standards and + protocols. +Sec. 1562. Conforming amendments. +Sec. 1563. Sense of the Senate promoting fiscal responsibility. + + TITLE II--ROLE OF PUBLIC PROGRAMS + + Subtitle A--Improved Access to Medicaid + +Sec. 2001. Medicaid coverage for the lowest income populations. +Sec. 2002. Income eligibility for nonelderly determined using modified + gross income. +Sec. 2003. Requirement to offer premium assistance for employer- + sponsored insurance. +Sec. 2004. Medicaid coverage for former foster care children. +Sec. 2005. Payments to territories. +Sec. 2006. Special adjustment to FMAP determination for certain States + recovering from a major disaster. +Sec. 2007. Medicaid Improvement Fund rescission. + +Subtitle B--Enhanced Support for the Children's Health Insurance Program + +Sec. 2101. Additional federal financial participation for CHIP. +Sec. 2102. Technical corrections. + + Subtitle C--Medicaid and CHIP Enrollment Simplification + +Sec. 2201. Enrollment Simplification and coordination with State Health + Insurance Exchanges. +Sec. 2202. Permitting hospitals to make presumptive eligibility + determinations for all Medicaid eligible populations. + + Subtitle D--Improvements to Medicaid Services + +Sec. 2301. Coverage for freestanding birth center services. +Sec. 2302. Concurrent care for children. +Sec. 2303. State eligibility option for family planning services. +Sec. 2304. Clarification of definition of medical assistance. + + Subtitle E--New Options for States to Provide Long-Term Services and + Supports + +Sec. 2401. Community First Choice Option. +Sec. 2402. Removal of barriers to providing home and community-based + services. +Sec. 2403. Money Follows the Person Rebalancing Demonstration. +Sec. 2404. Protection for recipients of home and community-based + services against spousal impoverishment. +Sec. 2405. Funding to expand State Aging and Disability Resource + Centers. +Sec. 2406. Sense of the Senate regarding long-term care. + + Subtitle F--Medicaid Prescription Drug Coverage + +Sec. 2501. Prescription drug rebates. + +[[Page 124 STAT. 122]] + +Sec. 2502. Elimination of exclusion of coverage of certain drugs. +Sec. 2503. Providing adequate pharmacy reimbursement. + + Subtitle G--Medicaid Disproportionate Share Hospital (DSH) Payments + +Sec. 2551. Disproportionate share hospital payments. + + Subtitle H--Improved Coordination for Dual Eligible Beneficiaries + +Sec. 2601. 5-year period for demonstration projects. +Sec. 2602. Providing Federal coverage and payment coordination for dual + eligible beneficiaries. + +Subtitle I--Improving the Quality of Medicaid for Patients and Providers + +Sec. 2701. Adult health quality measures. +Sec. 2702. Payment Adjustment for Health Care-Acquired Conditions. +Sec. 2703. State option to provide health homes for enrollees with + chronic conditions. +Sec. 2704. Demonstration project to evaluate integrated care around a + hospitalization. +Sec. 2705. Medicaid Global Payment System Demonstration Project. +Sec. 2706. Pediatric Accountable Care Organization Demonstration + Project. +Sec. 2707. Medicaid emergency psychiatric demonstration project. + + Subtitle J--Improvements to the Medicaid and CHIP Payment and Access + Commission (MACPAC) + +Sec. 2801. MACPAC assessment of policies affecting all Medicaid + beneficiaries. + + Subtitle K--Protections for American Indians and Alaska Natives + +Sec. 2901. Special rules relating to Indians. +Sec. 2902. Elimination of sunset for reimbursement for all medicare part + B services furnished by certain indian hospitals and clinics. + + Subtitle L--Maternal and Child Health Services + +Sec. 2951. Maternal, infant, and early childhood home visiting programs. +Sec. 2952. Support, education, and research for postpartum depression. +Sec. 2953. Personal responsibility education. +Sec. 2954. Restoration of funding for abstinence education. +Sec. 2955. Inclusion of information about the importance of having a + health care power of attorney in transition planning for + children aging out of foster care and independent living + programs. + + TITLE III--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE + + Subtitle A--Transforming the Health Care Delivery System + + PART I--Linking Payment to Quality Outcomes Under the Medicare Program + +Sec. 3001. Hospital Value-Based purchasing program. +Sec. 3002. Improvements to the physician quality reporting system. +Sec. 3003. Improvements to the physician feedback program. +Sec. 3004. Quality reporting for long-term care hospitals, inpatient + rehabilitation hospitals, and hospice programs. +Sec. 3005. Quality reporting for PPS-exempt cancer hospitals. +Sec. 3006. Plans for a Value-Based purchasing program for skilled + nursing facilities and home health agencies. +Sec. 3007. Value-based payment modifier under the physician fee + schedule. +Sec. 3008. Payment adjustment for conditions acquired in hospitals. + + PART II--National Strategy to Improve Health Care Quality + +Sec. 3011. National strategy. +Sec. 3012. Interagency Working Group on Health Care Quality. +Sec. 3013. Quality measure development. +Sec. 3014. Quality measurement. +Sec. 3015. Data collection; public reporting. + + PART III--Encouraging Development of New Patient Care Models + +Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation + within CMS. +Sec. 3022. Medicare shared savings program. +Sec. 3023. National pilot program on payment bundling. +Sec. 3024. Independence at home demonstration program. +Sec. 3025. Hospital readmissions reduction program. + +[[Page 124 STAT. 123]] + +Sec. 3026. Community-Based Care Transitions Program. +Sec. 3027. Extension of gainsharing demonstration. + + Subtitle B--Improving Medicare for Patients and Providers + +PART I--Ensuring Beneficiary Access to Physician Care and Other Services + +Sec. 3101. Increase in the physician payment update. +Sec. 3102. Extension of the work geographic index floor and revisions to + the practice expense geographic adjustment under the Medicare + physician fee schedule. +Sec. 3103. Extension of exceptions process for Medicare therapy caps. +Sec. 3104. Extension of payment for technical component of certain + physician pathology services. +Sec. 3105. Extension of ambulance add-ons. +Sec. 3106. Extension of certain payment rules for long-term care + hospital services and of moratorium on the establishment of + certain hospitals and facilities. +Sec. 3107. Extension of physician fee schedule mental health add-on. +Sec. 3108. Permitting physician assistants to order post-Hospital + extended care services. +Sec. 3109. Exemption of certain pharmacies from accreditation + requirements. +Sec. 3110. Part B special enrollment period for disabled TRICARE + beneficiaries. +Sec. 3111. Payment for bone density tests. +Sec. 3112. Revision to the Medicare Improvement Fund. +Sec. 3113. Treatment of certain complex diagnostic laboratory tests. +Sec. 3114. Improved access for certified nurse-midwife services. + + PART II--Rural Protections + +Sec. 3121. Extension of outpatient hold harmless provision. +Sec. 3122. Extension of Medicare reasonable costs payments for certain + clinical diagnostic laboratory tests furnished to hospital + patients in certain rural areas. +Sec. 3123. Extension of the Rural Community Hospital Demonstration + Program. +Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program. +Sec. 3125. Temporary improvements to the Medicare inpatient hospital + payment adjustment for low-volume hospitals. +Sec. 3126. Improvements to the demonstration project on community health + integration models in certain rural counties. +Sec. 3127. MedPAC study on adequacy of Medicare payments for health care + providers serving in rural areas. +Sec. 3128. Technical correction related to critical access hospital + services. +Sec. 3129. Extension of and revisions to Medicare rural hospital + flexibility program. + + PART III--Improving Payment Accuracy + +Sec. 3131. Payment adjustments for home health care. +Sec. 3132. Hospice reform. +Sec. 3133. Improvement to medicare disproportionate share hospital (DSH) + payments. +Sec. 3134. Misvalued codes under the physician fee schedule. +Sec. 3135. Modification of equipment utilization factor for advanced + imaging services. +Sec. 3136. Revision of payment for power-driven wheelchairs. +Sec. 3137. Hospital wage index improvement. +Sec. 3138. Treatment of certain cancer hospitals. +Sec. 3139. Payment for biosimilar biological products. +Sec. 3140. Medicare hospice concurrent care demonstration program. +Sec. 3141. Application of budget neutrality on a national basis in the + calculation of the Medicare hospital wage index floor. +Sec. 3142. HHS study on urban Medicare-dependent hospitals. +Sec. 3143. Protecting home health benefits. + + Subtitle C--Provisions Relating to Part C + +Sec. 3201. Medicare Advantage payment. +Sec. 3202. Benefit protection and simplification. +Sec. 3203. Application of coding intensity adjustment during MA payment + transition. +Sec. 3204. Simplification of annual beneficiary election periods. +Sec. 3205. Extension for specialized MA plans for special needs + individuals. +Sec. 3206. Extension of reasonable cost contracts. +Sec. 3207. Technical correction to MA private fee-for-service plans. +Sec. 3208. Making senior housing facility demonstration permanent. + +[[Page 124 STAT. 124]] + +Sec. 3209. Authority to deny plan bids. +Sec. 3210. Development of new standards for certain Medigap plans. + +Subtitle D--Medicare Part D Improvements for Prescription Drug Plans and + MA-PD Plans + +Sec. 3301. Medicare coverage gap discount program. +Sec. 3302. Improvement in determination of Medicare part D low-income + benchmark premium. +Sec. 3303. Voluntary de minimis policy for subsidy eligible individuals + under prescription drug plans and MA-PD plans. +Sec. 3304. Special rule for widows and widowers regarding eligibility + for low-income assistance. +Sec. 3305. Improved information for subsidy eligible individuals + reassigned to prescription drug plans and MA-PD plans. +Sec. 3306. Funding outreach and assistance for low-income programs. +Sec. 3307. Improving formulary requirements for prescription drug plans + and MA-PD plans with respect to certain categories or classes + of drugs. +Sec. 3308. Reducing part D premium subsidy for high-income + beneficiaries. +Sec. 3309. Elimination of cost sharing for certain dual eligible + individuals. +Sec. 3310. Reducing wasteful dispensing of outpatient prescription drugs + in long-term care facilities under prescription drug plans + and MA-PD plans. +Sec. 3311. Improved Medicare prescription drug plan and MA-PD plan + complaint system. +Sec. 3312. Uniform exceptions and appeals process for prescription drug + plans and MA-PD plans. +Sec. 3313. Office of the Inspector General studies and reports. +Sec. 3314. Including costs incurred by AIDS drug assistance programs and + Indian Health Service in providing prescription drugs toward + the annual out-of-pocket threshold under part D. +Sec. 3315. Immediate reduction in coverage gap in 2010. + + Subtitle E--Ensuring Medicare Sustainability + +Sec. 3401. Revision of certain market basket updates and incorporation + of productivity improvements into market basket updates that + do not already incorporate such improvements. +Sec. 3402. Temporary adjustment to the calculation of part B premiums. +Sec. 3403. Independent Medicare Advisory Board. + + Subtitle F--Health Care Quality Improvements + +Sec. 3501. Health care delivery system research; Quality improvement + technical assistance. +Sec. 3502. Establishing community health teams to support the patient- + centered medical home. +Sec. 3503. Medication management services in treatment of chronic + disease. +Sec. 3504. Design and implementation of regionalized systems for + emergency care. +Sec. 3505. Trauma care centers and service availability. +Sec. 3506. Program to facilitate shared decisionmaking. +Sec. 3507. Presentation of prescription drug benefit and risk + information. +Sec. 3508. Demonstration program to integrate quality improvement and + patient safety training into clinical education of health + professionals. +Sec. 3509. Improving women's health. +Sec. 3510. Patient navigator program. +Sec. 3511. Authorization of appropriations. + + Subtitle G--Protecting and Improving Guaranteed Medicare Benefits + +Sec. 3601. Protecting and improving guaranteed Medicare benefits. +Sec. 3602. No cuts in guaranteed benefits. + + TITLE IV--PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH + + Subtitle A--Modernizing Disease Prevention and Public Health Systems + +Sec. 4001. National Prevention, Health Promotion and Public Health + Council. +Sec. 4002. Prevention and Public Health Fund. +Sec. 4003. Clinical and community preventive services. +Sec. 4004. Education and outreach campaign regarding preventive + benefits. + + Subtitle B--Increasing Access to Clinical Preventive Services + +Sec. 4101. School-based health centers. +Sec. 4102. Oral healthcare prevention activities. + +[[Page 124 STAT. 125]] + +Sec. 4103. Medicare coverage of annual wellness visit providing a + personalized prevention plan. +Sec. 4104. Removal of barriers to preventive services in Medicare. +Sec. 4105. Evidence-based coverage of preventive services in Medicare. +Sec. 4106. Improving access to preventive services for eligible adults + in Medicaid. +Sec. 4107. Coverage of comprehensive tobacco cessation services for + pregnant women in Medicaid. +Sec. 4108. Incentives for prevention of chronic diseases in medicaid. + + Subtitle C--Creating Healthier Communities + +Sec. 4201. Community transformation grants. +Sec. 4202. Healthy aging, living well; evaluation of community-based + prevention and wellness programs for Medicare beneficiaries. +Sec. 4203. Removing barriers and improving access to wellness for + individuals with disabilities. +Sec. 4204. Immunizations. +Sec. 4205. Nutrition labeling of standard menu items at chain + restaurants. +Sec. 4206. Demonstration project concerning individualized wellness + plan. +Sec. 4207. Reasonable break time for nursing mothers. + + Subtitle D--Support for Prevention and Public Health Innovation + +Sec. 4301. Research on optimizing the delivery of public health + services. +Sec. 4302. Understanding health disparities: data collection and + analysis. +Sec. 4303. CDC and employer-based wellness programs. +Sec. 4304. Epidemiology-Laboratory Capacity Grants. +Sec. 4305. Advancing research and treatment for pain care management. +Sec. 4306. Funding for Childhood Obesity Demonstration Project. + + Subtitle E--Miscellaneous Provisions + +Sec. 4401. Sense of the Senate concerning CBO scoring. +Sec. 4402. Effectiveness of Federal health and wellness initiatives. + + TITLE V--HEALTH CARE WORKFORCE + + Subtitle A--Purpose and Definitions + +Sec. 5001. Purpose. +Sec. 5002. Definitions. + + Subtitle B--Innovations in the Health Care Workforce + +Sec. 5101. National health care workforce commission. +Sec. 5102. State health care workforce development grants. +Sec. 5103. Health care workforce assessment. + + Subtitle C--Increasing the Supply of the Health Care Workforce + +Sec. 5201. Federally supported student loan funds. +Sec. 5202. Nursing student loan program. +Sec. 5203. Health care workforce loan repayment programs. +Sec. 5204. Public health workforce recruitment and retention programs. +Sec. 5205. Allied health workforce recruitment and retention programs. +Sec. 5206. Grants for State and local programs. +Sec. 5207. Funding for National Health Service Corps. +Sec. 5208. Nurse-managed health clinics. +Sec. 5209. Elimination of cap on commissioned corps. +Sec. 5210. Establishing a Ready Reserve Corps. + + Subtitle D--Enhancing Health Care Workforce Education and Training + +Sec. 5301. Training in family medicine, general internal medicine, + general pediatrics, and physician assistantship. +Sec. 5302. Training opportunities for direct care workers. +Sec. 5303. Training in general, pediatric, and public health dentistry. +Sec. 5304. Alternative dental health care providers demonstration + project. +Sec. 5305. Geriatric education and training; career awards; + comprehensive geriatric education. +Sec. 5306. Mental and behavioral health education and training grants. +Sec. 5307. Cultural competency, prevention, and public health and + individuals with disabilities training. +Sec. 5308. Advanced nursing education grants. +Sec. 5309. Nurse education, practice, and retention grants. +Sec. 5310. Loan repayment and scholarship program. +Sec. 5311. Nurse faculty loan program. + +[[Page 124 STAT. 126]] + +Sec. 5312. Authorization of appropriations for parts B through D of + title VIII. +Sec. 5313. Grants to promote the community health workforce. +Sec. 5314. Fellowship training in public health. +Sec. 5315. United States Public Health Sciences Track. + + Subtitle E--Supporting the Existing Health Care Workforce + +Sec. 5401. Centers of excellence. +Sec. 5402. Health care professionals training for diversity. +Sec. 5403. Interdisciplinary, community-based linkages. +Sec. 5404. Workforce diversity grants. +Sec. 5405. Primary care extension program. + + Subtitle F--Strengthening Primary Care and Other Workforce Improvements + +Sec. 5501. Expanding access to primary care services and general surgery + services. +Sec. 5502. Medicare Federally qualified health center improvements. +Sec. 5503. Distribution of additional residency positions. +Sec. 5504. Counting resident time in nonprovider settings. +Sec. 5505. Rules for counting resident time for didactic and scholarly + activities and other activities. +Sec. 5506. Preservation of resident cap positions from closed hospitals. +Sec. 5507. Demonstration projects To address health professions + workforce needs; extension of family-to-family health + information centers. +Sec. 5508. Increasing teaching capacity. +Sec. 5509. Graduate nurse education demonstration. + + Subtitle G--Improving Access to Health Care Services + +Sec. 5601. Spending for Federally Qualified Health Centers (FQHCs). +Sec. 5602. Negotiated rulemaking for development of methodology and + criteria for designating medically underserved populations + and health professions shortage areas. +Sec. 5603. Reauthorization of the Wakefield Emergency Medical Services + for Children Program. +Sec. 5604. Co-locating primary and specialty care in community-based + mental health settings. +Sec. 5605. Key National indicators. + + Subtitle H--General Provisions + +Sec. 5701. Reports. + + TITLE VI--TRANSPARENCY AND PROGRAM INTEGRITY + + Subtitle A--Physician Ownership and Other Transparency + +Sec. 6001. Limitation on Medicare exception to the prohibition on + certain physician referrals for hospitals. +Sec. 6002. Transparency reports and reporting of physician ownership or + investment interests. +Sec. 6003. Disclosure requirements for in-office ancillary services + exception to the prohibition on physician self-referral for + certain imaging services. +Sec. 6004. Prescription drug sample transparency. +Sec. 6005. Pharmacy benefit managers transparency requirements. + + Subtitle B--Nursing Home Transparency and Improvement + + PART I--Improving Transparency of Information + +Sec. 6101. Required disclosure of ownership and additional disclosable + parties information. +Sec. 6102. Accountability requirements for skilled nursing facilities + and nursing facilities. +Sec. 6103. Nursing home compare Medicare website. +Sec. 6104. Reporting of expenditures. +Sec. 6105. Standardized complaint form. +Sec. 6106. Ensuring staffing accountability. +Sec. 6107. GAO study and report on Five-Star Quality Rating System. + + PART II--Targeting Enforcement + +Sec. 6111. Civil money penalties. +Sec. 6112. National independent monitor demonstration project. +Sec. 6113. Notification of facility closure. +Sec. 6114. National demonstration projects on culture change and use of + information technology in nursing homes. + +[[Page 124 STAT. 127]] + + PART III--Improving Staff Training + +Sec. 6121. Dementia and abuse prevention training. + +Subtitle C--Nationwide Program for National and State Background Checks + on Direct Patient Access Employees of Long-term Care Facilities and + Providers + +Sec. 6201. Nationwide program for National and State background checks + on direct patient access employees of long-term care + facilities and providers. + + Subtitle D--Patient-Centered Outcomes Research + +Sec. 6301. Patient-Centered Outcomes Research. +Sec. 6302. Federal coordinating council for comparative effectiveness + research. + + Subtitle E--Medicare, Medicaid, and CHIP Program Integrity Provisions + +Sec. 6401. Provider screening and other enrollment requirements under + Medicare, Medicaid, and CHIP. +Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions. +Sec. 6403. Elimination of duplication between the Healthcare Integrity + and Protection Data Bank and the National Practitioner Data + Bank. +Sec. 6404. Maximum period for submission of Medicare claims reduced to + not more than 12 months. +Sec. 6405. Physicians who order items or services required to be + Medicare enrolled physicians or eligible professionals. +Sec. 6406. Requirement for physicians to provide documentation on + referrals to programs at high risk of waste and abuse. +Sec. 6407. Face to face encounter with patient required before + physicians may certify eligibility for home health services + or durable medical equipment under Medicare. +Sec. 6408. Enhanced penalties. +Sec. 6409. Medicare self-referral disclosure protocol. +Sec. 6410. Adjustments to the Medicare durable medical equipment, + prosthetics, orthotics, and supplies competitive acquisition + program. +Sec. 6411. Expansion of the Recovery Audit Contractor (RAC) program. + + Subtitle F--Additional Medicaid Program Integrity Provisions + +Sec. 6501. Termination of provider participation under Medicaid if + terminated under Medicare or other State plan. +Sec. 6502. Medicaid exclusion from participation relating to certain + ownership, control, and management affiliations. +Sec. 6503. Billing agents, clearinghouses, or other alternate payees + required to register under Medicaid. +Sec. 6504. Requirement to report expanded set of data elements under + MMIS to detect fraud and abuse. +Sec. 6505. Prohibition on payments to institutions or entities located + outside of the United States. +Sec. 6506. Overpayments. +Sec. 6507. Mandatory State use of national correct coding initiative. +Sec. 6508. General effective date. + + Subtitle G--Additional Program Integrity Provisions + +Sec. 6601. Prohibition on false statements and representations. +Sec. 6602. Clarifying definition. +Sec. 6603. Development of model uniform report form. +Sec. 6604. Applicability of State law to combat fraud and abuse. +Sec. 6605. Enabling the Department of Labor to issue administrative + summary cease and desist orders and summary seizures orders + against plans that are in financially hazardous condition. +Sec. 6606. MEWA plan registration with Department of Labor. +Sec. 6607. Permitting evidentiary privilege and confidential + communications. + + Subtitle H--Elder Justice Act + +Sec. 6701. Short title of subtitle. +Sec. 6702. Definitions. +Sec. 6703. Elder Justice. + + Subtitle I--Sense of the Senate Regarding Medical Malpractice + +Sec. 6801. Sense of the Senate regarding medical malpractice. + + TITLE VII--IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES + + Subtitle A--Biologics Price Competition and Innovation + +Sec. 7001. Short title. + +[[Page 124 STAT. 128]] + +Sec. 7002. Approval pathway for biosimilar biological products. +Sec. 7003. Savings. + + Subtitle B--More Affordable Medicines for Children and Underserved + Communities + +Sec. 7101. Expanded participation in 340B program. +Sec. 7102. Improvements to 340B program integrity. +Sec. 7103. GAO study to make recommendations on improving the 340B + program. + + TITLE VIII--CLASS ACT + +Sec. 8001. Short title of title. +Sec. 8002. Establishment of national voluntary insurance program for + purchasing community living assistance services and support. + + TITLE IX--REVENUE PROVISIONS + + Subtitle A--Revenue Offset Provisions + +Sec. 9001. Excise tax on high cost employer-sponsored health coverage. +Sec. 9002. Inclusion of cost of employer-sponsored health coverage on W- + 2. +Sec. 9003. Distributions for medicine qualified only if for prescribed + drug or insulin. +Sec. 9004. Increase in additional tax on distributions from HSAs and + Archer MSAs not used for qualified medical expenses. +Sec. 9005. Limitation on health flexible spending arrangements under + cafeteria plans. +Sec. 9006. Expansion of information reporting requirements. +Sec. 9007. Additional requirements for charitable hospitals. +Sec. 9008. Imposition of annual fee on branded prescription + pharmaceutical manufacturers and importers. +Sec. 9009. Imposition of annual fee on medical device manufacturers and + importers. +Sec. 9010. Imposition of annual fee on health insurance providers. +Sec. 9011. Study and report of effect on veterans health care. +Sec. 9012. Elimination of deduction for expenses allocable to Medicare + Part D subsidy. +Sec. 9013. Modification of itemized deduction for medical expenses. +Sec. 9014. Limitation on excessive remuneration paid by certain health + insurance providers. +Sec. 9015. Additional hospital insurance tax on high-income taxpayers. +Sec. 9016. Modification of section 833 treatment of certain health + organizations. +Sec. 9017. Excise tax on elective cosmetic medical procedures. + + Subtitle B--Other Provisions + +Sec. 9021. Exclusion of health benefits provided by Indian tribal + governments. +Sec. 9022. Establishment of simple cafeteria plans for small businesses. +Sec. 9023. Qualifying therapeutic discovery project credit. + +TITLE X--STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS + + Subtitle A--Provisions Relating to Title I + +Sec. 10101. Amendments to subtitle A. +Sec. 10102. Amendments to subtitle B. +Sec. 10103. Amendments to subtitle C. +Sec. 10104. Amendments to subtitle D. +Sec. 10105. Amendments to subtitle E. +Sec. 10106. Amendments to subtitle F. +Sec. 10107. Amendments to subtitle G. +Sec. 10108. Free choice vouchers. +Sec. 10109. Development of standards for financial and administrative + transactions. + + Subtitle B--Provisions Relating to Title II + + PART I--Medicaid and CHIP + +Sec. 10201. Amendments to the Social Security Act and title II of this + Act. +Sec. 10202. Incentives for States to offer home and community-based + services as a long-term care alternative to nursing homes. +Sec. 10203. Extension of funding for CHIP through fiscal year 2015 and + other CHIP-related provisions. + + PART II--Support for Pregnant and Parenting Teens and Women + +Sec. 10211. Definitions. + +[[Page 124 STAT. 129]] + +Sec. 10212. Establishment of pregnancy assistance fund. +Sec. 10213. Permissible uses of Fund. +Sec. 10214. Appropriations. + + PART III--Indian Health Care Improvement + +Sec. 10221. Indian health care improvement. + + Subtitle C--Provisions Relating to Title III + +Sec. 10301. Plans for a Value-Based purchasing program for ambulatory + surgical centers. +Sec. 10302. Revision to national strategy for quality improvement in + health care. +Sec. 10303. Development of outcome measures. +Sec. 10304. Selection of efficiency measures. +Sec. 10305. Data collection; public reporting. +Sec. 10306. Improvements under the Center for Medicare and Medicaid + Innovation. +Sec. 10307. Improvements to the Medicare shared savings program. +Sec. 10308. Revisions to national pilot program on payment bundling. +Sec. 10309. Revisions to hospital readmissions reduction program. +Sec. 10310. Repeal of physician payment update. +Sec. 10311. Revisions to extension of ambulance add-ons. +Sec. 10312. Certain payment rules for long-term care hospital services + and moratorium on the establishment of certain hospitals and + facilities. +Sec. 10313. Revisions to the extension for the rural community hospital + demonstration program. +Sec. 10314. Adjustment to low-volume hospital provision. +Sec. 10315. Revisions to home health care provisions. +Sec. 10316. Medicare DSH. +Sec. 10317. Revisions to extension of section 508 hospital provisions. +Sec. 10318. Revisions to transitional extra benefits under Medicare + Advantage. +Sec. 10319. Revisions to market basket adjustments. +Sec. 10320. Expansion of the scope of, and additional improvements to, + the Independent Medicare Advisory Board. +Sec. 10321. Revision to community health teams. +Sec. 10322. Quality reporting for psychiatric hospitals. +Sec. 10323. Medicare coverage for individuals exposed to environmental + health hazards. +Sec. 10324. Protections for frontier States. +Sec. 10325. Revision to skilled nursing facility prospective payment + system. +Sec. 10326. Pilot testing pay-for-performance programs for certain + Medicare providers. +Sec. 10327. Improvements to the physician quality reporting system. +Sec. 10328. Improvement in part D medication therapy management (MTM) + programs. +Sec. 10329. Developing methodology to assess health plan value. +Sec. 10330. Modernizing computer and data systems of the Centers for + Medicare & Medicaid services to support improvements in care + delivery. +Sec. 10331. Public reporting of performance information. +Sec. 10332. Availability of medicare data for performance measurement. +Sec. 10333. Community-based collaborative care networks. +Sec. 10334. Minority health. +Sec. 10335. Technical correction to the hospital value-based purchasing + program. +Sec. 10336. GAO study and report on Medicare beneficiary access to high- + quality dialysis services. + + Subtitle D--Provisions Relating to Title IV + +Sec. 10401. Amendments to subtitle A. +Sec. 10402. Amendments to subtitle B. +Sec. 10403. Amendments to subtitle C. +Sec. 10404. Amendments to subtitle D. +Sec. 10405. Amendments to subtitle E. +Sec. 10406. Amendment relating to waiving coinsurance for preventive + services. +Sec. 10407. Better diabetes care. +Sec. 10408. Grants for small businesses to provide comprehensive + workplace wellness programs. +Sec. 10409. Cures Acceleration Network. +Sec. 10410. Centers of Excellence for Depression. +Sec. 10411. Programs relating to congenital heart disease. +Sec. 10412. Automated Defibrillation in Adam's Memory Act. +Sec. 10413. Young women's breast health awareness and support of young + women diagnosed with breast cancer. + + Subtitle E--Provisions Relating to Title V + +Sec. 10501. Amendments to the Public Health Service Act, the Social + Security Act, and title V of this Act. + +[[Page 124 STAT. 130]] + +Sec. 10502. Infrastructure to Expand Access to Care. +Sec. 10503. Community Health Centers and the National Health Service + Corps Fund. +Sec. 10504. Demonstration project to provide access to affordable care. + + Subtitle F--Provisions Relating to Title VI + +Sec. 10601. Revisions to limitation on medicare exception to the + prohibition on certain physician referrals for hospitals. +Sec. 10602. Clarifications to patient-centered outcomes research. +Sec. 10603. Striking provisions relating to individual provider + application fees. +Sec. 10604. Technical correction to section 6405. +Sec. 10605. Certain other providers permitted to conduct face to face + encounter for home health services. +Sec. 10606. Health care fraud enforcement. +Sec. 10607. State demonstration programs to evaluate alternatives to + current medical tort litigation. +Sec. 10608. Extension of medical malpractice coverage to free clinics. +Sec. 10609. Labeling changes. + + Subtitle G--Provisions Relating to Title VIII + +Sec. 10801. Provisions relating to title VIII. + + Subtitle H--Provisions Relating to Title IX + +Sec. 10901. Modifications to excise tax on high cost employer-sponsored + health coverage. +Sec. 10902. Inflation adjustment of limitation on health flexible + spending arrangements under cafeteria plans. +Sec. 10903. Modification of limitation on charges by charitable + hospitals. +Sec. 10904. Modification of annual fee on medical device manufacturers + and importers. +Sec. 10905. Modification of annual fee on health insurance providers. +Sec. 10906. Modifications to additional hospital insurance tax on high- + income taxpayers. +Sec. 10907. Excise tax on indoor tanning services in lieu of elective + cosmetic medical procedures. +Sec. 10908. Exclusion for assistance provided to participants in State + student loan repayment programs for certain health + professionals. +Sec. 10909. Expansion of adoption credit and adoption assistance + programs. + + TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS + + Subtitle A--Immediate Improvements in Health Care Coverage for All + Americans + +SEC. 1001. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT. + + Part A of title XXVII of the Public Health Service Act (42 U.S.C. +300gg et seq.) is amended-- + (1) by striking the part heading and inserting the + following: + + ``PART A--INDIVIDUAL AND GROUP MARKET REFORMS''; + + (2) by redesignating sections 2704 through 2707 <<NOTE: 42 + USC 300gg-4-- 300gg-7, 300gg-25-- 300gg-28.>> as sections 2725 + through 2728, respectively; + (3) by redesignating sections 2711 through 2713 <<NOTE: 42 + USC 300gg-11-- 300gg-13, 300gg-9.>> as sections 2731 through + 2733, respectively; + (4) by redesignating sections 2721 through 2723 <<NOTE: 42 + USC 300gg-21-- 300gg-23.>> as sections 2735 through 2737, + respectively; and + (5) by inserting after section 2702, the following: + +[[Page 124 STAT. 131]] + + ``Subpart II--Improving Coverage + +``SEC. 2711. <<NOTE: 42 USC 300gg-11.>> NO LIFETIME OR ANNUAL LIMITS. + + ``(a) In General.--A group health plan and a health insurance issuer +offering group or individual health insurance coverage may not +establish-- + ``(1) lifetime limits on the dollar value of benefits for + any participant or beneficiary; or + ``(2) unreasonable annual limits (within the meaning of + section 223 of the Internal Revenue Code of 1986) on the dollar + value of benefits for any participant or beneficiary. + + ``(b) Per Beneficiary Limits.--Subsection (a) shall not be construed +to prevent a group health plan or health insurance coverage that is not +required to provide essential health benefits under section 1302(b) of +the Patient Protection and Affordable Care Act from placing annual or +lifetime per beneficiary limits on specific covered benefits to the +extent that such limits are otherwise permitted under Federal or State +law. + +``SEC. 2712. <<NOTE: 42 USC 300gg-12.>> PROHIBITION ON RESCISSIONS. + + ``A group health plan and a health insurance issuer offering group +or individual health insurance coverage shall not rescind such plan or +coverage with respect to an enrollee once the enrollee is covered under +such plan or coverage involved, except that this section shall not apply +to a covered individual who has performed an act or practice that +constitutes fraud or makes an intentional misrepresentation of material +fact as prohibited by the terms of the plan or coverage. Such plan or +coverage may not be cancelled except with prior notice to the enrollee, +and only as permitted under section 2702(c) or 2742(b). + +``SEC. 2713. <<NOTE: 42 USC 300gg-13.>> COVERAGE OF PREVENTIVE HEALTH + SERVICES. + + ``(a) In General.--A group health plan and a health insurance issuer +offering group or individual health insurance coverage shall, at a +minimum provide coverage for and shall not impose any cost sharing +requirements for-- + ``(1) evidence-based items or services that have in effect a + rating of `A' or `B' in the current recommendations of the + United States Preventive Services Task Force; + ``(2) immunizations that have in effect a recommendation + from the Advisory Committee on Immunization Practices of the + Centers for Disease Control and Prevention with respect to the + individual involved; and + ``(3) with respect to infants, children, and adolescents, + evidence-informed preventive care and screenings provided for in + the comprehensive guidelines supported by the Health Resources + and Services Administration. + ``(4) with respect to women, such additional preventive care + and screenings not described in paragraph (1) as provided for in + comprehensive guidelines supported by the Health Resources and + Services Administration for purposes of this paragraph. + ``(5) for the purposes of this Act, and for the purposes of + any other provision of law, the current recommendations of the + United States Preventive Service Task Force regarding breast + cancer screening, mammography, and prevention shall + +[[Page 124 STAT. 132]] + + be considered the most current other than those issued in or + around November 2009. + +Nothing in this subsection shall be construed to prohibit a plan or +issuer from providing coverage for services in addition to those +recommended by United States Preventive Services Task Force or to deny +coverage for services that are not recommended by such Task Force. + ``(b) Interval.-- + ``(1) In general.--The Secretary shall establish a minimum + interval between the date on which a recommendation described in + subsection (a)(1) or (a)(2) or a guideline under subsection + (a)(3) is issued and the plan year with respect to which the + requirement described in subsection (a) is effective with + respect to the service described in such recommendation or + guideline. + ``(2) Minimum.--The interval described in paragraph (1) + shall not be less than 1 year. + + ``(c) Value-based Insurance Design.--The Secretary may develop +guidelines to permit a group health plan and a health insurance issuer +offering group or individual health insurance coverage to utilize value- +based insurance designs. + +``SEC. 2714. <<NOTE: 42 USC 300gg-14.>> EXTENSION OF DEPENDENT COVERAGE. + + ``(a) In General.--A group health plan and a health insurance issuer +offering group or individual health insurance coverage that provides +dependent coverage of children shall continue to make such coverage +available for an adult child (who is not married) until the child turns +26 years of age. Nothing in this section shall require a health plan or +a health insurance issuer described in the preceding sentence to make +coverage available for a child of a child receiving dependent coverage. + ``(b) Regulations.--The Secretary shall promulgate regulations to +define the dependents to which coverage shall be made available under +subsection (a). + ``(c) Rule of Construction.--Nothing in this section shall be +construed to modify the definition of `dependent' as used in the +Internal Revenue Code of 1986 with respect to the tax treatment of the +cost of coverage. + +``SEC. 2715. <<NOTE: 42 USC 300gg-15.>> DEVELOPMENT AND UTILIZATION OF + UNIFORM EXPLANATION OF COVERAGE DOCUMENTS AND STANDARDIZED + DEFINITIONS. + + ``(a) In <<NOTE: Deadline.>> General.--Not later than 12 months +after the date of enactment of the Patient Protection and Affordable +Care Act, the Secretary shall develop standards for use by a group +health plan and a health insurance issuer offering group or individual +health insurance coverage, in compiling and providing to enrollees a +summary of benefits and coverage explanation that accurately describes +the benefits and coverage under the applicable plan or coverage. In +developing such standards, the Secretary shall consult with the National +Association of Insurance Commissioners (referred to in this section as +the `NAIC'), a working group composed of representatives of health +insurance-related consumer advocacy organizations, health insurance +issuers, health care professionals, patient advocates including those +representing individuals with limited English proficiency, and other +qualified individuals. + + ``(b) Requirements.--The standards for the summary of benefits and +coverage developed under subsection (a) shall provide for the following: + +[[Page 124 STAT. 133]] + + ``(1) Appearance.--The standards shall ensure that the + summary of benefits and coverage is presented in a uniform + format that does not exceed 4 pages in length and does not + include print smaller than 12-point font. + ``(2) Language.--The standards shall ensure that the summary + is presented in a culturally and linguistically appropriate + manner and utilizes terminology understandable by the average + plan enrollee. + ``(3) Contents.--The standards shall ensure that the summary + of benefits and coverage includes-- + ``(A) uniform definitions of standard insurance + terms and medical terms (consistent with subsection (g)) + so that consumers may compare health insurance coverage + and understand the terms of coverage (or exception to + such coverage); + ``(B) a description of the coverage, including cost + sharing for-- + ``(i) each of the categories of the essential + health benefits described in subparagraphs (A) + through (J) of section 1302(b)(1) of the Patient + Protection and Affordable Care Act; and + ``(ii) other benefits, as identified by the + Secretary; + ``(C) the exceptions, reductions, and limitations on + coverage; + ``(D) the cost-sharing provisions, including + deductible, coinsurance, and co-payment obligations; + ``(E) the renewability and continuation of coverage + provisions; + ``(F) a coverage facts label that includes examples + to illustrate common benefits scenarios, including + pregnancy and serious or chronic medical conditions and + related cost sharing, such scenarios to be based on + recognized clinical practice guidelines; + ``(G) a statement of whether the plan or coverage-- + ``(i) provides minimum essential coverage (as + defined under section 5000A(f) of the Internal + Revenue Code 1986); and + ``(ii) ensures that the plan or coverage share + of the total allowed costs of benefits provided + under the plan or coverage is not less than 60 + percent of such costs; + ``(H) a statement that the outline is a summary of + the policy or certificate and that the coverage document + itself should be consulted to determine the governing + contractual provisions; and + ``(I) a contact number for the consumer to call with + additional questions and an Internet web address where a + copy of the actual individual coverage policy or group + certificate of coverage can be reviewed and obtained. + + ``(c) Periodic Review and Updating.--The Secretary shall +periodically review and update, as appropriate, the standards developed +under this section. + ``(d) Requirement To Provide.-- + ``(1) In general.--Not later <<NOTE: Deadline.>> than 24 + months after the date of enactment of the Patient Protection and + Affordable Care Act, each entity described in paragraph (3) + shall provide, prior + +[[Page 124 STAT. 134]] + + to any enrollment restriction, a summary of benefits and + coverage explanation pursuant to the standards developed by + the Secretary under subsection (a) to-- + ``(A) an applicant at the time of application; + ``(B) an enrollee prior to the time of enrollment or + reenrollment, as applicable; and + ``(C) a policyholder or certificate holder at the + time of issuance of the policy or delivery of the + certificate. + ``(2) Compliance.--An entity described in paragraph (3) is + deemed to be in compliance with this section if the summary of + benefits and coverage described in subsection (a) is provided in + paper or electronic form. + ``(3) Entities in general.--An entity described in this + paragraph is-- + ``(A) a health insurance issuer (including a group + health plan that is not a self-insured plan) offering + health insurance coverage within the United States; or + ``(B) in the case of a self-insured group health + plan, the plan sponsor or designated administrator of + the plan (as such terms are defined in section 3(16) of + the Employee Retirement Income Security Act of 1974). + ``(4) Notice <<NOTE: Deadline.>> of modifications.--If a + group health plan or health insurance issuer makes any material + modification in any of the terms of the plan or coverage + involved (as defined for purposes of section 102 of the Employee + Retirement Income Security Act of 1974) that is not reflected in + the most recently provided summary of benefits and coverage, the + plan or issuer shall provide notice of such modification to + enrollees not later than 60 days prior to the date on which such + modification will become effective. + + ``(e) Preemption.--The standards developed under subsection (a) +shall preempt any related State standards that require a summary of +benefits and coverage that provides less information to consumers than +that required to be provided under this section, as determined by the +Secretary. + ``(f) Failure To Provide.--An entity <<NOTE: Fine.>> described in +subsection (d)(3) that willfully fails to provide the information +required under this section shall be subject to a fine of not more than +$1,000 for each such failure. Such failure with respect to each enrollee +shall constitute a separate offense for purposes of this subsection. + + ``(g) Development of Standard Definitions.-- + ``(1) In general.--The + Secretary <<NOTE: Regulations.>> shall, by regulation, provide + for the development of standards for the definitions of terms + used in health insurance coverage, including the insurance- + related terms described in paragraph (2) and the medical terms + described in paragraph (3). + ``(2) Insurance-related terms.--The insurance-related terms + described in this paragraph are premium, deductible, co- + insurance, co-payment, out-of-pocket limit, preferred provider, + non-preferred provider, out-of-network co-payments, UCR (usual, + customary and reasonable) fees, excluded services, grievance and + appeals, and such other terms as the Secretary determines are + important to define so that consumers may compare health + insurance coverage and understand the terms of their coverage. + +[[Page 124 STAT. 135]] + + ``(3) Medical terms.--The medical terms described in this + paragraph are hospitalization, hospital outpatient care, + emergency room care, physician services, prescription drug + coverage, durable medical equipment, home health care, skilled + nursing care, rehabilitation services, hospice services, + emergency medical transportation, and such other terms as the + Secretary determines are important to define so that consumers + may compare the medical benefits offered by health insurance and + understand the extent of those medical benefits (or exceptions + to those benefits). + +``SEC. 2716. <<NOTE: 42 USC 300gg-16.>> PROHIBITION OF DISCRIMINATION + BASED ON SALARY. + + ``(a) In General.--The plan sponsor of a group health plan (other +than a self-insured plan) may not establish rules relating to the health +insurance coverage eligibility (including continued eligibility) of any +full-time employee under the terms of the plan that are based on the +total hourly or annual salary of the employee or otherwise establish +eligibility rules that have the effect of discriminating in favor of +higher wage employees. + ``(b) Limitation.--Subsection (a) shall not be construed to prohibit +a plan sponsor from establishing contribution requirements for +enrollment in the plan or coverage that provide for the payment by +employees with lower hourly or annual compensation of a lower dollar or +percentage contribution than the payment required of similarly situated +employees with a higher hourly or annual compensation. + +``SEC. 2717. <<NOTE: 42 USC 300gg-17.>> ENSURING THE QUALITY OF CARE. + + ``(a) Quality Reporting.-- + ``(1) In general.--Not later than 2 years after the date of + enactment of the Patient Protection and Affordable Care Act, the + Secretary, in consultation with experts in health care quality + and stakeholders, shall develop reporting requirements for use + by a group health plan, and a health insurance issuer offering + group or individual health insurance coverage, with respect to + plan or coverage benefits and health care provider reimbursement + structures that-- + ``(A) improve health outcomes through the + implementation of activities such as quality reporting, + effective case management, care coordination, chronic + disease management, and medication and care compliance + initiatives, including through the use of the medical + homes model as defined for purposes of section 3602 of + the Patient Protection and Affordable Care Act, for + treatment or services under the plan or coverage; + ``(B) implement activities to prevent hospital + readmissions through a comprehensive program for + hospital discharge that includes patient-centered + education and counseling, comprehensive discharge + planning, and post discharge reinforcement by an + appropriate health care professional; + ``(C) implement activities to improve patient safety + and reduce medical errors through the appropriate use of + best clinical practices, evidence based medicine, and + health information technology under the plan or + coverage; and + ``(D) implement wellness and health promotion + activities. + ``(2) Reporting requirements.-- + +[[Page 124 STAT. 136]] + + ``(A) In general.--A group health plan and a health + insurance issuer offering group or individual health + insurance coverage shall annually submit to the + Secretary, and to enrollees under the plan or coverage, + a report on whether the benefits under the plan or + coverage satisfy the elements described in subparagraphs + (A) through (D) of paragraph (1). + ``(B) Timing of reports.--A report under + subparagraph (A) shall be made available to an enrollee + under the plan or coverage during each open enrollment + period. + ``(C) Availability of reports.--The Secretary shall + make reports submitted under subparagraph (A) available + to the public through an Internet website. + ``(D) Penalties.--In developing the reporting + requirements under paragraph (1), the Secretary may + develop and impose appropriate penalties for non- + compliance with such requirements. + ``(E) Exceptions.--In developing the reporting + requirements under paragraph (1), the Secretary may + provide for exceptions to such requirements for group + health plans and health insurance issuers that + substantially meet the goals of this section. + + ``(b) Wellness and Prevention Programs.--For purposes of subsection +(a)(1)(D), wellness and health promotion activities may include +personalized wellness and prevention services, which are coordinated, +maintained or delivered by a health care provider, a wellness and +prevention plan manager, or a health, wellness or prevention services +organization that conducts health risk assessments or offers ongoing +face-to-face, telephonic or web-based intervention efforts for each of +the program's participants, and which may include the following wellness +and prevention efforts: + ``(1) Smoking cessation. + ``(2) Weight management. + ``(3) Stress management. + ``(4) Physical fitness. + ``(5) Nutrition. + ``(6) Heart disease prevention. + ``(7) Healthy lifestyle support. + ``(8) Diabetes prevention. + + ``(c) Regulations.--Not <<NOTE: Deadline.>> later than 2 years after +the date of enactment of the Patient Protection and Affordable Care Act, +the Secretary shall promulgate regulations that provide criteria for +determining whether a reimbursement structure is described in subsection +(a). + + ``(d) Study and Report.--Not later than 180 days after the date on +which regulations are promulgated under subsection (c), the Government +Accountability Office shall review such regulations and conduct a study +and submit to the Committee on Health, Education, Labor, and Pensions of +the Senate and the Committee on Energy and Commerce of the House of +Representatives a report regarding the impact the activities under this +section have had on the quality and cost of health care. + +``SEC. 2718. BRINGING <<NOTE: 42 USC 300gg-18.>> DOWN THE COST OF HEALTH + CARE COVERAGE. + + ``(a) Clear <<NOTE: Reports.>> Accounting for Costs.--A health +insurance issuer offering group or individual health insurance coverage +shall, with + +[[Page 124 STAT. 137]] + +respect to each plan year, submit to the Secretary a report concerning +the percentage of total premium revenue that such coverage expends-- + ``(1) on reimbursement for clinical services provided to + enrollees under such coverage; + ``(2) for activities that improve health care quality; and + ``(3) on all other non-claims costs, including an + explanation of the nature of such costs, and excluding State + taxes and licensing or regulatory fees. + +The <<NOTE: Public information. Web posting.>> Secretary shall make +reports received under this section available to the public on the +Internet website of the Department of Health and Human Services. + + ``(b) Ensuring That Consumers Receive Value for Their Premium +Payments.-- + ``(1) Requirement to provide value for premium payments.--A + health insurance issuer offering group or individual health + insurance coverage shall, with respect to each plan year, + provide an annual rebate to each enrollee under such coverage, + on a pro rata basis, in an amount that is equal to the amount by + which premium revenue expended by the issuer on activities + described in subsection (a)(3) exceeds-- + ``(A) with respect to a health insurance issuer + offering coverage in the group market, 20 percent, or + such lower percentage as a State may by regulation + determine; or + ``(B) with respect to a health insurance issuer + offering coverage in the individual market, 25 percent, + or such lower percentage as a State may by regulation + determine, except that such percentage shall be adjusted + to the extent the Secretary determines that the + application of such percentage with a State may + destabilize the existing individual market in such + State. + ``(2) Consideration in setting percentages.--In determining + the percentages under paragraph (1), a State shall seek to + ensure adequate participation by health insurance issuers, + competition in the health insurance market in the State, and + value for consumers so that premiums are used for clinical + services and quality improvements. + ``(3) Termination.--The provisions of this subsection shall + have no force or effect after December 31, 2013. + + ``(c) Standard Hospital Charges.--Each hospital operating within the +United States shall for each year establish (and update) and make public +(in accordance with guidelines developed by the Secretary) a list of the +hospital's standard charges for items and services provided by the +hospital, including for diagnosis-related groups established under +section 1886(d)(4) of the Social Security Act. + ``(d) Definitions.--The Secretary, in consultation with the National +Association of Insurance Commissions, shall establish uniform +definitions for the activities reported under subsection (a). + +``SEC. 2719. <<NOTE: 42 USC 300gg-19.>> APPEALS PROCESS. + + ``A group health plan and a health insurance issuer offering group +or individual health insurance coverage shall implement an effective +appeals process for appeals of coverage determinations and claims, under +which the plan or issuer shall, at a minimum-- + ``(1) have in effect an internal claims appeal process; + +[[Page 124 STAT. 138]] + + ``(2) provide <<NOTE: Notification.>> notice to enrollees, + in a culturally and linguistically appropriate manner, of + available internal and external appeals processes, and the + availability of any applicable office of health insurance + consumer assistance or ombudsman established under section 2793 + to assist such enrollees with the appeals processes; + ``(3) allow an enrollee to review their file, to present + evidence and testimony as part of the appeals process, and to + receive continued coverage pending the outcome of the appeals + process; and + ``(4) provide an external review process for such plans and + issuers that, at a minimum, includes the consumer protections + set forth in the Uniform External Review Model Act promulgated + by the National Association of Insurance Commissioners and is + binding on such plans.''. + +SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION. + + Part C of title XXVII of the Public Health Service Act (42 U.S.C. +300gg-91 et seq.) is amended by adding at the end the following: + +``SEC. 2793. <<NOTE: 42 USC 300gg-93.>> HEALTH INSURANCE CONSUMER + INFORMATION. + + ``(a) In <<NOTE: Grants.>> General.--The Secretary shall award +grants to States to enable such States (or the Exchanges operating in +such States) to establish, expand, or provide support for-- + ``(1) offices of health insurance consumer assistance; or + ``(2) health insurance ombudsman programs. + + ``(b) Eligibility.-- + ``(1) In general.--To be eligible to receive a grant, a + State shall designate an independent office of health insurance + consumer assistance, or an ombudsman, that, directly or in + coordination with State health insurance regulators and consumer + assistance organizations, receives and responds to inquiries and + complaints concerning health insurance coverage with respect to + Federal health insurance requirements and under State law. + ``(2) Criteria.--A State that receives a grant under this + section shall comply with criteria established by the Secretary + for carrying out activities under such grant. + + ``(c) Duties.--The office of health insurance consumer assistance or +health insurance ombudsman shall-- + ``(1) assist with the filing of complaints and appeals, + including filing appeals with the internal appeal or grievance + process of the group health plan or health insurance issuer + involved and providing information about the external appeal + process; + ``(2) collect, track, and quantify problems and inquiries + encountered by consumers; + ``(3) educate consumers on their rights and responsibilities + with respect to group health plans and health insurance + coverage; + ``(4) assist consumers with enrollment in a group health + plan or health insurance coverage by providing information, + referral, and assistance; and + ``(5) resolve problems with obtaining premium tax credits + under section 36B of the Internal Revenue Code of 1986. + +[[Page 124 STAT. 139]] + + ``(d) Data Collection.--As a condition of receiving a grant under +subsection (a), an office of health insurance consumer assistance or +ombudsman program shall be required to collect and report data to the +Secretary on the types of problems and inquiries encountered by +consumers. The Secretary shall utilize such data to identify areas where +more enforcement action is necessary and shall share such information +with State insurance regulators, the Secretary of Labor, and the +Secretary of the Treasury for use in the enforcement activities of such +agencies. + ``(e) Funding.-- + ``(1) Initial funding.--There is hereby appropriated to the + Secretary, out of any funds in the Treasury not otherwise + appropriated, $30,000,000 for the first fiscal year for which + this section applies to carry out this section. Such amount + shall remain available without fiscal year limitation. + ``(2) Authorization for subsequent years.--There is + authorized to be appropriated to the Secretary for each fiscal + year following the fiscal year described in paragraph (1), such + sums as may be necessary to carry out this section.''. + +SEC. 1003. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOLLARS. + + Part C of title XXVII of the Public Health Service Act (42 U.S.C. +300gg-91 et seq.), as amended by section 1002, is further amended by +adding at the end the following: + +``SEC. 2794. <<NOTE: 42 USC 300gg-94.>> ENSURING THAT CONSUMERS GET + VALUE FOR THEIR DOLLARS. + + ``(a) Initial Premium Review Process.-- + ``(1) In <<NOTE: Effective date.>> general.--The Secretary, + in conjunction with States, shall establish a process for the + annual review, beginning with the 2010 plan year and subject to + subsection (b)(2)(A), of unreasonable increases in premiums for + health insurance coverage. + ``(2) Justification and disclosure.--The process established + under paragraph (1) shall require health insurance issuers to + submit to the Secretary and the relevant State a justification + for an unreasonable premium increase prior to the implementation + of the <<NOTE: Web posting.>> increase. Such issuers shall + prominently post such information on their Internet websites. + The Secretary shall ensure the public disclosure of information + on such increases and justifications for all health insurance + issuers. + + ``(b) Continuing Premium Review Process.-- + ``(1) Informing secretary of premium increase patterns.--As + a condition of receiving a grant under subsection (c)(1), a + State, through its Commissioner of Insurance, shall-- + ``(A) provide the Secretary with information about + trends in premium increases in health insurance coverage + in premium rating areas in the State; and + ``(B) make recommendations, as appropriate, to the + State Exchange about whether particular health insurance + issuers should be excluded from participation in the + Exchange based on a pattern or practice of excessive or + unjustified premium increases. + ``(2) Monitoring by secretary of premium increases.-- + ``(A) In general.--Beginning <<NOTE: Effective + date.>> with plan years beginning in 2014, the + Secretary, in conjunction with the States + +[[Page 124 STAT. 140]] + + and consistent with the provisions of subsection (a)(2), + shall monitor premium increases of health insurance + coverage offered through an Exchange and outside of an + Exchange. + ``(B) Consideration in opening exchange.--In + determining under section 1312(f)(2)(B) of the Patient + Protection and Affordable Care Act whether to offer + qualified health plans in the large group market through + an Exchange, the State shall take into account any + excess of premium growth outside of the Exchange as + compared to the rate of such growth inside the Exchange. + + ``(c) Grants in Support of Process.-- + ``(1) Premium review grants during 2010 through 2014.--The + Secretary shall carry out a program to award grants to States + during the 5-year period beginning with fiscal year 2010 to + assist such States in carrying out subsection (a), including-- + ``(A) in reviewing and, if appropriate under State + law, approving premium increases for health insurance + coverage; and + ``(B) in providing information and recommendations + to the Secretary under subsection (b)(1). + ``(2) Funding.-- + ``(A) In general.--Out of all funds in the Treasury + not otherwise appropriated, there are appropriated to + the Secretary $250,000,000, to be available for + expenditure for grants under paragraph (1) and + subparagraph (B). + ``(B) Further availability for insurance reform and + consumer protection.--If the amounts appropriated under + subparagraph (A) are not fully obligated under grants + under paragraph (1) by the end of fiscal year 2014, any + remaining funds shall remain available to the Secretary + for grants to States for planning and implementing the + insurance reforms and consumer protections under part A. + ``(C) Allocation.--The Secretary shall establish a + formula for determining the amount of any grant to a + State under this subsection. Under such formula-- + ``(i) the Secretary shall consider the number + of plans of health insurance coverage offered in + each State and the population of the State; and + ``(ii) no State qualifying for a grant under + paragraph (1) shall receive less than $1,000,000, + or more than $5,000,000 for a grant year.''. + +SEC. 1004. <<NOTE: 42 USC 300gg-11 note.>> EFFECTIVE DATES. + + (a) In General.--Except as provided for in subsection (b), this +subtitle (and the amendments made by this subtitle) shall become +effective for plan years beginning on or after the date that is 6 months +after the date of enactment of this Act, except that the amendments made +by sections 1002 and 1003 shall become effective for fiscal years +beginning with fiscal year 2010. + (b) Special Rule.--The amendments made by sections 1002 and 1003 +shall take effect on the date of enactment of this Act. + +[[Page 124 STAT. 141]] + + Subtitle B--Immediate Actions to Preserve and Expand Coverage + +SEC. 1101. IMMEDIATE <<NOTE: 42 USC 18001.>> ACCESS TO INSURANCE FOR + UNINSURED INDIVIDUALS WITH A PREEXISTING CONDITION. + + (a) In General.--Not <<NOTE: Deadline. Time period.>> later than 90 +days after the date of enactment of this Act, the Secretary shall +establish a temporary high risk health insurance pool program to provide +health insurance coverage for eligible individuals during the period +beginning on the date on which such program is established and ending on +January 1, 2014. + + (b) Administration.-- + (1) In general.--The Secretary may carry out the program + under this section directly or through contracts to eligible + entities. + (2) Eligible entities.--To be eligible for a contract under + paragraph (1), an entity shall-- + (A) be a State or nonprofit private entity; + (B) submit to the Secretary an application at such + time, in such manner, and containing such information as + the Secretary may require; and + (C) agree to utilize contract funding to establish + and administer a qualified high risk pool for eligible + individuals. + (3) Maintenance of effort.--To be eligible to enter into a + contract with the Secretary under this subsection, a State shall + agree not to reduce the annual amount the State expended for the + operation of one or more State high risk pools during the year + preceding the year in which such contract is entered into. + + (c) Qualified High Risk Pool.-- + (1) In general.--Amounts made available under this section + shall be used to establish a qualified high risk pool that meets + the requirements of paragraph (2). + (2) Requirements.--A qualified high risk pool meets the + requirements of this paragraph if such pool-- + (A) provides to all eligible individuals health + insurance coverage that does not impose any preexisting + condition exclusion with respect to such coverage; + (B) provides health insurance coverage-- + (i) in which the issuer's share of the total + allowed costs of benefits provided under such + coverage is not less than 65 percent of such + costs; and + (ii) that has an out of pocket limit not + greater than the applicable amount described in + section 223(c)(2) of the Internal Revenue Code of + 1986 for the year involved, except that the + Secretary may modify such limit if necessary to + ensure the pool meets the actuarial value limit + under clause (i); + (C) ensures that with respect to the premium rate + charged for health insurance coverage offered to + eligible individuals through the high risk pool, such + rate shall-- + (i) except as provided in clause (ii), vary + only as provided for under section 2701 of the + Public Health Service Act (as amended by this Act + and notwithstanding the date on which such + amendments take effect); + +[[Page 124 STAT. 142]] + + (ii) vary on the basis of age by a factor of + not greater than 4 to 1; and + (iii) be established at a standard rate for a + standard population; and + (D) meets any other requirements determined + appropriate by the Secretary. + + (d) Eligible Individual.--An individual shall be deemed to be an +eligible individual for purposes of this section if such individual-- + (1) is a citizen or national of the United States or is + lawfully present in the United States (as determined in + accordance with section 1411); + (2) has not been covered under creditable coverage (as + defined in section 2701(c)(1) of the Public Health Service Act + as in effect on the date of enactment of this Act) during the 6- + month period prior to the date on which such individual is + applying for coverage through the high risk pool; and + (3) has a pre-existing condition, as determined in a manner + consistent with guidance issued by the Secretary. + + (e) Protection Against Dumping Risk by Insurers.-- + (1) In general.--The <<NOTE: Criteria.>> Secretary shall + establish criteria for determining whether health insurance + issuers and employment-based health plans have discouraged an + individual from remaining enrolled in prior coverage based on + that individual's health status. + (2) Sanctions.--An issuer or employment-based health plan + shall be responsible for reimbursing the program under this + section for the medical expenses incurred by the program for an + individual who, based on criteria established by the Secretary, + the Secretary finds was encouraged by the issuer to disenroll + from health benefits coverage prior to enrolling in coverage + through the program. The criteria shall include at least the + following circumstances: + (A) In the case of prior coverage obtained through + an employer, the provision by the employer, group health + plan, or the issuer of money or other financial + consideration for disenrolling from the coverage. + (B) In the case of prior coverage obtained directly + from an issuer or under an employment-based health + plan-- + (i) the provision by the issuer or plan of + money or other financial consideration for + disenrolling from the coverage; or + (ii) in the case of an individual whose + premium for the prior coverage exceeded the + premium required by the program (adjusted based on + the age factors applied to the prior coverage)-- + (I) the prior coverage is a policy + that is no longer being actively + marketed (as defined by the Secretary) + by the issuer; or + (II) the prior coverage is a policy + for which duration of coverage form + issue or health status are factors that + can be considered in determining + premiums at renewal. + (3) Construction.--Nothing in this subsection shall be + construed as constituting exclusive remedies for violations of + criteria established under paragraph (1) or as preventing States + +[[Page 124 STAT. 143]] + + from applying or enforcing such paragraph or other provisions + under law with respect to health insurance issuers. + + (f) Oversight.--The Secretary shall establish-- + (1) an appeals process to enable individuals to appeal a + determination under this section; and + (2) procedures to protect against waste, fraud, and abuse. + + (g) Funding; Termination of Authority.-- + (1) In general.--There is appropriated to the Secretary, out + of any moneys in the Treasury not otherwise appropriated, + $5,000,000,000 to pay claims against (and the administrative + costs of) the high risk pool under this section that are in + excess of the amount of premiums collected from eligible + individuals enrolled in the high risk pool. Such funds shall be + available without fiscal year limitation. + (2) Insufficient funds.--If the Secretary estimates for any + fiscal year that the aggregate amounts available for the payment + of the expenses of the high risk pool will be less than the + actual amount of such expenses, the Secretary shall make such + adjustments as are necessary to eliminate such deficit. + (3) Termination of authority.-- + (A) In general.--Except as provided in subparagraph + (B), coverage of eligible individuals under a high risk + pool in a State shall terminate on January 1, 2014. + (B) Transition <<NOTE: Procedures.>> to exchange.-- + The Secretary shall develop procedures to provide for + the transition of eligible individuals enrolled in + health insurance coverage offered through a high risk + pool established under this section into qualified + health plans offered through an Exchange. Such + procedures shall ensure that there is no lapse in + coverage with respect to the individual and may extend + coverage after the termination of the risk pool + involved, if the Secretary determines necessary to avoid + such a lapse. + (4) Limitations.--The Secretary has the authority to stop + taking applications for participation in the program under this + section to comply with the funding limitation provided for in + paragraph (1). + (5) Relation to state laws.--The standards established under + this section shall supersede any State law or regulation (other + than State licensing laws or State laws relating to plan + solvency) with respect to qualified high risk pools which are + established in accordance with this section. + +SEC. 1102. <<NOTE: 42 USC 18002.>> REINSURANCE FOR EARLY RETIREES. + + (a) Administration.-- + (1) In general.--Not <<NOTE: Deadline. Time period.>> later + than 90 days after the date of enactment of this Act, the + Secretary shall establish a temporary reinsurance program to + provide reimbursement to participating employment-based plans + for a portion of the cost of providing health insurance coverage + to early retirees (and to the eligible spouses, surviving + spouses, and dependents of such retirees) during the period + beginning on the date on which such program is established and + ending on January 1, 2014. + (2) Reference.--In this section: + (A) Health benefits.--The term ``health benefits'' + means medical, surgical, hospital, prescription drug, + and such other benefits as shall be determined by the + Secretary, + +[[Page 124 STAT. 144]] + + whether self-funded, or delivered through the purchase + of insurance or otherwise. + (B) Employment-based plan.--The term ``employment- + based plan'' means a group health benefits plan that-- + (i) is-- + (I) maintained by one or more + current or former employers (including + without limitation any State or local + government or political subdivision + thereof), employee organization, a + voluntary employees' beneficiary + association, or a committee or board of + individuals appointed to administer such + plan; or + (II) a multiemployer plan (as + defined in section 3(37) of the Employee + Retirement Income Security Act of 1974); + and + (ii) provides health benefits to early + retirees. + (C) Early retirees.--The term ``early retirees'' + means individuals who are age 55 and older but are not + eligible for coverage under title XVIII of the Social + Security Act, and who are not active employees of an + employer maintaining, or currently contributing to, the + employment-based plan or of any employer that has made + substantial contributions to fund such plan. + + (b) Participation.-- + (1) Employment-based plan eligibility.--A participating + employment-based plan is an employment-based plan that-- + (A) meets the requirements of paragraph (2) with + respect to health benefits provided under the plan; and + (B) submits to the Secretary an application for + participation in the program, at such time, in such + manner, and containing such information as the Secretary + shall require. + (2) Employment-based health benefits.--An employment-based + plan meets the requirements of this paragraph if the plan-- + (A) implements programs and procedures to generate + cost-savings with respect to participants with chronic + and high-cost conditions; + (B) provides documentation of the actual cost of + medical claims involved; and + (C) is certified <<NOTE: Certification.>> by the + Secretary. + + (c) Payments.-- + (1) Submission of claims.-- + (A) In general.--A participating employment-based + plan shall submit claims for reimbursement to the + Secretary which shall contain documentation of the + actual costs of the items and services for which each + claim is being submitted. + (B) Basis for claims.--Claims submitted under + subparagraph (A) shall be based on the actual amount + expended by the participating employment-based plan + involved within the plan year for the health benefits + provided to an early retiree or the spouse, surviving + spouse, or dependent of such retiree. In determining the + amount of a claim for purposes of this subsection, the + participating + +[[Page 124 STAT. 145]] + + employment-based plan shall take into account any + negotiated price concessions (such as discounts, direct + or indirect subsidies, rebates, and direct or indirect + remunerations) obtained by such plan with respect to + such health benefit. For purposes of determining the + amount of any such claim, the costs paid by the early + retiree or the retiree's spouse, surviving spouse, or + dependent in the form of deductibles, co-payments, or + co-insurance shall be included in the amounts paid by + the participating employment-based plan. + (2) Program payments.--If the Secretary determines that a + participating employment-based plan has submitted a valid claim + under paragraph (1), the Secretary shall reimburse such plan for + 80 percent of that portion of the costs attributable to such + claim that exceed $15,000, subject to the limits contained in + paragraph (3). + (3) Limit.--To be eligible for reimbursement under the + program, a claim submitted by a participating employment-based + plan shall not be less than $15,000 nor greater than $90,000. + Such amounts shall be adjusted each fiscal year based on the + percentage increase in the Medical Care Component of the + Consumer Price Index for all urban consumers (rounded to the + nearest multiple of $1,000) for the year involved. + (4) Use of payments.--Amounts paid to a participating + employment-based plan under this subsection shall be used to + lower costs for the plan. Such payments may be used to reduce + premium costs for an entity described in subsection (a)(2)(B)(i) + or to reduce premium contributions, co-payments, deductibles, + co-insurance, or other out-of-pocket costs for plan + participants. Such payments shall not be used as general + revenues for an entity described in subsection (a)(2)(B)(i). The + Secretary shall develop a mechanism to monitor the appropriate + use of such payments by such entities. + (5) Payments not treated as income.--Payments received under + this subsection shall not be included in determining the gross + income of an entity described in subsection (a)(2)(B)(i) that is + maintaining or currently contributing to a participating + employment-based plan. + (6) Appeals.--The Secretary shall establish-- + (A) an appeals process to permit participating + employment-based plans to appeal a determination of the + Secretary with respect to claims submitted under this + section; and + (B) procedures to protect against fraud, waste, and + abuse under the program. + + (d) Audits.--The Secretary shall conduct annual audits of claims +data submitted by participating employment-based plans under this +section to ensure that such plans are in compliance with the +requirements of this section. + (e) Funding.--There is appropriated to the Secretary, out of any +moneys in the Treasury not otherwise appropriated, $5,000,000,000 to +carry out the program under this section. Such funds shall be available +without fiscal year limitation. + (f) Limitation.--The Secretary has the authority to stop taking +applications for participation in the program based on the availability +of funding under subsection (e). + +[[Page 124 STAT. 146]] + +SEC. 1103. IMMEDIATE <<NOTE: Deadlines. 42 USC 18003.>> INFORMATION THAT + ALLOWS CONSUMERS TO IDENTIFY AFFORDABLE COVERAGE OPTIONS. + + (a) Internet Portal to Affordable Coverage Options.-- + (1) Immediate establishment.--Not later than July 1, 2010, + the Secretary, in consultation with the States, shall establish + a mechanism, including an Internet website, through which a + resident of any State may identify affordable health insurance + coverage options in that State. + (2) Connecting to affordable coverage.--An Internet website + established under paragraph (1) shall, to the extent + practicable, provide ways for residents of any State to receive + information on at least the following coverage options: + (A) Health insurance coverage offered by health + insurance issuers, other than coverage that provides + reimbursement only for the treatment or mitigation of-- + (i) a single disease or condition; or + (ii) an unreasonably limited set of diseases + or conditions (as determined by the Secretary); + (B) Medicaid coverage under title XIX of the Social + Security Act. + (C) Coverage under title XXI of the Social Security + Act. + (D) A State health benefits high risk pool, to the + extent that such high risk pool is offered in such + State; and + (E) Coverage under a high risk pool under section + 1101. + + (b) Enhancing Comparative Purchasing Options.-- + (1) In general.--Not later <<NOTE: Deadline. Standard + format.>> than 60 days after the date of enactment of this Act, + the Secretary shall develop a standardized format to be used for + the presentation of information relating to the coverage options + described in subsection (a)(2). Such format shall, at a minimum, + require the inclusion of information on the percentage of total + premium revenue expended on nonclinical costs (as reported under + section 2718(a) of the Public Health Service Act), eligibility, + availability, premium rates, and cost sharing with respect to + such coverage options and be consistent with the standards + adopted for the uniform explanation of coverage as provided for + in section 2715 of the Public Health Service Act. + (2) Use of format.--The Secretary shall utilize the format + developed under paragraph (1) in compiling information + concerning coverage options on the Internet website established + under subsection (a). + + (c) Authority To Contract.--The Secretary may carry out this section +through contracts entered into with qualified entities. + +SEC. 1104. ADMINISTRATIVE SIMPLIFICATION. + + (a) Purpose of Administrative Simplification.--Section 261 of the +Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. +1320d note) is amended-- + (1) by inserting ``uniform'' before ``standards''; and + (2) by inserting ``and to reduce the clerical burden on + patients, health care providers, and health plans'' before the + period at the end. + + (b) Operating Rules for Health Information Transactions.-- + +[[Page 124 STAT. 147]] + + (1) Definition of operating rules.--Section 1171 of the + Social Security Act (42 U.S.C. 1320d) is amended by adding at + the end the following: + ``(9) Operating rules.--The term `operating rules' means the + necessary business rules and guidelines for the electronic + exchange of information that are not defined by a standard or + its implementation specifications as adopted for purposes of + this part.''. + (2) Transaction standards; operating rules and compliance.-- + Section 1173 of the Social Security Act (42 U.S.C. 1320d-2) is + amended-- + (A) in subsection (a)(2), by adding at the end the + following new subparagraph: + ``(J) Electronic funds transfers.''; + (B) in subsection (a), by adding at the end the + following new paragraph: + ``(4) Requirements for financial and administrative + transactions.-- + ``(A) In general.--The standards and associated + operating rules adopted by the Secretary shall-- + ``(i) to the extent feasible and appropriate, + enable determination of an individual's + eligibility and financial responsibility for + specific services prior to or at the point of + care; + ``(ii) be comprehensive, requiring minimal + augmentation by paper or other communications; + ``(iii) provide for timely acknowledgment, + response, and status reporting that supports a + transparent claims and denial management process + (including adjudication and appeals); and + ``(iv) describe all data elements (including + reason and remark codes) in unambiguous terms, + require that such data elements be required or + conditioned upon set values in other fields, and + prohibit additional conditions (except where + necessary to implement State or Federal law, or to + protect against fraud and abuse). + ``(B) Reduction of clerical burden.--In adopting + standards and operating rules for the transactions + referred to under paragraph (1), the Secretary shall + seek to reduce the number and complexity of forms + (including paper and electronic forms) and data entry + required by patients and providers.''; and + (C) by adding at the end the following new + subsections: + + ``(g) Operating Rules.-- + ``(1) In general.--The Secretary shall adopt a single set of + operating rules for each transaction referred to under + subsection (a)(1) with the goal of creating as much uniformity + in the implementation of the electronic standards as possible. + Such operating rules shall be consensus-based and reflect the + necessary business rules affecting health plans and health care + providers and the manner in which they operate pursuant to + standards issued under Health Insurance Portability and + Accountability Act of 1996. + ``(2) Operating rules development.--In adopting operating + rules under this subsection, the Secretary shall consider + recommendations for operating rules developed by a qualified + nonprofit entity that meets the following requirements: + +[[Page 124 STAT. 148]] + + ``(A) The entity focuses its mission on + administrative simplification. + ``(B) The entity demonstrates a multi-stakeholder + and consensus-based process for development of operating + rules, including representation by or participation from + health plans, health care providers, vendors, relevant + Federal agencies, and other standard development + organizations. + ``(C) The entity has a public set of guiding + principles that ensure the operating rules and process + are open and transparent, and supports nondiscrimination + and conflict of interest policies that demonstrate a + commitment to open, fair, and nondiscriminatory + practices. + ``(D) The entity builds on the transaction standards + issued under Health Insurance Portability and + Accountability Act of 1996. + ``(E) The entity allows for public review and + updates of the operating rules. + ``(3) Review and recommendations.--The National Committee on + Vital and Health Statistics shall-- + ``(A) advise the Secretary as to whether a nonprofit + entity meets the requirements under paragraph (2); + ``(B) review the operating rules developed and + recommended by such nonprofit entity; + ``(C) determine whether such operating rules + represent a consensus view of the health care + stakeholders and are consistent with and do not conflict + with other existing standards; + ``(D) evaluate whether such operating rules are + consistent with electronic standards adopted for health + information technology; and + ``(E) submit to the Secretary a recommendation as to + whether the Secretary should adopt such operating rules. + ``(4) Implementation.-- + ``(A) In general.-- + The <<NOTE: Regulations.>> Secretary shall adopt + operating rules under this subsection, by regulation in + accordance with subparagraph (C), following + consideration of the operating rules developed by the + non-profit entity described in paragraph (2) and the + recommendation submitted by the National Committee on + Vital and Health Statistics under paragraph (3)(E) and + having ensured consultation with providers. + ``(B) Adoption <<NOTE: Deadlines.>> requirements; + effective dates.-- + ``(i) Eligibility for a health plan and health + claim status.--The set of operating rules for + eligibility for a health plan and health claim + status transactions shall be adopted not later + than July 1, 2011, in a manner ensuring that such + operating rules are effective not later than + January 1, 2013, and may allow for the use of a + machine readable identification card. + ``(ii) Electronic funds transfers and health + care payment and remittance advice.--The set of + operating rules for electronic funds transfers and + health care payment and remittance advice + transactions shall-- + ``(I) allow for automated + reconciliation of the electronic payment + with the remittance advice; and + +[[Page 124 STAT. 149]] + + ``(II) be adopted not later than + July 1, 2012, in a manner ensuring that + such operating rules are effective not + later than January 1, 2014. + ``(iii) Health claims or equivalent encounter + information, enrollment and disenrollment in a + health plan, health plan premium payments, + referral certification and authorization.--The set + of operating rules for health claims or equivalent + encounter information, enrollment and + disenrollment in a health plan, health plan + premium payments, and referral certification and + authorization transactions shall be adopted not + later than July 1, 2014, in a manner ensuring that + such operating rules are effective not later than + January 1, 2016. + ``(C) Expedited rulemaking.--The Secretary shall + promulgate an interim final rule applying any standard + or operating rule recommended by the National Committee + on Vital and Health Statistics pursuant to paragraph + (3). The Secretary <<NOTE: Public comments.>> shall + accept and consider public comments on any interim final + rule published under this subparagraph for 60 days after + the date of such publication. + + ``(h) Compliance.-- + ``(1) Health <<NOTE: Deadlines.>> plan certification.-- + ``(A) Eligibility for a health plan, health claim + status, electronic funds transfers, health care payment + and remittance advice.-- + Not <<NOTE: Certification.>> later than December 31, + 2013, a health plan shall file a statement with the + Secretary, in such form as the Secretary may require, + certifying that the data and information systems for + such plan are in compliance with any applicable + standards (as described under paragraph (7) of section + 1171) and associated operating rules (as described under + paragraph (9) of such section) for electronic funds + transfers, eligibility for a health plan, health claim + status, and health care payment and remittance advice, + respectively. + ``(B) Health claims or equivalent encounter + information, enrollment and disenrollment in a health + plan, health plan premium payments, health claims + attachments, referral certification and authorization.-- + Not later than December 31, 2015, a health plan shall + file a statement with the Secretary, in such form as the + Secretary may require, certifying that the data and + information systems for such plan are in compliance with + any applicable standards and associated operating rules + for health claims or equivalent encounter information, + enrollment and disenrollment in a health plan, health + plan premium payments, health claims attachments, and + referral certification and authorization, respectively. + A health plan shall provide the same level of + documentation to certify compliance with such + transactions as is required to certify compliance with + the transactions specified in subparagraph (A). + ``(2) Documentation of compliance.--A health plan shall + provide the Secretary, in such form as the Secretary may + require, with adequate documentation of compliance with the + standards and operating rules described under paragraph (1). A + health plan shall not be considered to have provided adequate + +[[Page 124 STAT. 150]] + + documentation and shall not be certified as being in compliance + with such standards, unless the health plan-- + ``(A) demonstrates to the Secretary that the plan + conducts the electronic transactions specified in + paragraph (1) in a manner that fully complies with the + regulations of the Secretary; and + ``(B) provides documentation showing that the plan + has completed end-to-end testing for such transactions + with their partners, such as hospitals and physicians. + ``(3) Service contracts.--A health plan shall be required to + ensure that any entities that provide services pursuant to a + contract with such health plan shall comply with any applicable + certification and compliance requirements (and provide the + Secretary with adequate documentation of such compliance) under + this subsection. + ``(4) Certification by outside entity.--The Secretary may + designate independent, outside entities to certify that a health + plan has complied with the requirements under this subsection, + provided that the certification standards employed by such + entities are in accordance with any standards or operating rules + issued by the Secretary. + ``(5) Compliance with revised standards and operating + rules.-- + ``(A) In general.--A <<NOTE: Certification.>> health + plan (including entities described under paragraph (3)) + shall file a statement with the Secretary, in such form + as the Secretary may require, certifying that the data + and information systems for such plan are in compliance + with any applicable revised standards and associated + operating rules under this subsection for any interim + final rule promulgated by the Secretary under subsection + (i) that-- + ``(i) amends any standard or operating rule + described under paragraph (1) of this subsection; + or + ``(ii) establishes a standard (as described + under subsection (a)(1)(B)) or associated + operating rules (as described under subsection + (i)(5)) for any other financial and administrative + transactions. + ``(B) Date of compliance.--A health plan shall + comply with such requirements not later than the + effective date of the applicable standard or operating + rule. + ``(6) Audits of health plans.--The Secretary shall conduct + periodic audits to ensure that health plans (including entities + described under paragraph (3)) are in compliance with any + standards and operating rules that are described under paragraph + (1) or subsection (i)(5). + + ``(i) Review <<NOTE: Deadlines.>> and Amendment of Standards and +Operating Rules.-- + ``(1) Establishment.--Not later than January 1, 2014, the + Secretary shall establish a review committee (as described under + paragraph (4)). + ``(2) Evaluations and reports.-- + ``(A) Hearings.--Not later than April 1, 2014, and + not less than biennially thereafter, the Secretary, + acting through the review committee, shall conduct + hearings to evaluate and review the adopted standards + and operating rules established under this section. + +[[Page 124 STAT. 151]] + + ``(B) Report.--Not later than July 1, 2014, and not + less than biennially thereafter, the review committee + shall provide recommendations for updating and improving + such standards and operating rules. The review committee + shall recommend a single set of operating rules per + transaction standard and maintain the goal of creating + as much uniformity as possible in the implementation of + the electronic standards. + ``(3) Interim final rulemaking.-- + ``(A) In general.--Any recommendations to amend + adopted standards and operating rules that have been + approved by the review committee and reported to the + Secretary under paragraph (2)(B) shall be adopted by the + Secretary through promulgation of an interim final rule + not later than 90 days after receipt of the committee's + report. + ``(B) Public comment.-- + ``(i) Public comment period.--The Secretary + shall accept and consider public comments on any + interim final rule published under this paragraph + for 60 days after the date of such publication. + ``(ii) Effective date.--The effective date of + any amendment to existing standards or operating + rules that is adopted through an interim final + rule published under this paragraph shall be 25 + months following the close of such public comment + period. + ``(4) Review committee.-- + ``(A) Definition.--For the purposes of this + subsection, the term `review committee' means a + committee chartered by or within the Department of + Health and Human services that has been designated by + the Secretary to carry out this subsection, including-- + ``(i) the National Committee on Vital and + Health Statistics; or + ``(ii) any appropriate committee as determined + by the Secretary. + ``(B) Coordination of hit standards.--In developing + recommendations under this subsection, the review + committee shall ensure coordination, as appropriate, + with the standards that support the certified electronic + health record technology approved by the Office of the + National Coordinator for Health Information Technology. + ``(5) Operating rules for other standards adopted by the + secretary.--The Secretary shall adopt a single set of operating + rules (pursuant to the process described under subsection (g)) + for any transaction for which a standard had been adopted + pursuant to subsection (a)(1)(B). + + ``(j) Penalties.-- + ``(1) Penalty fee.-- + ``(A) In general.--Not <<NOTE: Deadline.>> later + than April 1, 2014, and annually thereafter, the + Secretary shall assess a penalty fee (as determined + under subparagraph (B)) against a health plan that has + failed to meet the requirements under subsection (h) + with respect to certification and documentation of + compliance with-- + ``(i) the standards and associated operating + rules described under paragraph (1) of such + subsection; and + +[[Page 124 STAT. 152]] + + ``(ii) a standard (as described under + subsection (a)(1)(B)) and associated operating + rules (as described under subsection (i)(5)) for + any other financial and administrative + transactions. + ``(B) Fee amount.--Subject to subparagraphs (C), + (D), and (E), the Secretary shall assess a penalty fee + against a health plan in the amount of $1 per covered + life until certification is complete. The penalty shall + be assessed per person covered by the plan for which its + data systems for major medical policies are not in + compliance and shall be imposed against the health plan + for each day that the plan is not in compliance with the + requirements under subsection (h). + ``(C) Additional penalty for misrepresentation.--A + health plan that knowingly provides inaccurate or + incomplete information in a statement of certification + or documentation of compliance under subsection (h) + shall be subject to a penalty fee that is double the + amount that would otherwise be imposed under this + subsection. + ``(D) Annual fee increase.--The amount of the + penalty fee imposed under this subsection shall be + increased on an annual basis by the annual percentage + increase in total national health care expenditures, as + determined by the Secretary. + ``(E) Penalty limit.--A penalty fee assessed against + a health plan under this subsection shall not exceed, on + an annual basis-- + ``(i) an amount equal to $20 per covered life + under such plan; or + ``(ii) an amount equal to $40 per covered life + under the plan if such plan has knowingly provided + inaccurate or incomplete information (as described + under subparagraph (C)). + ``(F) Determination of covered individuals.--The + Secretary shall determine the number of covered lives + under a health plan based upon the most recent + statements and filings that have been submitted by such + plan to the Securities and Exchange Commission. + ``(2) Notice and dispute procedure.--The Secretary shall + establish a procedure for assessment of penalty fees under this + subsection that provides a health plan with reasonable notice + and a dispute resolution procedure prior to provision of a + notice of assessment by the Secretary of the Treasury (as + described under paragraph (4)(B)). + ``(3) Penalty fee report.--Not later than May 1, 2014, and + annually thereafter, the Secretary shall provide the Secretary + of the Treasury with a report identifying those health plans + that have been assessed a penalty fee under this subsection. + ``(4) Collection of penalty fee.-- + ``(A) In general.--The Secretary of the Treasury, + acting through the Financial Management Service, shall + administer the collection of penalty fees from health + plans that have been identified by the Secretary in the + penalty fee report provided under paragraph (3). + ``(B) Notice.--Not <<NOTE: Deadline.>> later than + August 1, 2014, and annually thereafter, the Secretary + of the Treasury shall + +[[Page 124 STAT. 153]] + + provide notice to each health plan that has been + assessed a penalty fee by the Secretary under this + subsection. Such notice shall include the amount of the + penalty fee assessed by the Secretary and the due date + for payment of such fee to the Secretary of the Treasury + (as described in subparagraph (C)). + ``(C) Payment due date.--Payment by a health plan + for a penalty fee assessed under this subsection shall + be made to the Secretary of the Treasury not later than + November 1, 2014, and annually thereafter. + ``(D) Unpaid penalty fees.--Any amount of a penalty + fee assessed against a health plan under this subsection + for which payment has not been made by the due date + provided under subparagraph (C) shall be-- + ``(i) increased by the interest accrued on + such amount, as determined pursuant to the + underpayment rate established under section 6621 + of the Internal Revenue Code of 1986; and + ``(ii) treated as a past-due, legally + enforceable debt owed to a Federal agency for + purposes of section 6402(d) of the Internal + Revenue Code of 1986. + ``(E) Administrative fees.--Any fee charged or + allocated for collection activities conducted by the + Financial Management Service will be passed on to a + health plan on a pro-rata basis and added to any penalty + fee collected from the plan.''. + + (c) Promulgation <<NOTE: 42 USC 1320d-2 note.>> of Rules.-- + (1) Unique health plan identifier.--The Secretary shall + promulgate a final rule to establish a unique health plan + identifier (as described in section 1173(b) of the Social + Security Act (42 U.S.C. 1320d-2(b))) based on the input of the + National Committee on Vital and Health <<NOTE: Effective + date.>> Statistics. The Secretary may do so on an interim final + basis and such rule shall be effective not later than October 1, + 2012. + (2) Electronic funds transfer.--The Secretary shall + promulgate a final rule to establish a standard for electronic + funds transfers (as described in section 1173(a)(2)(J) of the + Social Security Act, as added by subsection + (b)(2)(A)). <<NOTE: Deadline. Effective date.>> The Secretary + may do so on an interim final basis and shall adopt such + standard not later than January 1, 2012, in a manner ensuring + that such standard is effective not later than January 1, 2014. + (3) Health claims attachments.--The Secretary shall + promulgate a final rule to establish a transaction standard and + a single set of associated operating rules for health claims + attachments (as described in section 1173(a)(2)(B) of the Social + Security Act (42 U.S.C. 1320d-2(a)(2)(B))) that is consistent + with the X12 Version 5010 + transaction <<NOTE: Deadline. Effective date.>> standards. The + Secretary may do so on an interim final basis and shall adopt a + transaction standard and a single set of associated operating + rules not later than January 1, 2014, in a manner ensuring that + such standard is effective not later than January 1, 2016. + + (d) Expansion of Electronic Transactions in Medicare.--Section +1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended-- + (1) in paragraph (23), by striking the ``or'' at the end; + +[[Page 124 STAT. 154]] + + (2) in paragraph (24), by striking the period and inserting + ``; or''; and + (3) by inserting after paragraph (24) the following new + paragraph: + ``(25) not later than January 1, 2014, for which the payment + is other than by electronic funds transfer (EFT) or an + electronic remittance in a form as specified in ASC X12 835 + Health Care Payment and Remittance Advice or subsequent + standard.''. + +SEC. 1105. <<NOTE: 42 USC 1320d note.>> EFFECTIVE DATE. + + This subtitle shall take effect on the date of enactment of this +Act. + + Subtitle C--Quality Health Insurance Coverage for All Americans + + PART I--HEALTH INSURANCE MARKET REFORMS + +SEC. 1201. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT. + + Part A of title XXVII of the Public Health Service Act (42 U.S.C. +300gg et seq.), as amended by section 1001, is further amended-- + (1) by striking the heading for subpart 1 and inserting the + following: + + ``Subpart I--General Reform''; + + (2)(A) in section 2701 (42 U.S.C. 300gg), by striking the + section heading and subsection (a) and inserting the following: + +``SEC. 2704. PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS OR OTHER + DISCRIMINATION BASED ON HEALTH STATUS. + + ``(a) In General.--A group health plan and a health insurance issuer +offering group or individual health insurance coverage may not impose +any preexisting condition exclusion with respect to such plan or +coverage.''; and + (B) by <<NOTE: 42 USC 300gg-3.>> transferring such section + (as amended by subparagraph (A)) so as to appear after the + section 2703 added by paragraph (4); + (3)(A) in <<NOTE: 42 USC 300gg-1, 300gg-4.>> section 2702 + (42 U.S.C. 300gg-1)-- + (i) by striking the section heading and all that + follows through subsection (a); + (ii) in subsection (b)-- + (I) by striking ``health insurance issuer + offering health insurance coverage in connection + with a group health plan'' each place that such + appears and inserting ``health insurance issuer + offering group or individual health insurance + coverage''; and + (II) in paragraph (2)(A)-- + (aa) by inserting ``or individual'' + after ``employer''; and + (bb) by inserting ``or individual + health coverage, as the case may be'' + before the semicolon; and + (iii) in subsection (e)-- + +[[Page 124 STAT. 155]] + + (I) by striking ``(a)(1)(F)'' and inserting + ``(a)(6)''; + (II) by striking ``2701'' and inserting + ``2704''; and + (III) by striking ``2721(a)'' and inserting + ``2735(a)''; and + (B) by transferring such section (as amended by + subparagraph (A)) to appear after section 2705(a) as + added by paragraph (4); and + (4) by inserting after the subpart heading (as added by + paragraph (1)) the following: + +``SEC. 2701. FAIR <<NOTE: 42 USC 300gg.>> HEALTH INSURANCE PREMIUMS. + + ``(a) Prohibiting Discriminatory Premium Rates.-- + ``(1) In general.--With respect to the premium rate charged + by a health insurance issuer for health insurance coverage + offered in the individual or small group market-- + ``(A) such rate shall vary with respect to the + particular plan or coverage involved only by-- + ``(i) whether such plan or coverage covers an + individual or family; + ``(ii) rating area, as established in + accordance with paragraph (2); + ``(iii) age, except that such rate shall not + vary by more than 3 to 1 for adults (consistent + with section 2707(c)); and + ``(iv) tobacco use, except that such rate + shall not vary by more than 1.5 to 1; and + ``(B) such rate shall not vary with respect to the + particular plan or coverage involved by any other factor + not described in subparagraph (A). + ``(2) Rating area.-- + ``(A) In general.--Each State shall establish 1 or + more rating areas within that State for purposes of + applying the requirements of this title. + ``(B) Secretarial review.--The Secretary shall + review the rating areas established by each State under + subparagraph (A) to ensure the adequacy of such areas + for purposes of carrying out the requirements of this + title. If the Secretary determines a State's rating + areas are not adequate, or that a State does not + establish such areas, the Secretary may establish rating + areas for that State. + ``(3) Permissible <<NOTE: Definition.>> age bands.--The + Secretary, in consultation with the National Association of + Insurance Commissioners, shall define the permissible age bands + for rating purposes under paragraph (1)(A)(iii). + ``(4) Application of variations based on age or tobacco + use.--With respect to family coverage under a group health plan + or health insurance coverage, the rating variations permitted + under clauses (iii) and (iv) of paragraph (1)(A) shall be + applied based on the portion of the premium that is attributable + to each family member covered under the plan or coverage. + ``(5) Special rule for large group market.--If a State + permits health insurance issuers that offer coverage in the + large group market in the State to offer such coverage through + the State Exchange (as provided for under section 1312(f)(2)(B) + +[[Page 124 STAT. 156]] + + of the Patient Protection and Affordable Care Act), the + provisions of this subsection shall apply to all coverage + offered in such market in the State. + +``SEC. 2702. GUARANTEED <<NOTE: 42 USC 300gg-1.>> AVAILABILITY OF + COVERAGE. + + ``(a) Guaranteed Issuance of Coverage in the Individual and Group +Market.--Subject to subsections (b) through (e), each health insurance +issuer that offers health insurance coverage in the individual or group +market in a State must accept every employer and individual in the State +that applies for such coverage. + ``(b) Enrollment.-- + ``(1) Restriction.--A health insurance issuer described in + subsection (a) may restrict enrollment in coverage described in + such subsection to open or special enrollment periods. + ``(2) Establishment.--A health insurance issuer described in + subsection (a) shall, in accordance with the regulations + promulgated under paragraph (3), establish special enrollment + periods for qualifying events (under section 603 of the Employee + Retirement Income Security Act of 1974). + ``(3) Regulations.--The Secretary shall promulgate + regulations with respect to enrollment periods under paragraphs + (1) and (2). + +``SEC. 2703. GUARANTEED <<NOTE: 42 USC 300gg-2.>> RENEWABILITY OF + COVERAGE. + + ``(a) In General.--Except as provided in this section, if a health +insurance issuer offers health insurance coverage in the individual or +group market, the issuer must renew or continue in force such coverage +at the option of the plan sponsor or the individual, as applicable. + +``SEC. 2705. PROHIBITING <<NOTE: 42 USC 300gg-4.>> DISCRIMINATION + AGAINST INDIVIDUAL PARTICIPANTS AND BENEFICIARIES BASED ON + HEALTH STATUS. + + ``(a) In General.--A group health plan and a health insurance issuer +offering group or individual health insurance coverage may not establish +rules for eligibility (including continued eligibility) of any +individual to enroll under the terms of the plan or coverage based on +any of the following health status-related factors in relation to the +individual or a dependent of the individual: + ``(1) Health status. + ``(2) Medical condition (including both physical and mental + illnesses). + ``(3) Claims experience. + ``(4) Receipt of health care. + ``(5) Medical history. + ``(6) Genetic information. + ``(7) Evidence of insurability (including conditions arising + out of acts of domestic violence). + ``(8) Disability. + ``(9) Any other health status-related factor determined + appropriate by the Secretary. + + ``(j) Programs of Health Promotion or Disease Prevention.-- + ``(1) General provisions.-- + ``(A) General rule.--For purposes of subsection + (b)(2)(B), a program of health promotion or disease + prevention (referred to in this subsection as a + `wellness program') shall be a program offered by an + employer that is designed + +[[Page 124 STAT. 157]] + + to promote health or prevent disease that meets the + applicable requirements of this subsection. + ``(B) No conditions based on health status factor.-- + If none of the conditions for obtaining a premium + discount or rebate or other reward for participation in + a wellness program is based on an individual satisfying + a standard that is related to a health status factor, + such wellness program shall not violate this section if + participation in the program is made available to all + similarly situated individuals and the requirements of + paragraph (2) are complied with. + ``(C) Conditions based on health status factor.--If + any of the conditions for obtaining a premium discount + or rebate or other reward for participation in a + wellness program is based on an individual satisfying a + standard that is related to a health status factor, such + wellness program shall not violate this section if the + requirements of paragraph (3) are complied with. + ``(2) Wellness programs not subject to requirements.--If + none of the conditions for obtaining a premium discount or + rebate or other reward under a wellness program as described in + paragraph (1)(B) are based on an individual satisfying a + standard that is related to a health status factor (or if such a + wellness program does not provide such a reward), the wellness + program shall not violate this section if participation in the + program is made available to all similarly situated individuals. + The following programs shall not have to comply with the + requirements of paragraph (3) if participation in the program is + made available to all similarly situated individuals: + ``(A) A program that reimburses all or part of the + cost for memberships in a fitness center. + ``(B) A diagnostic testing program that provides a + reward for participation and does not base any part of + the reward on outcomes. + ``(C) A program that encourages preventive care + related to a health condition through the waiver of the + copayment or deductible requirement under group health + plan for the costs of certain items or services related + to a health condition (such as prenatal care or well- + baby visits). + ``(D) A program that reimburses individuals for the + costs of smoking cessation programs without regard to + whether the individual quits smoking. + ``(E) A program that provides a reward to + individuals for attending a periodic health education + seminar. + ``(3) Wellness programs subject to requirements.--If any of + the conditions for obtaining a premium discount, rebate, or + reward under a wellness program as described in paragraph (1)(C) + is based on an individual satisfying a standard that is related + to a health status factor, the wellness program shall not + violate this section if the following requirements are complied + with: + ``(A) The reward for the wellness program, together + with the reward for other wellness programs with respect + to the plan that requires satisfaction of a standard + related to a health status factor, shall not exceed 30 + percent of the cost of employee-only coverage under the + plan. If, in + +[[Page 124 STAT. 158]] + + addition to employees or individuals, any class of + dependents (such as spouses or spouses and dependent + children) may participate fully in the wellness program, + such reward shall not exceed 30 percent of the cost of + the coverage in which an employee or individual and any + dependents are enrolled. For purposes of this paragraph, + the cost of coverage shall be determined based on the + total amount of employer and employee contributions for + the benefit package under which the employee is (or the + employee and any dependents are) receiving coverage. A + reward may be in the form of a discount or rebate of a + premium or contribution, a waiver of all or part of a + cost-sharing mechanism (such as deductibles, copayments, + or coinsurance), the absence of a surcharge, or the + value of a benefit that would otherwise not be provided + under the plan. The Secretaries of Labor, Health and + Human Services, and the Treasury may increase the reward + available under this subparagraph to up to 50 percent of + the cost of coverage if the Secretaries determine that + such an increase is appropriate. + ``(B) The wellness program shall be reasonably + designed to promote health or prevent disease. A program + complies with the preceding sentence if the program has + a reasonable chance of improving the health of, or + preventing disease in, participating individuals and it + is not overly burdensome, is not a subterfuge for + discriminating based on a health status factor, and is + not highly suspect in the method chosen to promote + health or prevent disease. + ``(C) The plan shall give individuals eligible for + the program the opportunity to qualify for the reward + under the program at least once each year. + ``(D) The full reward under the wellness program + shall be made available to all similarly situated + individuals. For such purpose, among other things: + ``(i) The reward is not available to all + similarly situated individuals for a period unless + the wellness program allows-- + ``(I) for a reasonable alternative + standard (or waiver of the otherwise + applicable standard) for obtaining the + reward for any individual for whom, for + that period, it is unreasonably + difficult due to a medical condition to + satisfy the otherwise applicable + standard; and + ``(II) for a reasonable alternative + standard (or waiver of the otherwise + applicable standard) for obtaining the + reward for any individual for whom, for + that period, it is medically inadvisable + to attempt to satisfy the otherwise + applicable standard. + ``(ii) If reasonable under the circumstances, + the plan or issuer may seek verification, such as + a statement from an individual's physician, that a + health status factor makes it unreasonably + difficult or medically inadvisable for the + individual to satisfy or attempt to satisfy the + otherwise applicable standard. + +[[Page 124 STAT. 159]] + + ``(E) The plan or issuer involved shall disclose in + all plan materials describing the terms of the wellness + program the availability of a reasonable alternative + standard (or the possibility of waiver of the otherwise + applicable standard) required under subparagraph (D). If + plan materials disclose that such a program is + available, without describing its terms, the disclosure + under this subparagraph shall not be required. + + ``(k) Existing Programs.--Nothing in this section shall prohibit a +program of health promotion or disease prevention that was established +prior to the date of enactment of this section and applied with all +applicable regulations, and that is operating on such date, from +continuing to be carried out for as long as such regulations remain in +effect. + ``(l) Wellness Program Demonstration Project.-- + ``(1) In general.--Not <<NOTE: Deadline.>> later than July + 1, 2014, the Secretary, in consultation with the Secretary of + the Treasury and the Secretary of Labor, shall establish a 10- + State demonstration project under which participating States + shall apply the provisions of subsection (j) to programs of + health promotion offered by a health insurance issuer that + offers health insurance coverage in the individual market in + such State. + ``(2) Expansion of demonstration <<NOTE: Expansion + date.>> project.--If the Secretary, in consultation with the + Secretary of the Treasury and the Secretary of Labor, determines + that the demonstration project described in paragraph (1) is + effective, such Secretaries may, beginning on July 1, 2017 + expand such demonstration project to include additional + participating States. + ``(3) Requirements.-- + ``(A) Maintenance of coverage.--The Secretary, in + consultation with the Secretary of the Treasury and the + Secretary of Labor, shall not approve the participation + of a State in the demonstration project under this + section unless the Secretaries determine that the + State's project is designed in a manner that-- + ``(i) will not result in any decrease in + coverage; and + ``(ii) will not increase the cost to the + Federal Government in providing credits under + section 36B of the Internal Revenue Code of 1986 + or cost-sharing assistance under section 1402 of + the Patient Protection and Affordable Care Act. + ``(B) Other requirements.--States that participate + in the demonstration project under this subsection-- + ``(i) may permit premium discounts or rebates + or the modification of otherwise applicable + copayments or deductibles for adherence to, or + participation in, a reasonably designed program of + health promotion and disease prevention; + ``(ii) shall ensure that requirements of + consumer protection are met in programs of health + promotion in the individual market; + ``(iii) shall require verification from health + insurance issuers that offer health insurance + coverage in the individual market of such State + that premium discounts-- + +[[Page 124 STAT. 160]] + + ``(I) do not create undue burdens + for individuals insured in the + individual market; + ``(II) do not lead to cost shifting; + and + ``(III) are not a subterfuge for + discrimination; + ``(iv) shall ensure that consumer data is + protected in accordance with the requirements of + section 264(c) of the Health Insurance Portability + and Accountability Act of 1996 (42 U.S.C. 1320d-2 + note); and + ``(v) shall ensure and demonstrate to the + satisfaction of the Secretary that the discounts + or other rewards provided under the project + reflect the expected level of participation in the + wellness program involved and the anticipated + effect the program will have on utilization or + medical claim costs. + + ``(m) Report.-- + ``(1) In general.--Not later than 3 years after the date of + enactment of the Patient Protection and Affordable Care Act, the + Secretary, in consultation with the Secretary of the Treasury + and the Secretary of Labor, shall submit a report to the + appropriate committees of Congress concerning-- + ``(A) the effectiveness of wellness programs (as + defined in subsection (j)) in promoting health and + preventing disease; + ``(B) the impact of such wellness programs on the + access to care and affordability of coverage for + participants and non-participants of such programs; + ``(C) the impact of premium-based and cost-sharing + incentives on participant behavior and the role of such + programs in changing behavior; and + ``(D) the effectiveness of different types of + rewards. + ``(2) Data collection.--In preparing the report described in + paragraph (1), the Secretaries shall gather relevant information + from employers who provide employees with access to wellness + programs, including State and Federal agencies. + + ``(n) Regulations.--Nothing in this section shall be construed as +prohibiting the Secretaries of Labor, Health and Human Services, or the +Treasury from promulgating regulations in connection with this section. + +``SEC. 2706. NON-DISCRIMINATION <<NOTE: 42 USC 300gg-5.>> IN HEALTH + CARE. + + ``(a) Providers.--A group health plan and a health insurance issuer +offering group or individual health insurance coverage shall not +discriminate with respect to participation under the plan or coverage +against any health care provider who is acting within the scope of that +provider's license or certification under applicable State law. This +section shall not require that a group health plan or health insurance +issuer contract with any health care provider willing to abide by the +terms and conditions for participation established by the plan or +issuer. Nothing in this section shall be construed as preventing a group +health plan, a health insurance issuer, or the Secretary from +establishing varying reimbursement rates based on quality or performance +measures. + ``(b) Individuals.--The <<NOTE: Applicability.>> provisions of +section 1558 of the Patient Protection and Affordable Care Act (relating +to non-discrimination) shall apply with respect to a group health plan +or health insurance issuer offering group or individual health insurance +coverage. + +[[Page 124 STAT. 161]] + +``SEC. 2707. COMPREHENSIVE <<NOTE: 42 USC 300gg-6.>> HEALTH INSURANCE + COVERAGE. + + ``(a) Coverage for Essential Health Benefits Package.--A health +insurance issuer that offers health insurance coverage in the individual +or small group market shall ensure that such coverage includes the +essential health benefits package required under section 1302(a) of the +Patient Protection and Affordable Care Act. + ``(b) Cost-sharing Under Group Health Plans.--A group health plan +shall ensure that any annual cost-sharing imposed under the plan does +not exceed the limitations provided for under paragraphs (1) and (2) of +section 1302(c). + ``(c) Child-only Plans.--If a health insurance issuer offers health +insurance coverage in any level of coverage specified under section +1302(d) of the Patient Protection and Affordable Care Act, the issuer +shall also offer such coverage in that level as a plan in which the only +enrollees are individuals who, as of the beginning of a plan year, have +not attained the age of 21. + ``(d) Dental Only.--This section shall not apply to a plan described +in section 1302(d)(2)(B)(ii)(I). + +``SEC. 2708. PROHIBITION <<NOTE: 42 USC 300gg-7.>> ON EXCESSIVE WAITING + PERIODS. + + ``A group health plan and a health insurance issuer offering group +or individual health insurance coverage shall not apply any waiting +period (as defined in section 2704(b)(4)) that exceeds 90 days.''. + + PART II--OTHER PROVISIONS + +SEC. 1251. PRESERVATION <<NOTE: 42 USC 18011.>> OF RIGHT TO MAINTAIN + EXISTING COVERAGE. + + (a) No Changes to Existing Coverage.-- + (1) In general.--Nothing in this Act (or an amendment made + by this Act) shall be construed to require that an individual + terminate coverage under a group health plan or health insurance + coverage in which such individual was enrolled on the date of + enactment of this Act. + (2) Continuation of coverage.--With respect to a group + health plan or health insurance coverage in which an individual + was enrolled on the date of enactment of this Act, this subtitle + and subtitle A (and the amendments made by such subtitles) shall + not apply to such plan or coverage, regardless of whether the + individual renews such coverage after such date of enactment. + + (b) Allowance for Family Members To Join Current Coverage.--With +respect to a group health plan or health insurance coverage in which an +individual was enrolled on the date of enactment of this Act and which +is renewed after such date, family members of such individual shall be +permitted to enroll in such plan or coverage if such enrollment is +permitted under the terms of the plan in effect as of such date of +enactment. + (c) Allowance for New Employees To Join Current Plan.--A group +health plan that provides coverage on the date of enactment of this Act +may provide for the enrolling of new employees (and their families) in +such plan, and this subtitle and subtitle A (and the amendments made by +such subtitles) shall not apply with respect to such plan and such new +employees (and their families). + +[[Page 124 STAT. 162]] + + (d) Effect on Collective Bargaining Agreements.--In the case of +health insurance coverage maintained pursuant to one or more collective +bargaining agreements between employee representatives and one or more +employers that was ratified before the date of enactment of this Act, +the provisions of this subtitle and subtitle A (and the amendments made +by such subtitles) shall not apply until the date on which the last of +the collective bargaining agreements relating to the coverage +terminates. Any coverage amendment made pursuant to a collective +bargaining agreement relating to the coverage which amends the coverage +solely to conform to any requirement added by this subtitle or subtitle +A (or amendments) shall not be treated as a termination of such +collective bargaining agreement. + (e) Definition.--In this title, the term ``grandfathered health +plan'' means any group health plan or health insurance coverage to which +this section applies. + +SEC. 1252. RATING REFORMS <<NOTE: 42 USC 18012.>> MUST APPLY UNIFORMLY + TO ALL HEALTH INSURANCE ISSUERS AND GROUP HEALTH PLANS. + + Any standard or requirement adopted by a State pursuant to this +title, or any amendment made by this title, shall be applied uniformly +to all health plans in each insurance market to which the standard and +requirements apply. The preceding sentence shall also apply to a State +standard or requirement relating to the standard or requirement required +by this title (or any such amendment) that is not the same as the +standard or requirement but that is not preempted under section 1321(d). + +SEC. 1253. <<NOTE: 42 USC 300gg note.>> EFFECTIVE DATES. + + This subtitle (and the amendments made by this subtitle) shall +become effective for plan years beginning on or after January 1, 2014. + + Subtitle D--Available Coverage Choices for All Americans + + PART I--ESTABLISHMENT OF QUALIFIED HEALTH PLANS + +SEC. 1301. QUALIFIED <<NOTE: 42 USC 18021.>> HEALTH PLAN DEFINED. + + (a) Qualified Health Plan.--In this title: + (1) In general.--The term ``qualified health plan'' means a + health plan that-- + (A) has in effect a certification (which may include + a seal or other indication of approval) that such plan + meets the criteria for certification described in + section 1311(c) issued or recognized by each Exchange + through which such plan is offered; + (B) provides the essential health benefits package + described in section 1302(a); and + (C) is offered by a health insurance issuer that-- + (i) is licensed and in good standing to offer + health insurance coverage in each State in which + such issuer offers health insurance coverage under + this title; + +[[Page 124 STAT. 163]] + + (ii) agrees to offer at least one qualified + health plan in the silver level and at least one + plan in the gold level in each such Exchange; + (iii) agrees to charge the same premium rate + for each qualified health plan of the issuer + without regard to whether the plan is offered + through an Exchange or whether the plan is offered + directly from the issuer or through an agent; and + (iv) complies with the regulations developed + by the Secretary under section 1311(d) and such + other requirements as an applicable Exchange may + establish. + (2) Inclusion of co-op plans and community health insurance + option.--Any reference in this title to a qualified health plan + shall be deemed to include a qualified health plan offered + through the CO-OP program under section 1322 or a community + health insurance option under section 1323, unless specifically + provided for otherwise. + + (b) Terms Relating to Health Plans.--In this title: + (1) Health plan.-- + (A) In general.--The term ``health plan'' means + health insurance coverage and a group health plan. + (B) Exception for self-insured plans and mewas.-- + Except to the extent specifically provided by this + title, the term ``health plan'' shall not include a + group health plan or multiple employer welfare + arrangement to the extent the plan or arrangement is not + subject to State insurance regulation under section 514 + of the Employee Retirement Income Security Act of 1974. + (2) Health insurance coverage and issuer.--The terms + ``health insurance coverage'' and ``health insurance issuer'' + have the meanings given such terms by section 2791(b) of the + Public Health Service Act. + (3) Group health plan.--The term ``group health plan'' has + the meaning given such term by section 2791(a) of the Public + Health Service Act. + +SEC. 1302. ESSENTIAL <<NOTE: 42 USC 18022.>> HEALTH BENEFITS + REQUIREMENTS. + + (a) Essential Health Benefits Package.--In this title, the term +``essential health benefits package'' means, with respect to any health +plan, coverage that-- + (1) provides for the essential health benefits defined by + the Secretary under subsection (b); + (2) limits cost-sharing for such coverage in accordance with + subsection (c); and + (3) subject to subsection (e), provides either the bronze, + silver, gold, or platinum level of coverage described in + subsection (d). + + (b) Essential Health Benefits.-- + (1) In general.--Subject to paragraph (2), the Secretary + shall define the essential health benefits, except that such + benefits shall include at least the following general categories + and the items and services covered within the categories: + (A) Ambulatory patient services. + (B) Emergency services. + (C) Hospitalization. + (D) Maternity and newborn care. + +[[Page 124 STAT. 164]] + + (E) Mental health and substance use disorder + services, including behavioral health treatment. + (F) Prescription drugs. + (G) Rehabilitative and habilitative services and + devices. + (H) Laboratory services. + (I) Preventive and wellness services and chronic + disease management. + (J) Pediatric services, including oral and vision + care. + (2) Limitation.-- + (A) In general.-- + The <<NOTE: Determination.>> Secretary shall ensure that + the scope of the essential health benefits under + paragraph (1) is equal to the scope of benefits provided + under a typical employer plan, as determined by the + Secretary. To <<NOTE: Survey. Reports.>> inform this + determination, the Secretary of Labor shall conduct a + survey of employer-sponsored coverage to determine the + benefits typically covered by employers, including + multiemployer plans, and provide a report on such survey + to the Secretary. + (B) Certification.--In <<NOTE: Reports.>> defining + the essential health benefits described in paragraph + (1), and in revising the benefits under paragraph + (4)(H), the Secretary shall submit a report to the + appropriate committees of Congress containing a + certification from the Chief Actuary of the Centers for + Medicare & Medicaid Services that such essential health + benefits meet the limitation described in paragraph (2). + (3) Notice and hearing.--In defining the essential health + benefits described in paragraph (1), and in revising the + benefits under paragraph (4)(H), the Secretary shall provide + notice and an opportunity for public comment. + (4) Required elements for consideration.--In defining the + essential health benefits under paragraph (1), the Secretary + shall-- + (A) ensure that such essential health benefits + reflect an appropriate balance among the categories + described in such subsection, so that benefits are not + unduly weighted toward any category; + (B) not make coverage decisions, determine + reimbursement rates, establish incentive programs, or + design benefits in ways that discriminate against + individuals because of their age, disability, or + expected length of life; + (C) take into account the health care needs of + diverse segments of the population, including women, + children, persons with disabilities, and other groups; + (D) ensure that health benefits established as + essential not be subject to denial to individuals + against their wishes on the basis of the individuals' + age or expected length of life or of the individuals' + present or predicted disability, degree of medical + dependency, or quality of life; + (E) provide that a qualified health plan shall not + be treated as providing coverage for the essential + health benefits described in paragraph (1) unless the + plan provides that-- + (i) coverage for emergency department services + will be provided without imposing any requirement + under the plan for prior authorization of services + or any limitation on coverage where the provider + of services does not have a contractual + relationship with the plan + +[[Page 124 STAT. 165]] + + for the providing of services that is more + restrictive than the requirements or limitations + that apply to emergency department services + received from providers who do have such a + contractual relationship with the plan; and + (ii) if such services are provided out-of- + network, the cost-sharing requirement (expressed + as a copayment amount or coinsurance rate) is the + same requirement that would apply if such services + were provided in-network; + (F) provide that if a plan described in section + 1311(b)(2)(B)(ii) (relating to stand-alone dental + benefits plans) is offered through an Exchange, another + health plan offered through such Exchange shall not fail + to be treated as a qualified health plan solely because + the plan does not offer coverage of benefits offered + through the stand-alone plan that are otherwise required + under paragraph (1)(J); and + (G) periodically review the essential health + benefits under paragraph (1), and provide a report to + Congress and the public that contains-- + (i) an assessment of whether enrollees are + facing any difficulty accessing needed services + for reasons of coverage or cost; + (ii) an assessment of whether the essential + health benefits needs to be modified or updated to + account for changes in medical evidence or + scientific advancement; + (iii) information on how the essential health + benefits will be modified to address any such gaps + in access or changes in the evidence base; + (iv) an assessment of the potential of + additional or expanded benefits to increase costs + and the interactions between the addition or + expansion of benefits and reductions in existing + benefits to meet actuarial limitations described + in paragraph (2); and + (H) periodically update the essential health + benefits under paragraph (1) to address any gaps in + access to coverage or changes in the evidence base the + Secretary identifies in the review conducted under + subparagraph (G). + (5) Rule of construction.--Nothing in this title shall be + construed to prohibit a health plan from providing benefits in + excess of the essential health benefits described in this + subsection. + + (c) Requirements Relating to Cost-Sharing.-- + (1) Annual limitation on cost-sharing.-- + (A) 2014.--The cost-sharing incurred under a health + plan with respect to self-only coverage or coverage + other than self-only coverage for a plan year beginning + in 2014 shall not exceed the dollar amounts in effect + under section 223(c)(2)(A)(ii) of the Internal Revenue + Code of 1986 for self-only and family coverage, + respectively, for taxable years beginning in 2014. + (B) 2015 and later.--In the case of any plan year + beginning in a calendar year after 2014, the limitation + under this paragraph shall-- + +[[Page 124 STAT. 166]] + + (i) in the case of self-only coverage, be + equal to the dollar amount under subparagraph (A) + for self-only coverage for plan years beginning in + 2014, increased by an amount equal to the product + of that amount and the premium adjustment + percentage under paragraph (4) for the calendar + year; and + (ii) in the case of other coverage, twice the + amount in effect under clause (i). + If the amount of any increase under clause (i) is not a + multiple of $50, such increase shall be rounded to the + next lowest multiple of $50. + (2) Annual limitation on deductibles for employer-sponsored + plans.-- + (A) In general.--In the case of a health plan + offered in the small group market, the deductible under + the plan shall not exceed-- + (i) $2,000 in the case of a plan covering a + single individual; and + (ii) $4,000 in the case of any other plan. + The amounts under clauses (i) and (ii) may be increased + by the maximum amount of reimbursement which is + reasonably available to a participant under a flexible + spending arrangement described in section 106(c)(2) of + the Internal Revenue Code of 1986 (determined without + regard to any salary reduction arrangement). + (B) Indexing of limits.--In the case of any plan + year beginning in a calendar year after 2014-- + (i) the dollar amount under subparagraph + (A)(i) shall be increased by an amount equal to + the product of that amount and the premium + adjustment percentage under paragraph (4) for the + calendar year; and + (ii) the dollar amount under subparagraph + (A)(ii) shall be increased to an amount equal to + twice the amount in effect under subparagraph + (A)(i) for plan years beginning in the calendar + year, determined after application of clause (i). + If the amount of any increase under clause (i) is not a + multiple of $50, such increase shall be rounded to the + next lowest multiple of $50. + (C) Actuarial value.--The limitation under this + paragraph shall be applied in such a manner so as to not + affect the actuarial value of any health plan, including + a plan in the bronze level. + (D) Coordination with preventive limits.--Nothing in + this paragraph shall be construed to allow a plan to + have a deductible under the plan apply to benefits + described in section 2713 of the Public Health Service + Act. + (3) Cost-sharing.--In this title-- + (A) In general.--The term ``cost-sharing'' + includes-- + (i) deductibles, coinsurance, copayments, or + similar charges; and + (ii) any other expenditure required of an + insured individual which is a qualified medical + expense (within the meaning of section 223(d)(2) + of the Internal Revenue Code of 1986) with respect + to essential health benefits covered under the + plan. + +[[Page 124 STAT. 167]] + + (B) Exceptions.--Such term does not include + premiums, balance billing amounts for non-network + providers, or spending for non-covered services. + (4) Premium <<NOTE: Determination. Deadline.>> adjustment + percentage.--For purposes of paragraphs (1)(B)(i) and (2)(B)(i), + the premium adjustment percentage for any calendar year is the + percentage (if any) by which the average per capita premium for + health insurance coverage in the United States for the preceding + calendar year (as estimated by the Secretary no later than + October 1 of such preceding calendar year) exceeds such average + per capita premium for 2013 (as determined by the Secretary). + + (d) Levels of Coverage.-- + (1) Levels of coverage defined.--The levels of coverage + described in this subsection are as follows: + (A) Bronze level.--A plan in the bronze level shall + provide a level of coverage that is designed to provide + benefits that are actuarially equivalent to 60 percent + of the full actuarial value of the benefits provided + under the plan. + (B) Silver level.--A plan in the silver level shall + provide a level of coverage that is designed to provide + benefits that are actuarially equivalent to 70 percent + of the full actuarial value of the benefits provided + under the plan. + (C) Gold level.--A plan in the gold level shall + provide a level of coverage that is designed to provide + benefits that are actuarially equivalent to 80 percent + of the full actuarial value of the benefits provided + under the plan. + (D) Platinum level.--A plan in the platinum level + shall provide a level of coverage that is designed to + provide benefits that are actuarially equivalent to 90 + percent of the full actuarial value of the benefits + provided under the plan. + (2) Actuarial value.-- + (A) In general.--Under regulations issued by the + Secretary, the level of coverage of a plan shall be + determined on the basis that the essential health + benefits described in subsection (b) shall be provided + to a standard population (and without regard to the + population the plan may actually provide benefits to). + (B) Employer contributions.--The Secretary may issue + regulations under which employer contributions to a + health savings account (within the meaning of section + 223 of the Internal Revenue Code of 1986) may be taken + into account in determining the level of coverage for a + plan of the employer. + (C) Application.--In determining under this title, + the Public Health Service Act, or the Internal Revenue + Code of 1986 the percentage of the total allowed costs + of benefits provided under a group health plan or health + insurance coverage that are provided by such plan or + coverage, the rules contained in the regulations under + this paragraph shall apply. + (3) Allowable variance.-- <<NOTE: Guidelines.>> The + Secretary shall develop guidelines to provide for a de minimis + variation in the actuarial valuations used in determining the + level of coverage of a plan to account for differences in + actuarial estimates. + +[[Page 124 STAT. 168]] + + (4) Plan reference.--In this title, any reference to a + bronze, silver, gold, or platinum plan shall be treated as a + reference to a qualified health plan providing a bronze, silver, + gold, or platinum level of coverage, as the case may be. + + (e) Catastrophic Plan.-- + (1) In general.--A health plan not providing a bronze, + silver, gold, or platinum level of coverage shall be treated as + meeting the requirements of subsection (d) with respect to any + plan year if-- + (A) the only individuals who are eligible to enroll + in the plan are individuals described in paragraph (2); + and + (B) the plan provides-- + (i) except as provided in clause (ii), the + essential health benefits determined under + subsection (b), except that the plan provides no + benefits for any plan year until the individual + has incurred cost-sharing expenses in an amount + equal to the annual limitation in effect under + subsection (c)(1) for the plan year (except as + provided for in section 2713); and + (ii) coverage for at least three primary care + visits. + (2) Individuals eligible for enrollment.--An individual is + described in this paragraph for any plan year if the + individual-- + (A) has not attained the age of 30 before the + beginning of the plan year; or + (B) has a certification in effect for any plan year + under this title that the individual is exempt from the + requirement under section 5000A of the Internal Revenue + Code of 1986 by reason of-- + (i) section 5000A(e)(1) of such Code (relating + to individuals without affordable coverage); or + (ii) section 5000A(e)(5) of such Code + (relating to individuals with hardships). + (3) Restriction to individual market.--If a health insurance + issuer offers a health plan described in this subsection, the + issuer may only offer the plan in the individual market. + + (f) Child-only Plans.--If a qualified health plan is offered through +the Exchange in any level of coverage specified under subsection (d), +the issuer shall also offer that plan through the Exchange in that level +as a plan in which the only enrollees are individuals who, as of the +beginning of a plan year, have not attained the age of 21, and such plan +shall be treated as a qualified health plan. + +SEC. 1303. <<NOTE: 42 USC 18023.>> SPECIAL RULES. + + (a) Special Rules Relating to Coverage of Abortion Services.-- + (1) Voluntary choice of coverage of abortion services.-- + (A) In general.--Notwithstanding any other provision + of this title (or any amendment made by this title), and + subject to subparagraphs (C) and (D)-- + (i) nothing in this title (or any amendment + made by this title), shall be construed to require + a qualified health plan to provide coverage of + services described in subparagraph (B)(i) or + (B)(ii) as part of its essential health benefits + for any plan year; and + +[[Page 124 STAT. 169]] + + (ii) <<NOTE: Determination.>> the issuer of a + qualified health plan shall determine whether or + not the plan provides coverage of services + described in subparagraph (B)(i) or (B)(ii) as + part of such benefits for the plan year. + (B) Abortion services.-- + (i) Abortions for which public funding is + prohibited.--The services described in this clause + are abortions for which the expenditure of Federal + funds appropriated for the Department of Health + and Human Services is not permitted, based on the + law as in effect as of the date that is 6 months + before the beginning of the plan year involved. + (ii) Abortions for which public funding is + allowed.--The services described in this clause + are abortions for which the expenditure of Federal + funds appropriated for the Department of Health + and Human Services is permitted, based on the law + as in effect as of the date that is 6 months + before the beginning of the plan year involved. + (C) Prohibition on federal funds for abortion + services in community health insurance option.-- + (i) Determination by secretary.--The Secretary + may not determine, in accordance with subparagraph + (A)(ii), that the community health insurance + option established under section 1323 shall + provide coverage of services described in + subparagraph (B)(i) as part of benefits for the + plan year unless the Secretary-- + (I) assures compliance with the + requirements of paragraph (2); + (II) assures, in accordance with + applicable provisions of generally + accepted accounting requirements, + circulars on funds management of the + Office of Management and Budget, and + guidance on accounting of the Government + Accountability Office, that no Federal + funds are used for such coverage; and + (III) notwithstanding section + 1323(e)(1)(C) or any other provision of + this title, takes all necessary steps to + assure that the United States does not + bear the insurance risk for a community + health insurance option's coverage of + services described in subparagraph + (B)(i). + (ii) State requirement.--If a State requires, + in addition to the essential health benefits + required under section 1323(b)(3) (A), coverage of + services described in subparagraph (B)(i) for + enrollees of a community health insurance option + offered in such State, the State shall assure that + no funds flowing through or from the community + health insurance option, and no other Federal + funds, pay or defray the cost of providing + coverage of services described in subparagraph + (B)(i). The United States shall not bear the + insurance risk for a State's required coverage of + services described in subparagraph (B)(i). + (iii) Exceptions.--Nothing in this + subparagraph shall apply to coverage of services + described in subparagraph (B)(ii) by the community + health insurance + +[[Page 124 STAT. 170]] + + option. Services described in subparagraph (B)(ii) + shall be covered to the same extent as such + services are covered under title XIX of the Social + Security Act. + (D) Assured availability of varied coverage through + exchanges.-- + (i) In general.--The Secretary shall assure + that with respect to qualified health plans + offered in any Exchange established pursuant to + this title-- + (I) there is at least one such plan + that provides coverage of services + described in clauses (i) and (ii) of + subparagraph (B); and + (II) there is at least one such plan + that does not provide coverage of + services described in subparagraph + (B)(i). + (ii) Special rules.--For purposes of clause + (i)-- + (I) a plan shall be treated as + described in clause (i)(II) if the plan + does not provide coverage of services + described in either subparagraph (B)(i) + or (B)(ii); and + (II) if a State has one Exchange + covering more than 1 insurance market, + the Secretary shall meet the + requirements of clause (i) separately + with respect to each such market. + (2) Prohibition on the use of federal funds.-- + (A) In general.--If a qualified health plan provides + coverage of services described in paragraph (1)(B)(i), + the issuer of the plan shall not use any amount + attributable to any of the following for purposes of + paying for such services: + (i) The credit under section 36B of the + Internal Revenue Code of 1986 (and the amount (if + any) of the advance payment of the credit under + section 1412 of the Patient Protection and + Affordable Care Act). + (ii) Any cost-sharing reduction under section + 1402 of thePatient Protection and Affordable Care + Act (and the amount (if any) of the advance + payment of the reduction under section 1412 of the + Patient Protection and Affordable Care Act). + (B) Segregation of funds.--In the case of a plan to + which subparagraph (A) applies, the issuer of the plan + shall, out of amounts not described in subparagraph (A), + segregate an amount equal to the actuarial amounts + determined under subparagraph (C) for all enrollees from + the amounts described in subparagraph (A). + (C) <<NOTE: Cost estimate.>> Actuarial value of + optional service coverage.-- + (i) In general.--The Secretary shall estimate + the basic per enrollee, per month cost, determined + on an average actuarial basis, for including + coverage under a qualified health plan of the + services described in paragraph (1)(B)(i). + (ii) Considerations.--In making such estimate, + the Secretary-- + (I) may take into account the impact + on overall costs of the inclusion of + such coverage, but may not take into + account any cost reduction estimated + +[[Page 124 STAT. 171]] + + to result from such services, including + prenatal care, delivery, or postnatal + care; + (II) shall estimate such costs as if + such coverage were included for the + entire population covered; and + (III) may not estimate such a cost + at less than $1 per enrollee, per month. + (3) Provider conscience protections.-- + <<NOTE: Abortions.>> No individual health care provider or + health care facility may be discriminated against because of a + willingness or an unwillingness, if doing so is contrary to the + religious or moral beliefs of the provider or facility, to + provide, pay for, provide coverage of, or refer for abortions. + + (b) Application of State and Federal Laws Regarding Abortion.-- + (1) No preemption of state laws regarding abortion.--Nothing + in this Act shall be construed to preempt or otherwise have any + effect on State laws regarding the prohibition of (or + requirement of) coverage, funding, or procedural requirements on + abortions, including parental notification or consent for the + performance of an abortion on a minor. + (2) No effect on federal laws regarding abortion.-- + (A) In general.--Nothing in this Act shall be + construed to have any effect on Federal laws regarding-- + (i) conscience protection; + (ii) willingness or refusal to provide + abortion; and + (iii) discrimination on the basis of the + willingness or refusal to provide, pay for, cover, + or refer for abortion or to provide or participate + in training to provide abortion. + (3) No effect on federal civil rights law.--Nothing in this + subsection shall alter the rights and obligations of employees + and employers under title VII of the Civil Rights Act of 1964. + + (c) Application of Emergency Services Laws.--Nothing in this Act +shall be construed to relieve any health care provider from providing +emergency services as required by State or Federal law, including +section 1867 of the Social Security Act (popularly known as ``EMTALA''). + +SEC. 1304. <<NOTE: 42 USC 18024.>> RELATED DEFINITIONS. + + (a) Definitions Relating to Markets.--In this title: + (1) Group market.--The term ``group market'' means the + health insurance market under which individuals obtain health + insurance coverage (directly or through any arrangement) on + behalf of themselves (and their dependents) through a group + health plan maintained by an employer. + (2) Individual market.--The term ``individual market'' means + the market for health insurance coverage offered to individuals + other than in connection with a group health plan. + (3) Large and small group markets.--The terms ``large group + market'' and ``small group market'' mean the health insurance + market under which individuals obtain health insurance coverage + (directly or through any arrangement) on behalf of themselves + (and their dependents) through a group health plan maintained by + a large employer (as defined in subsection + +[[Page 124 STAT. 172]] + + (b)(1)) or by a small employer (as defined in subsection + (b)(2)), respectively. + + (b) Employers.--In this title: + (1) Large employer.--The term ``large employer'' means, in + connection with a group health plan with respect to a calendar + year and a plan year, an employer who employed an average of at + least 101 employees on business days during the preceding + calendar year and who employs at least 1 employee on the first + day of the plan year. + (2) Small employer.--The term ``small employer'' means, in + connection with a group health plan with respect to a calendar + year and a plan year, an employer who employed an average of at + least 1 but not more than 100 employees on business days during + the preceding calendar year and who employs at least 1 employee + on the first day of the plan year. + (3) State option to treat 50 employees as small.--In the + case of plan years beginning before January 1, 2016, a State may + elect to apply this subsection by substituting ``51 employees'' + for ``101 employees'' in paragraph (1) and by substituting ``50 + employees'' for ``100 employees'' in paragraph (2). + (4) Rules for determining employer size.--For purposes of + this subsection-- + (A) Application of aggregation rule for employers.-- + All persons treated as a single employer under + subsection (b), (c), (m), or (o) of section 414 of the + Internal Revenue Code of 1986 shall be treated as 1 + employer. + (B) Employers not in existence in preceding year.-- + In the case of an employer which was not in existence + throughout the preceding calendar year, the + determination of whether such employer is a small or + large employer shall be based on the average number of + employees that it is reasonably expected such employer + will employ on business days in the current calendar + year. + (C) Predecessors.--Any reference in this subsection + to an employer shall include a reference to any + predecessor of such employer. + (D) Continuation of participation for growing small + employers.--If-- + (i) a qualified employer that is a small + employer makes enrollment in qualified health + plans offered in the small group market available + to its employees through an Exchange; and + (ii) the employer ceases to be a small + employer by reason of an increase in the number of + employees of such employer; + <<NOTE: Time period.>> the employer shall continue to be + treated as a small employer for purposes of this + subtitle for the period beginning with the increase and + ending with the first day on which the employer does not + make such enrollment available to its employees. + + (c) Secretary.--In this title, the term ``Secretary'' means the +Secretary of Health and Human Services. + (d) State.--In this title, the term ``State'' means each of the 50 +States and the District of Columbia. + +[[Page 124 STAT. 173]] + + PART II--CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH + BENEFIT EXCHANGES + +SEC. 1311. <<NOTE: 42 USC 18031.>> AFFORDABLE CHOICES OF HEALTH BENEFIT + PLANS. + + (a) Assistance to States to Establish American Health Benefit +Exchanges.-- + (1) Planning and establishment grants.-- + <<NOTE: Deadline.>> There shall be appropriated to the + Secretary, out of any moneys in the Treasury not otherwise + appropriated, an amount necessary to enable the Secretary to + make awards, not later than 1 year after the date of enactment + of this Act, to States in the amount specified in paragraph (2) + for the uses described in paragraph (3). + (2) Amount specified.-- <<NOTE: Determination.>> For each + fiscal year, the Secretary shall determine the total amount that + the Secretary will make available to each State for grants under + this subsection. + (3) Use of funds.--A State shall use amounts awarded under + this subsection for activities (including planning activities) + related to establishing an American Health Benefit Exchange, as + described in subsection (b). + (4) Renewability of grant.-- + (A) In general.--Subject to subsection (d)(4), the + Secretary may renew a grant awarded under paragraph (1) + if the State recipient of such grant-- + (i) is making progress, as determined by the + Secretary, toward-- + (I) establishing an Exchange; and + (II) implementing the reforms + described in subtitles A and C (and the + amendments made by such subtitles); and + (ii) is meeting such other benchmarks as the + Secretary may establish. + (B) Limitation.--No <<NOTE: Deadline.>> grant shall + be awarded under this subsection after January 1, 2015. + (5) Technical assistance to facilitate participation in shop + exchanges.--The Secretary shall provide technical assistance to + States to facilitate the participation of qualified small + businesses in such States in SHOP Exchanges. + + (b) American Health Benefit Exchanges.-- + (1) In general.-- + Each <<NOTE: Establishment. Deadline.>> State shall, not later + than January 1, 2014, establish an American Health Benefit + Exchange (referred to in this title as an ``Exchange'') for the + State that-- + (A) facilitates the purchase of qualified health + plans; + (B) provides for the establishment of a Small + Business Health Options Program (in this title referred + to as a ``SHOP Exchange'') that is designed to assist + qualified employers in the State who are small employers + in facilitating the enrollment of their employees in + qualified health plans offered in the small group market + in the State; and + (C) meets the requirements of subsection (d). + (2) Merger of individual and shop exchanges.--A State may + elect to provide only one Exchange in the State for providing + both Exchange and SHOP Exchange services to both qualified + individuals and qualified small employers, but only + +[[Page 124 STAT. 174]] + + if the Exchange has adequate resources to assist such + individuals and employers. + + (c) Responsibilities of the Secretary.-- + (1) In general.--The <<NOTE: Regulations.>> Secretary shall, + by regulation, establish criteria for the certification of + health plans as qualified health plans. Such criteria shall + require that, to be certified, a plan shall, at a minimum-- + (A) meet marketing requirements, and not employ + marketing practices or benefit designs that have the + effect of discouraging the enrollment in such plan by + individuals with significant health needs; + (B) ensure a sufficient choice of providers (in a + manner consistent with applicable network adequacy + provisions under section 2702(c) of the Public Health + Service Act), and provide information to enrollees and + prospective enrollees on the availability of in-network + and out-of-network providers; + (C) include within health insurance plan networks + those essential community providers, where available, + that serve predominately low-income, medically- + underserved individuals, such as health care providers + defined in section 340B(a)(4) of the Public Health + Service Act and providers described in section + 1927(c)(1)(D)(i)(IV) of the Social Security Act as set + forth by section 221 of Public Law 111-8, except that + nothing in this subparagraph shall be construed to + require any health plan to provide coverage for any + specific medical procedure; + (D)(i) be accredited with respect to local + performance on clinical quality measures such as the + Healthcare Effectiveness Data and Information Set, + patient experience ratings on a standardized Consumer + Assessment of Healthcare Providers and Systems survey, + as well as consumer access, utilization management, + quality assurance, provider credentialing, complaints + and appeals, network adequacy and access, and patient + information programs by any entity recognized by the + Secretary for the accreditation of health insurance + issuers or plans (so long as any such entity has + transparent and rigorous methodological and scoring + criteria); or + (ii) receive such accreditation within a period + established by an Exchange for such accreditation that + is applicable to all qualified health plans; + (E) implement a quality improvement strategy + described in subsection (g)(1); + (F) utilize a uniform enrollment form that qualified + individuals and qualified employers may use (either + electronically or on paper) in enrolling in qualified + health plans offered through such Exchange, and that + takes into account criteria that the National + Association of Insurance Commissioners develops and + submits to the Secretary; + (G) utilize the standard format established for + presenting health benefits plan options; and + (H) provide information to enrollees and prospective + enrollees, and to each Exchange in which the plan is + offered, on any quality measures for health plan + performance endorsed under section 399JJ of the Public + Health Service Act, as applicable. + +[[Page 124 STAT. 175]] + + (2) Rule of construction.-- <<NOTE: Contracts.>> Nothing in + paragraph (1)(C) shall be construed to require a qualified + health plan to contract with a provider described in such + paragraph if such provider refuses to accept the generally + applicable payment rates of such plan. + (3) Rating system.--The Secretary shall develop a rating + system that would rate qualified health plans offered through an + Exchange in each benefits level on the basis of the relative + quality and price. The Exchange shall include the quality rating + in the information provided to individuals and employers through + the Internet portal established under paragraph (4). + (4) Enrollee satisfaction system.--The Secretary shall + develop an enrollee satisfaction survey system that would + evaluate the level of enrollee satisfaction with qualified + health plans offered through an Exchange, for each such + qualified health plan that had more than 500 enrollees in the + previous year. The Exchange shall include enrollee satisfaction + information in the information provided to individuals and + employers through the Internet portal established under + paragraph (5) in a manner that allows individuals to easily + compare enrollee satisfaction levels between comparable plans. + (5) Internet portals.--The Secretary shall-- + (A) continue to operate, maintain, and update the + Internet portal developed under section 1103(a) and to + assist States in developing and maintaining their own + such portal; and + (B) make available for use by Exchanges a model + template for an Internet portal that may be used to + direct qualified individuals and qualified employers to + qualified health plans, to assist such individuals and + employers in determining whether they are eligible to + participate in an Exchange or eligible for a premium tax + credit or cost-sharing reduction, and to present + standardized information (including quality ratings) + regarding qualified health plans offered through an + Exchange to assist consumers in making easy health + insurance choices. + Such template shall include, with respect to each qualified + health plan offered through the Exchange in each rating area, + access to the uniform outline of coverage the plan is required + to provide under section 2716 of the Public Health Service Act + and to a copy of the plan's written policy. + (6) Enrollment periods.--The Secretary shall require an + Exchange to provide for-- + (A) <<NOTE: Determination.>> an initial open + enrollment, as determined by the Secretary (such + determination to be made not later than July 1, 2012); + (B) <<NOTE: Determination.>> annual open enrollment + periods, as determined by the Secretary for calendar + years after the initial enrollment period; + (C) special enrollment periods specified in section + 9801 of the Internal Revenue Code of 1986 and other + special enrollment periods under circumstances similar + to such periods under part D of title XVIII of the + Social Security Act; and + (D) <<NOTE: Native Americans.>> special monthly + enrollment periods for Indians (as defined in section 4 + of the Indian Health Care Improvement Act). + +[[Page 124 STAT. 176]] + + (d) Requirements.-- + (1) In general.--An Exchange shall be a governmental agency + or nonprofit entity that is established by a State. + (2) Offering of coverage.-- + (A) In general.--An Exchange shall make available + qualified health plans to qualified individuals and + qualified employers. + (B) Limitation.-- + (i) In general.--An Exchange may not make + available any health plan that is not a qualified + health plan. + (ii) Offering of stand-alone dental + benefits.--Each Exchange within a State shall + allow an issuer of a plan that only provides + limited scope dental benefits meeting the + requirements of section 9832(c)(2)(A) of the + Internal Revenue Code of 1986 to offer the plan + through the Exchange (either separately or in + conjunction with a qualified health plan) if the + plan provides pediatric dental benefits meeting + the requirements of section 1302(b)(1)(J)). + (3) Rules relating to additional required benefits.-- + (A) In general.--Except as provided in subparagraph + (B), an Exchange may make available a qualified health + plan notwithstanding any provision of law that may + require benefits other than the essential health + benefits specified under section 1302(b). + (B) States may require additional benefits.-- + (i) In general.--Subject to the requirements + of clause (ii), a State may require that a + qualified health plan offered in such State offer + benefits in addition to the essential health + benefits specified under section 1302(b). + (ii) State must assume cost.-- + A <<NOTE: Payments.>> State shall make payments to + or on behalf of an individual eligible for the + premium tax credit under section 36B of the + Internal Revenue Code of 1986 and any cost-sharing + reduction under section 1402 to defray the cost to + the individual of any additional benefits + described in clause (i) which are not eligible for + such credit or reduction under section + 36B(b)(3)(D) of such Code and section 1402(c)(4). + (4) Functions.--An Exchange shall, at a minimum-- + (A) <<NOTE: Procedures.>> implement procedures for + the certification, recertification, and decertification, + consistent with guidelines developed by the Secretary + under subsection (c), of health plans as qualified + health plans; + (B) <<NOTE: Hotline.>> provide for the operation of + a toll-free telephone hotline to respond to requests for + assistance; + (C) <<NOTE: Web site.>> maintain an Internet website + through which enrollees and prospective enrollees of + qualified health plans may obtain standardized + comparative information on such plans; + (D) assign a rating to each qualified health plan + offered through such Exchange in accordance with the + criteria developed by the Secretary under subsection + (c)(3); + (E) utilize a standardized format for presenting + health benefits plan options in the Exchange, including + the use + +[[Page 124 STAT. 177]] + + of the uniform outline of coverage established under + section 2715 of the Public Health Service Act; + (F) in accordance with section 1413, inform + individuals of eligibility requirements for the medicaid + program under title XIX of the Social Security Act, the + CHIP program under title XXI of such Act, or any + applicable State or local public program and if through + screening of the application by the Exchange, the + Exchange determines that such individuals are eligible + for any such program, enroll such individuals in such + program; + (G) establish and make available by electronic means + a calculator to determine the actual cost of coverage + after the application of any premium tax credit under + section 36B of the Internal Revenue Code of 1986 and any + cost-sharing reduction under section 1402; + (H) <<NOTE: Certification.>> subject to section + 1411, grant a certification attesting that, for purposes + of the individual responsibility penalty under section + 5000A of the Internal Revenue Code of 1986, an + individual is exempt from the individual requirement or + from the penalty imposed by such section because-- + (i) there is no affordable qualified health + plan available through the Exchange, or the + individual's employer, covering the individual; or + (ii) the individual meets the requirements for + any other such exemption from the individual + responsibility requirement or penalty; + (I) transfer to the Secretary of the Treasury-- + (i) <<NOTE: Lists.>> a list of the individuals + who are issued a certification under subparagraph + (H), including the name and taxpayer + identification number of each individual; + (ii) the name and taxpayer identification + number of each individual who was an employee of + an employer but who was determined to be eligible + for the premium tax credit under section 36B of + the Internal Revenue Code of 1986 because-- + (I) the employer did not provide + minimum essential coverage; or + (II) the employer provided such + minimum essential coverage but it was + determined under section 36B(c)(2)(C) of + such Code to either be unaffordable to + the employee or not provide the required + minimum actuarial value; and + (iii) the name and taxpayer identification + number of each individual who notifies the + Exchange under section 1411(b)(4) that they have + changed employers and of each individual who + ceases coverage under a qualified health plan + during a plan year (and the effective date of such + cessation); + (J) provide to each employer the name of each + employee of the employer described in subparagraph + (I)(ii) who ceases coverage under a qualified health + plan during a plan year (and the effective date of such + cessation); and + (K) establish the Navigator program described in + subsection (i). + (5) Funding limitations.-- + +[[Page 124 STAT. 178]] + + (A) No federal funds for continued + operations. <<NOTE: Effective date.>> --In establishing + an Exchange under this section, the State shall ensure + that such Exchange is self-sustaining beginning on + January 1, 2015, including allowing the Exchange to + charge assessments or user fees to participating health + insurance issuers, or to otherwise generate funding, to + support its operations. + (B) Prohibiting wasteful use of funds.--In carrying + out activities under this subsection, an Exchange shall + not utilize any funds intended for the administrative + and operational expenses of the Exchange for staff + retreats, promotional giveaways, excessive executive + compensation, or promotion of Federal or State + legislative and regulatory modifications. + (6) Consultation.--An Exchange shall consult with + stakeholders relevant to carrying out the activities under this + section, including-- + (A) health care consumers who are enrollees in + qualified health plans; + (B) individuals and entities with experience in + facilitating enrollment in qualified health plans; + (C) representatives of small businesses and self- + employed individuals; + (D) State Medicaid offices; and + (E) advocates for enrolling hard to reach + populations. + (7) Publication of costs.-- <<NOTE: Web site.>> An Exchange + shall publish the average costs of licensing, regulatory fees, + and any other payments required by the Exchange, and the + administrative costs of such Exchange, on an Internet website to + educate consumers on such costs. Such information shall also + include monies lost to waste, fraud, and abuse. + + (e) Certification.-- + (1) In general.--An Exchange may certify a health plan as a + qualified health plan if-- + (A) such health plan meets the requirements for + certification as promulgated by the Secretary under + subsection (c)(1); and + (B) <<NOTE: Determination.>> the Exchange determines + that making available such health plan through such + Exchange is in the interests of qualified individuals + and qualified employers in the State or States in which + such Exchange operates, except that the Exchange may not + exclude a health plan-- + (i) on the basis that such plan is a fee-for- + service plan; + (ii) through the imposition of premium price + controls; or + (iii) on the basis that the plan provides + treatments necessary to prevent patients' deaths + in circumstances the Exchange determines are + inappropriate or too costly. + (2) Premium considerations.--The Exchange shall require + health plans seeking certification as qualified health plans to + submit a justification for any premium increase prior to + implementation of the increase. <<NOTE: Web site.>> Such plans + shall prominently post such information on their websites. The + Exchange may take this information, and the information and the + recommendations provided to the Exchange by the State under + +[[Page 124 STAT. 179]] + + section 2794(b)(1) of the Public Health Service Act (relating to + patterns or practices of excessive or unjustified premium + increases), into consideration when determining whether to make + such health plan available through the Exchange. The Exchange + shall take into account any excess of premium growth outside the + Exchange as compared to the rate of such growth inside the + Exchange, including information reported by the States. + + (f) Flexibility.-- + (1) Regional or other interstate exchanges.--An Exchange may + operate in more than one State if-- + (A) each State in which such Exchange operates + permits such operation; and + (B) the Secretary approves such regional or + interstate Exchange. + (2) Subsidiary exchanges.--A State may establish one or more + subsidiary Exchanges if-- + (A) each such Exchange serves a geographically + distinct area; and + (B) the area served by each such Exchange is at + least as large as a rating area described in section + 2701(a) of the Public Health Service Act. + (3) Authority to contract.-- + (A) In general.--A State may elect to authorize an + Exchange established by the State under this section to + enter into an agreement with an eligible entity to carry + out 1 or more responsibilities of the Exchange. + (B) Eligible entity. <<NOTE: Definition.>> --In this + paragraph, the term ``eligible entity'' means-- + (i) a person-- + (I) incorporated under, and subject + to the laws of, 1 or more States; + (II) that has demonstrated + experience on a State or regional basis + in the individual and small group health + insurance markets and in benefits + coverage; and + (III) that is not a health insurance + issuer or that is treated under + subsection (a) or (b) of section 52 of + the Internal Revenue Code of 1986 as a + member of the same controlled group of + corporations (or under common control + with) as a health insurance issuer; or + (ii) the State medicaid agency under title XIX + of the Social Security Act. + + (g) Rewarding Quality Through Market-Based Incentives.-- + (1) Strategy described.--A strategy described in this + paragraph is a payment structure that provides increased + reimbursement or other incentives for-- + (A) improving health outcomes through the + implementation of activities that shall include quality + reporting, effective case management, care coordination, + chronic disease management, medication and care + compliance initiatives, including through the use of the + medical home model, for treatment or services under the + plan or coverage; + +[[Page 124 STAT. 180]] + + (B) the implementation of activities to prevent + hospital readmissions through a comprehensive program + for hospital discharge that includes patient-centered + education and counseling, comprehensive discharge + planning, and post discharge reinforcement by an + appropriate health care professional; + (C) the implementation of activities to improve + patient safety and reduce medical errors through the + appropriate use of best clinical practices, evidence + based medicine, and health information technology under + the plan or coverage; and + (D) the implementation of wellness and health + promotion activities. + (2) Guidelines.--The Secretary, in consultation with experts + in health care quality and stakeholders, shall develop + guidelines concerning the matters described in paragraph (1). + (3) Requirements.-- <<NOTE: Reports.>> The guidelines + developed under paragraph (2) shall require the periodic + reporting to the applicable Exchange of the activities that a + qualified health plan has conducted to implement a strategy + described in paragraph (1). + + (h) Quality Improvement.-- + (1) Enhancing patient safety.-- <<NOTE: Effective + date.>> Beginning on January 1, 2015, a qualified health plan + may contract with-- + (A) a hospital with greater than 50 beds only if + such hospital-- + (i) utilizes a patient safety evaluation + system as described in part C of title IX of the + Public Health Service Act; and + (ii) implements a mechanism to ensure that + each patient receives a comprehensive program for + hospital discharge that includes patient-centered + education and counseling, comprehensive discharge + planning, and post discharge reinforcement by an + appropriate health care professional; or + (B) a health care provider only if such provider + implements such mechanisms to improve health care + quality as the Secretary may by regulation require. + (2) Exceptions.--The Secretary may establish reasonable + exceptions to the requirements described in paragraph (1). + (3) Adjustment.--The Secretary may by regulation adjust the + number of beds described in paragraph (1)(A). + + (i) Navigators.-- + (1) <<NOTE: Grants.>> In general.--An Exchange shall + establish a program under which it awards grants to entities + described in paragraph (2) to carry out the duties described in + paragraph (3). + (2) Eligibility.-- + (A) In general.--To be eligible to receive a grant + under paragraph (1), an entity shall demonstrate to the + Exchange involved that the entity has existing + relationships, or could readily establish relationships, + with employers and employees, consumers (including + uninsured and underinsured consumers), or self-employed + individuals likely to be qualified to enroll in a + qualified health plan. + (B) Types.--Entities described in subparagraph (A) + may include trade, industry, and professional + associations, commercial fishing industry organizations, + ranching and farming organizations, community and + consumer-focused + +[[Page 124 STAT. 181]] + + nonprofit groups, chambers of commerce, unions, small + business development centers, other licensed insurance + agents and brokers, and other entities that-- + (i) are capable of carrying out the duties + described in paragraph (3); + (ii) meet the standards described in paragraph + (4); and + (iii) provide information consistent with the + standards developed under paragraph (5). + (3) Duties.--An entity that serves as a navigator under a + grant under this subsection shall-- + (A) conduct public education activities to raise + awareness of the availability of qualified health plans; + (B) distribute fair and impartial information + concerning enrollment in qualified health plans, and the + availability of premium tax credits under section 36B of + the Internal Revenue Code of 1986 and cost-sharing + reductions under section 1402; + (C) facilitate enrollment in qualified health plans; + (D) provide referrals to any applicable office of + health insurance consumer assistance or health insurance + ombudsman established under section 2793 of the Public + Health Service Act, or any other appropriate State + agency or agencies, for any enrollee with a grievance, + complaint, or question regarding their health plan, + coverage, or a determination under such plan or + coverage; and + (E) provide information in a manner that is + culturally and linguistically appropriate to the needs + of the population being served by the Exchange or + Exchanges. + (4) Standards.-- + (A) In general.--The Secretary shall establish + standards for navigators under this subsection, + including provisions to ensure that any private or + public entity that is selected as a navigator is + qualified, and licensed if appropriate, to engage in the + navigator activities described in this subsection and to + avoid conflicts of interest. Under such standards, a + navigator shall not-- + (i) be a health insurance issuer; or + (ii) receive any consideration directly or + indirectly from any health insurance issuer in + connection with the enrollment of any qualified + individuals or employees of a qualified employer + in a qualified health plan. + (5) Fair and impartial information and services.-- + <<NOTE: Standards.>> The Secretary, in collaboration with + States, shall develop standards to ensure that information made + available by navigators is fair, accurate, and impartial. + (6) Funding.--Grants under this subsection shall be made + from the operational funds of the Exchange and not Federal funds + received by the State to establish the Exchange. + + (j) Applicability of Mental Health Parity.--Section 2726 of the +Public Health Service Act shall apply to qualified health plans in the +same manner and to the same extent as such section applies to health +insurance issuers and group health plans. + (k) Conflict.--An Exchange may not establish rules that conflict +with or prevent the application of regulations promulgated by the +Secretary under this subtitle. + +[[Page 124 STAT. 182]] + +SEC. 1312. <<NOTE: 42 USC 18032.>> CONSUMER CHOICE. + + (a) Choice.-- + (1) Qualified individuals.--A qualified individual may + enroll in any qualified health plan available to such + individual. + (2) Qualified employers.-- + (A) Employer may specify level.--A qualified + employer may provide support for coverage of employees + under a qualified health plan by selecting any level of + coverage under section 1302(d) to be made available to + employees through an Exchange. + (B) Employee may choose plans within a level.--Each + employee of a qualified employer that elects a level of + coverage under subparagraph (A) may choose to enroll in + a qualified health plan that offers coverage at that + level. + + (b) Payment of Premiums by Qualified Individuals.--A qualified +individual enrolled in any qualified health plan may pay any applicable +premium owed by such individual to the health insurance issuer issuing +such qualified health plan. + (c) Single Risk Pool.-- + (1) Individual market.--A health insurance issuer shall + consider all enrollees in all health plans (other than + grandfathered health plans) offered by such issuer in the + individual market, including those enrollees who do not enroll + in such plans through the Exchange, to be members of a single + risk pool. + (2) Small group market.--A health insurance issuer shall + consider all enrollees in all health plans (other than + grandfathered health plans) offered by such issuer in the small + group market, including those enrollees who do not enroll in + such plans through the Exchange, to be members of a single risk + pool. + (3) Merger of markets.--A State may require the individual + and small group insurance markets within a State to be merged if + the State determines appropriate. + (4) State law.--A State law requiring grandfathered health + plans to be included in a pool described in paragraph (1) or (2) + shall not apply. + + (d) Empowering Consumer Choice.-- + (1) Continued operation of market outside exchanges.-- + Nothing in this title shall be construed to prohibit-- + (A) a health insurance issuer from offering outside + of an Exchange a health plan to a qualified individual + or qualified employer; and + (B) a qualified individual from enrolling in, or a + qualified employer from selecting for its employees, a + health plan offered outside of an Exchange. + (2) Continued operation of state benefit requirements.-- + Nothing in this title shall be construed to terminate, abridge, + or limit the operation of any requirement under State law with + respect to any policy or plan that is offered outside of an + Exchange to offer benefits. + (3) Voluntary nature of an exchange.-- + (A) Choice to enroll or not to enroll.--Nothing in + this title shall be construed to restrict the choice of + +[[Page 124 STAT. 183]] + + a qualified individual to enroll or not to enroll in a + qualified health plan or to participate in an Exchange. + (B) Prohibition against compelled enrollment.-- + Nothing in this title shall be construed to compel an + individual to enroll in a qualified health plan or to + participate in an Exchange. + (C) Individuals allowed to enroll in any plan.--A + qualified individual may enroll in any qualified health + plan, except that in the case of a catastrophic plan + described in section 1302(e), a qualified individual may + enroll in the plan only if the individual is eligible to + enroll in the plan under section 1302(e)(2). + (D) Members of congress in the exchange.-- + (i) Requirement.--Notwithstanding any other + provision of law, after the effective date of this + subtitle, the only health plans that the Federal + Government may make available to Members of + Congress and congressional staff with respect to + their service as a Member of Congress or + congressional staff shall be health plans that + are-- + (I) created under this Act (or an + amendment made by this Act); or + (II) offered through an Exchange + established under this Act (or an + amendment made by this Act). + (ii) Definitions.--In this section: + (I) Member of congress.--The term + ``Member of Congress'' means any member + of the House of Representatives or the + Senate. + (II) Congressional staff.--The term + ``congressional staff'' means all full- + time and part-time employees employed by + the official office of a Member of + Congress, whether in Washington, DC or + outside of Washington, DC. + (4) No penalty for transferring to minimum essential + coverage outside exchange.--An Exchange, or a qualified health + plan offered through an Exchange, shall not impose any penalty + or other fee on an individual who cancels enrollment in a plan + because the individual becomes eligible for minimum essential + coverage (as defined in section 5000A(f) of the Internal Revenue + Code of 1986 without regard to paragraph (1)(C) or (D) thereof) + or such coverage becomes affordable (within the meaning of + section 36B(c)(2)(C) of such Code). + + (e) Enrollment Through Agents or Brokers. <<NOTE: Procedures.>> -- +The Secretary shall establish procedures under which a State may allow +agents or brokers-- + (1) to enroll individuals in any qualified health plans in + the individual or small group market as soon as the plan is + offered through an Exchange in the State; and + (2) to assist individuals in applying for premium tax + credits and cost-sharing reductions for plans sold through an + Exchange. + +Such procedures may include the establishment of rate schedules for +broker commissions paid by health benefits plans offered through an +exchange. + (f) Qualified Individuals and Employers; Access Limited to Citizens +and Lawful Residents.-- + (1) Qualified individuals.--In this title: + +[[Page 124 STAT. 184]] + + (A) In general. <<NOTE: Definition.>> --The term + ``qualified individual'' means, with respect to an + Exchange, an individual who-- + (i) is seeking to enroll in a qualified health + plan in the individual market offered through the + Exchange; and + (ii) resides in the State that established the + Exchange (except with respect to territorial + agreements under section 1312(f)). + (B) Incarcerated individuals excluded.--An + individual shall not be treated as a qualified + individual if, at the time of enrollment, the individual + is incarcerated, other than incarceration pending the + disposition of charges. + (2) Qualified employer.--In this title: + (A) In general. <<NOTE: Definition.>> --The term + ``qualified employer'' means a small employer that + elects to make all full-time employees of such employer + eligible for 1 or more qualified health plans offered in + the small group market through an Exchange that offers + qualified health plans. + (B) Extension to large groups.-- + (i) In general. <<NOTE: Effective date.>> -- + Beginning in 2017, each State may allow issuers of + health insurance coverage in the large group + market in the State to offer qualified health + plans in such market through an Exchange. Nothing + in this subparagraph shall be construed as + requiring the issuer to offer such plans through + an Exchange. + (ii) Large employers eligible.--If a State + under clause (i) allows issuers to offer qualified + health plans in the large group market through an + Exchange, the term ``qualified employer'' shall + include a large employer that elects to make all + full-time employees of such employer eligible for + 1 or more qualified health plans offered in the + large group market through the Exchange. + (3) Access limited to lawful residents.--If an individual is + not, or is not reasonably expected to be for the entire period + for which enrollment is sought, a citizen or national of the + United States or an alien lawfully present in the United States, + the individual shall not be treated as a qualified individual + and may not be covered under a qualified health plan in the + individual market that is offered through an Exchange. + +SEC. 1313. <<NOTE: 42 USC 18033.>> FINANCIAL INTEGRITY. + + (a) Accounting for Expenditures.-- + (1) In general.-- <<NOTE: Deadline. Reports.>> An Exchange + shall keep an accurate accounting of all activities, receipts, + and expenditures and shall annually submit to the Secretary a + report concerning such accountings. + (2) Investigations.--The Secretary, in coordination with the + Inspector General of the Department of Health and Human + Services, may investigate the affairs of an Exchange, may + examine the properties and records of an Exchange, and may + require periodic reports in relation to activities undertaken by + an Exchange. An Exchange shall fully cooperate in any + investigation conducted under this paragraph. + (3) Audits.-- <<NOTE: Deadline.>> An Exchange shall be + subject to annual audits by the Secretary. + +[[Page 124 STAT. 185]] + + (4) Pattern of abuse.-- <<NOTE: Determination.>> If the + Secretary determines that an Exchange or a State has engaged in + serious misconduct with respect to compliance with the + requirements of, or carrying out of activities required under, + this title, the Secretary may rescind from payments otherwise + due to such State involved under this or any other Act + administered by the Secretary an amount not to exceed 1 percent + of such payments per year until corrective actions are taken by + the State that are determined to be adequate by the Secretary. + (5) Protections against fraud and abuse.--With respect to + activities carried out under this title, the Secretary shall + provide for the efficient and non-discriminatory administration + of Exchange activities and implement any measure or procedure + that-- + (A) the Secretary determines is appropriate to + reduce fraud and abuse in the administration of this + title; and + (B) the Secretary has authority to implement under + this title or any other Act. + (6) Application of the false claims act.-- + (A) In general.--Payments made by, through, or in + connection with an Exchange are subject to the False + Claims Act (31 U.S.C. 3729 et seq.) if those payments + include any Federal funds. Compliance with the + requirements of this Act concerning eligibility for a + health insurance issuer to participate in the Exchange + shall be a material condition of an issuer's entitlement + to receive payments, including payments of premium tax + credits and cost-sharing reductions, through the + Exchange. + (B) Damages <<NOTE: Penalty.>> .--Notwithstanding + paragraph (1) of section 3729(a) of title 31, United + States Code, and subject to paragraph (2) of such + section, the civil penalty assessed under the False + Claims Act on any person found liable under such Act as + described in subparagraph (A) shall be increased by not + less than 3 times and not more than 6 times the amount + of damages which the Government sustains because of the + act of that person. + + (b) GAO Oversight. <<NOTE: Deadline. Study.>> --Not later than 5 +years after the first date on which Exchanges are required to be +operational under this title, the Comptroller General shall conduct an +ongoing study of Exchange activities and the enrollees in qualified +health plans offered through Exchanges. Such study shall review-- + (1) the operations and administration of Exchanges, + including surveys and reports of qualified health plans offered + through Exchanges and on the experience of such plans (including + data on enrollees in Exchanges and individuals purchasing health + insurance coverage outside of Exchanges), the expenses of + Exchanges, claims statistics relating to qualified health plans, + complaints data relating to such plans, and the manner in which + Exchanges meet their goals; + (2) any significant observations regarding the utilization + and adoption of Exchanges; + (3) where appropriate, recommendations for improvements in + the operations or policies of Exchanges; and + (4) how many physicians, by area and specialty, are not + taking or accepting new patients enrolled in Federal Government + health care programs, and the adequacy of provider networks of + Federal Government health care programs. + +[[Page 124 STAT. 186]] + + PART III--STATE FLEXIBILITY RELATING TO EXCHANGES + +SEC. 1321. <<NOTE: 42 USC 18041.>> STATE FLEXIBILITY IN OPERATION AND + ENFORCEMENT OF EXCHANGES AND RELATED REQUIREMENTS. + + (a) Establishment of Standards.-- + (1) In general.-- <<NOTE: Regulations.>> The Secretary + shall, as soon as practicable after the date of enactment of + this Act, issue regulations setting standards for meeting the + requirements under this title, and the amendments made by this + title, with respect to-- + (A) the establishment and operation of Exchanges + (including SHOP Exchanges); + (B) the offering of qualified health plans through + such Exchanges; + (C) the establishment of the reinsurance and risk + adjustment programs under part V; and + (D) such other requirements as the Secretary + determines appropriate. + The preceding sentence shall not apply to standards for + requirements under subtitles A and C (and the amendments made by + such subtitles) for which the Secretary issues regulations under + the Public Health Service Act. + (2) Consultation.--In issuing the regulations under + paragraph (1), the Secretary shall consult with the National + Association of Insurance Commissioners and its members and with + health insurance issuers, consumer organizations, and such other + individuals as the Secretary selects in a manner designed to + ensure balanced representation among interested parties. + + (b) State Action <<NOTE: Deadline.>> .--Each State that elects, at +such time and in such manner as the Secretary may prescribe, to apply +the requirements described in subsection (a) shall, not later than +January 1, 2014, adopt and have in effect-- + (1) the Federal standards established under subsection (a); + or + (2) a State law or regulation that the Secretary determines + implements the standards within the State. + + (c) Failure To Establish Exchange or Implement Requirements.-- + (1) In general.--If-- + (A) a State is not an electing State under + subsection (b); or + (B) <<NOTE: Determination. Deadline.>> the Secretary + determines, on or before January 1, 2013, that an + electing State-- + (i) will not have any required Exchange + operational by January 1, 2014; or + (ii) has not taken the actions the Secretary + determines necessary to implement-- + (I) the other requirements set forth + in the standards under subsection (a); + or + (II) the requirements set forth in + subtitles A and C and the amendments + made by such subtitles; + the Secretary shall (directly or through agreement with a not- + for-profit entity) establish and operate such Exchange within + the State and the Secretary shall take such actions as are + necessary to implement such other requirements. + +[[Page 124 STAT. 187]] + + (2) Enforcement authority.-- <<NOTE: Applicability.>> The + provisions of section 2736(b) of the Public Health Services Act + shall apply to the enforcement under paragraph (1) of + requirements of subsection (a)(1) (without regard to any + limitation on the application of those provisions to group + health plans). + + (d) No Interference With State Regulatory Authority.--Nothing in +this title shall be construed to preempt any State law that does not +prevent the application of the provisions of this title. + (e) Presumption for Certain State-Operated Exchanges.-- + (1) In general.-- <<NOTE: Determination.>> In the case of a + State operating an Exchange before January 1, 2010, and which + has insured a percentage of its population not less than the + percentage of the population projected to be covered nationally + after the implementation of this Act, that seeks to operate an + Exchange under this section, the Secretary shall presume that + such Exchange meets the standards under this section unless the + Secretary determines, after completion of the process + established under paragraph (2), that the Exchange does not + comply with such standards. + (2) Process.--The Secretary shall establish a process to + work with a State described in paragraph (1) to provide + assistance necessary to assist the State's Exchange in coming + into compliance with the standards for approval under this + section. + +SEC. 1322. <<NOTE: 42 USC 18042.>> FEDERAL PROGRAM TO ASSIST + ESTABLISHMENT AND OPERATION OF NONPROFIT, MEMBER-RUN HEALTH + INSURANCE ISSUERS. + + (a) Establishment of Program.-- + (1) In general.--The Secretary shall establish a program to + carry out the purposes of this section to be known as the + Consumer Operated and Oriented Plan (CO-OP) program. + (2) Purpose.--It is the purpose of the CO-OP program to + foster the creation of qualified nonprofit health insurance + issuers to offer qualified health plans in the individual and + small group markets in the States in which the issuers are + licensed to offer such plans. + + (b) Loans and Grants Under the CO-OP Program.-- + (1) In general.--The Secretary shall provide through the CO- + OP program for the awarding to persons applying to become + qualified nonprofit health insurance issuers of-- + (A) loans to provide assistance to such person in + meeting its start-up costs; and + (B) grants to provide assistance to such person in + meeting any solvency requirements of States in which the + person seeks to be licensed to issue qualified health + plans. + (2) Requirements for awarding loans and grants.-- + (A) In general.--In awarding loans and grants under + the CO-OP program, the Secretary shall-- + (i) take into account the recommendations of + the advisory board established under paragraph + (3); + (ii) give priority to applicants that will + offer qualified health plans on a Statewide basis, + will utilize integrated care models, and have + significant private support; and + (iii) ensure that there is sufficient funding + to establish at least 1 qualified nonprofit health + insurance + +[[Page 124 STAT. 188]] + + issuer in each State, except that nothing in this + clause shall prohibit the Secretary from funding + the establishment of multiple qualified nonprofit + health insurance issuers in any State if the + funding is sufficient to do so. + (B) States without issuers in program.--If no health + insurance issuer applies to be a qualified nonprofit + health insurance issuer within a State, the Secretary + may use amounts appropriated under this section for the + awarding of grants to encourage the establishment of a + qualified nonprofit health insurance issuer within the + State or the expansion of a qualified nonprofit health + insurance issuer from another State to the State. + (C) Agreement.-- + (i) In general.--The Secretary shall require + any person receiving a loan or grant under the CO- + OP program to enter into an agreement with the + Secretary which requires such person to meet (and + to continue to meet)-- + (I) any requirement under this + section for such person to be treated as + a qualified nonprofit health insurance + issuer; and + (II) any requirements contained in + the agreement for such person to receive + such loan or grant. + (ii) Restrictions on use of federal funds.-- + The agreement shall include a requirement that no + portion of the funds made available by any loan or + grant under this section may be used-- + (I) <<NOTE: Lobbying.>> for carrying + on propaganda, or otherwise attempting, + to influence legislation; or + (II) for marketing. + Nothing in this clause shall be construed to allow + a person to take any action prohibited by section + 501(c)(29) of the Internal Revenue Code of 1986. + (iii) Failure to meet + requirements <<NOTE: Determination. Payments.>> .-- + If the Secretary determines that a person has + failed to meet any requirement described in clause + (i) or (ii) and has failed to correct such failure + within a reasonable period of time of when the + person first knows (or reasonably should have + known) of such failure, such person shall repay to + the Secretary an amount equal to the sum of-- + (I) 110 percent of the aggregate + amount of loans and grants received + under this section; plus + (II) interest on the aggregate + amount of loans and grants received + under this section for the period the + loans or grants were outstanding. + <<NOTE: Notification.>> The Secretary shall notify + the Secretary of the Treasury of any determination + under this section of a failure that results in + the termination of an issuer's tax-exempt status + under section 501(c)(29) of such Code. + (D) Time for awarding loans and + grants. <<NOTE: Deadline.>> --The Secretary shall not + later than July 1, 2013, award the loans and grants + under the CO-OP program and begin the distribution of + amounts awarded under such loans and grants. + (3) <<NOTE: Establishment.>> Advisory board.-- + +[[Page 124 STAT. 189]] + + (A) In general.--The advisory board under this + paragraph shall consist of 15 members appointed by the + Comptroller General of the United States from among + individuals with qualifications described in section + 1805(c)(2) of the Social Security Act. + (B) Rules relating to appointments.-- + (i) Standards.--Any individual appointed under + subparagraph (A) shall meet ethics and conflict of + interest standards protecting against insurance + industry involvement and interference. + (ii) Original + appointments. <<NOTE: Deadline.>> --The original + appointment of board members under subparagraph + (A)(ii) shall be made no later than 3 months after + the date of enactment of this Act. + (C) Vacancy.--Any vacancy on the advisory board + shall be filled in the same manner as the original + appointment. + (D) Pay and reimbursement.-- + (i) No compensation for members of advisory + board.--Except as provided in clause (ii), a + member of the advisory board may not receive pay, + allowances, or benefits by reason of their service + on the board. + (ii) Travel expenses.--Each member shall + receive travel expenses, including per diem in + lieu of subsistence under subchapter I of chapter + 57 of title 5, United States Code. + (E) Application of faca.--The Federal Advisory + Committee Act (5 U.S.C. App.) shall apply to the + advisory board, except that section 14 of such Act shall + not apply. + (F) Termination.--The advisory board shall terminate + on the earlier of the date that it completes its duties + under this section or December 31, 2015. + + (c) Qualified Nonprofit Health Insurance Issuer.--For purposes of +this section-- + (1) In general.-- <<NOTE: Definition.>> The term ``qualified + nonprofit health insurance issuer'' means a health insurance + issuer that is an organization-- + (A) that is organized under State law as a + nonprofit, member corporation; + (B) substantially all of the activities of which + consist of the issuance of qualified health plans in the + individual and small group markets in each State in + which it is licensed to issue such plans; and + (C) that meets the other requirements of this + subsection. + (2) Certain organizations prohibited.--An organization shall + not be treated as a qualified nonprofit health insurance issuer + if-- + (A) the organization or a related entity (or any + predecessor of either) was a health insurance issuer on + July 16, 2009; or + (B) the organization is sponsored by a State or + local government, any political subdivision thereof, or + any instrumentality of such government or political + subdivision. + (3) Governance requirements.--An organization shall not be + treated as a qualified nonprofit health insurance issuer + unless-- + +[[Page 124 STAT. 190]] + + (A) the governance of the organization is subject to + a majority vote of its members; + (B) its governing documents incorporate ethics and + conflict of interest standards protecting against + insurance industry involvement and interference; and + (C) as provided in regulations promulgated by the + Secretary, the organization is required to operate with + a strong consumer focus, including timeliness, + responsiveness, and accountability to members. + (4) Profits inure to benefit of members.--An organization + shall not be treated as a qualified nonprofit health insurance + issuer unless any profits made by the organization are required + to be used to lower premiums, to improve benefits, or for other + programs intended to improve the quality of health care + delivered to its members. + (5) Compliance with state insurance laws.--An organization + shall not be treated as a qualified nonprofit health insurance + issuer unless the organization meets all the requirements that + other issuers of qualified health plans are required to meet in + any State where the issuer offers a qualified health plan, + including solvency and licensure requirements, rules on payments + to providers, and compliance with network adequacy rules, rate + and form filing rules, any applicable State premium assessments + and any other State law described in section 1324(b). + (6) Coordination with state insurance reforms.--An + organization shall not be treated as a qualified nonprofit + health insurance issuer unless the organization does not offer a + health plan in a State until that State has in effect (or the + Secretary has implemented for the State) the market reforms + required by part A of title XXVII of the Public Health Service + Act (as amended by subtitles A and C of this Act). + + (d) Establishment of Private Purchasing Council.-- + (1) In general.--Qualified nonprofit health insurance + issuers participating in the CO-OP program under this section + may establish a private purchasing council to enter into + collective purchasing arrangements for items and services that + increase administrative and other cost efficiencies, including + claims administration, administrative services, health + information technology, and actuarial services. + (2) Council may not set payment rates.--The private + purchasing council established under paragraph (1) shall not set + payment rates for health care facilities or providers + participating in health insurance coverage provided by qualified + nonprofit health insurance issuers. + (3) Continued application of antitrust laws.-- + (A) In general.--Nothing in this section shall be + construed to limit the application of the antitrust laws + to any private purchasing council (whether or not + established under this subsection) or to any qualified + nonprofit health insurance issuer participating in such + a council. + (B) Antitrust laws.--For purposes of this + subparagraph, the term ``antitrust laws'' has the + meaning given the term in subsection (a) of the first + section of the Clayton Act (15 U.S.C. 12(a)). Such term + also includes section 5 of the Federal Trade Commission + Act (15 U.S.C. 45) to + +[[Page 124 STAT. 191]] + + the extent that such section 5 applies to unfair methods + of competition. + + (e) Limitation on Participation.--No representative of any Federal, +State, or local government (or of any political subdivision or +instrumentality thereof), and no representative of a person described in +subsection (c)(2)(A), may serve on the board of directors of a qualified +nonprofit health insurance issuer or with a private purchasing council +established under subsection (d). + (f) Limitations on Secretary.-- + (1) In general.--The Secretary shall not-- + (A) participate in any negotiations between 1 or + more qualified nonprofit health insurance issuers (or a + private purchasing council established under subsection + (d)) and any health care facilities or providers, + including any drug manufacturer, pharmacy, or hospital; + and + (B) establish or maintain a price structure for + reimbursement of any health benefits covered by such + issuers. + (2) Competition.--Nothing in this section shall be construed + as authorizing the Secretary to interfere with the competitive + nature of providing health benefits through qualified nonprofit + health insurance issuers. + + (g) Appropriations.--There are hereby appropriated, out of any funds +in the Treasury not otherwise appropriated, $6,000,000,000 to carry out +this section. + (h) Tax Exemption for Qualified Nonprofit Health Insurance Issuer.-- + (1) In general.--Section 501(c) of the Internal Revenue Code + of 1986 <<NOTE: 26 USC 501.>> (relating to list of exempt + organizations) is amended by adding at the end the following: + ``(29) CO-OP health insurance issuers.-- + ``(A) In general.--A qualified nonprofit health + insurance issuer (within the meaning of section 1322 of + the Patient Protection and Affordable Care Act) which + has received a loan or grant under the CO-OP program + under such section, but only with respect to periods for + which the issuer is in compliance with the requirements + of such section and any agreement with respect to the + loan or grant. + ``(B) Conditions for + exemption <<NOTE: Applicability.>> .--Subparagraph (A) + shall apply to an organization only if-- + ``(i) <<NOTE: Notice.>> the organization has + given notice to the Secretary, in such manner as + the Secretary may by regulations prescribe, that + it is applying for recognition of its status under + this paragraph, + ``(ii) except as provided in section + 1322(c)(4) of the Patient Protection and + Affordable Care Act, no part of the net earnings + of which inures to the benefit of any private + shareholder or individual, + ``(iii) <<NOTE: Lobbying.>> no substantial + part of the activities of which is carrying on + propaganda, or otherwise attempting, to influence + legislation, and + ``(iv) the organization does not participate + in, or intervene in (including the publishing or + distributing of statements), any political + campaign on behalf of (or in opposition to) any + candidate for public office.''. + +[[Page 124 STAT. 192]] + + (2) Additional reporting requirement.--Section 6033 of such + Code (relating to returns by exempt organizations) is amended by + redesignating subsection (m) as subsection (n) and by inserting + after subsection (l) the following: + + ``(m) Additional Information Required From CO-OP Insurers.--An +organization described in section 501(c)(29) shall include on the return +required under subsection (a) the following information: + ``(1) The amount of the reserves required by each State in + which the organization is licensed to issue qualified health + plans. + ``(2) The amount of reserves on hand.''. + (3) Application of tax on excess benefit transactions.-- + Section 4958(e)(1) of such Code (defining applicable tax-exempt + organization) is amended by striking ``paragraph (3) or (4)'' + and inserting ``paragraph (3), (4), or (29)''. + + (i) GAO Study and Report.-- + (1) Study.--The Comptroller General of the General + Accountability Office shall conduct an ongoing study on + competition and market concentration in the health insurance + market in the United States after the implementation of the + reforms in such market under the provisions of, and the + amendments made by, this Act. Such study shall include an + analysis of new issuers of health insurance in such market. + (2) Report.-- <<NOTE: Effective date.>> The Comptroller + General shall, not later than December 31 of each even-numbered + year (beginning with 2014), report to the appropriate committees + of the Congress the results of the study conducted under + paragraph (1), including any recommendations for administrative + or legislative changes the Comptroller General determines + necessary or appropriate to increase competition in the health + insurance market. + +SEC. 1323. <<NOTE: 42 USC 18043.>> COMMUNITY HEALTH INSURANCE OPTION. + + (a) Voluntary Nature.-- + (1) No requirement for health care providers to + participate.--Nothing in this section shall be construed to + require a health care provider to participate in a community + health insurance option, or to impose any penalty for non- + participation. + (2) No requirement for individuals to join.--Nothing in this + section shall be construed to require an individual to + participate in a community health insurance option, or to impose + any penalty for non-participation. + (3) State opt out.-- + (A) In general.--A State may elect to prohibit + Exchanges in such State from offering a community health + insurance option if such State enacts a law to provide + for such prohibition. + (B) Termination of opt out.--A State may repeal a + law described in subparagraph (A) and provide for the + offering of such an option through the Exchange. + + (b) Establishment of Community Health Insurance Option.-- + (1) Establishment.--The Secretary shall establish a + community health insurance option to offer, through the + Exchanges established under this title (other than Exchanges + +[[Page 124 STAT. 193]] + + in States that elect to opt out as provided for in subsection + (a)(3)), health care coverage that provides value, choice, + competition, and stability of affordable, high quality coverage + throughout the United States. + (2) Community health insurance option.-- + <<NOTE: Definition.>> In this section, the term ``community + health insurance option'' means health insurance coverage that-- + (A) except as specifically provided for in this + section, complies with the requirements for being a + qualified health plan; + (B) provides high value for the premium charged; + (C) reduces administrative costs and promotes + administrative simplification for beneficiaries; + (D) promotes high quality clinical care; + (E) provides high quality customer service to + beneficiaries; + (F) offers a sufficient choice of providers; and + (G) complies with State laws (if any), except as + otherwise provided for in this title, relating to the + laws described in section 1324(b). + (3) Essential health benefits.-- + (A) General rule.--Except as provided in + subparagraph (B), a community health insurance option + offered under this section shall provide coverage only + for the essential health benefits described in section + 1302(b). + (B) States may offer additional benefits.--Nothing + in this section shall preclude a State from requiring + that benefits in addition to the essential health + benefits required under subparagraph (A) be provided to + enrollees of a community health insurance option offered + in such State. + (C) Credits.-- + (i) In general.--An individual enrolled in a + community health insurance option under this + section shall be eligible for credits under + section 36B of the Internal Revenue Code of 1986 + in the same manner as an individual who is + enrolled in a qualified health plan. + (ii) No additional federal cost.--A + requirement by a State under subparagraph (B) that + benefits in addition to the essential health + benefits required under subparagraph (A) be + provided to enrollees of a community health + insurance option shall not affect the amount of a + premium tax credit provided under section 36B of + the Internal Revenue Code of 1986 with respect to + such plan. + (D) State must assume cost <<NOTE: Payments.>> .--A + State shall make payments to or on behalf of an eligible + individual to defray the cost of any additional benefits + described in subparagraph (B). + (E) Ensuring access to all services.--Nothing in + this Act shall prohibit an individual enrolled in a + community health insurance option from paying out-of- + pocket the full cost of any item or service not included + as an essential health benefit or otherwise covered as a + benefit by a health plan. Nothing in subparagraph (B) + shall prohibit any type of medical provider from + accepting an out-of-pocket payment from an individual + enrolled in a community health + +[[Page 124 STAT. 194]] + + insurance option for a service otherwise not included as + an essential health benefit. + (F) Protecting access to end of life care.--A + community health insurance option offered under this + section shall be prohibited from limiting access to end + of life care. + (4) Cost sharing.--A community health insurance option shall + offer coverage at each of the levels of coverage described in + section 1302(d). + (5) Premiums.-- + (A) Premiums sufficient to cover costs.--The + Secretary shall establish geographically adjusted + premium rates in an amount sufficient to cover expected + costs (including claims and administrative costs) using + methods in general use by qualified health plans. + (B) Applicable rules.--The provisions of title XXVII + of the Public Health Service Act relating to premiums + shall apply to community health insurance options under + this section, including modified community rating + provisions under section 2701 of such Act. + (C) Collection of data.--The Secretary shall collect + data as necessary to set premium rates under + subparagraph (A). + (D) National pooling.--Notwithstanding any other + provision of law, the Secretary may treat all enrollees + in community health insurance options as members of a + single pool. + (E) Contingency margin.--In establishing premium + rates under subparagraph (A), the Secretary shall + include an appropriate amount for a contingency margin. + (6) Reimbursement rates.-- + (A) Negotiated rates.--The Secretary shall negotiate + rates for the reimbursement of health care providers for + benefits covered under a community health insurance + option. + (B) Limitation.--The rates described in subparagraph + (A) shall not be higher, in aggregate, than the average + reimbursement rates paid by health insurance issuers + offering qualified health plans through the Exchange. + (C) Innovation.--Subject to the limits contained in + subparagraph (A), a State Advisory Council established + or designated under subsection (d) may develop or + encourage the use of innovative payment policies that + promote quality, efficiency and savings to consumers. + (7) Solvency and consumer protection.-- + (A) <<NOTE: Standard.>> Solvency.--The Secretary + shall establish a Federal solvency standard to be + applied with respect to a community health insurance + option. A community health insurance option shall also + be subject to the solvency standard of each State in + which such community health insurance option is offered. + (B) Minimum required.--In establishing the standard + described under subparagraph (A), the Secretary shall + require a reserve fund that shall be equal to at least + the dollar value of the incurred but not reported claims + of a community health insurance option. + +[[Page 124 STAT. 195]] + + (C) Consumer + protections <<NOTE: Applicability.>> .--The consumer + protection laws of a State shall apply to a community + health insurance option. + (8) Requirements established in partnership with insurance + commissioners.-- + (A) In general.--The Secretary, in collaboration + with the National Association of Insurance Commissioners + (in this paragraph referred to as the ``NAIC''), may + promulgate regulations to establish additional + requirements for a community health insurance option. + (B) Applicability <<NOTE: Effective date.>> .--Any + requirement promulgated under subparagraph (A) shall be + applicable to such option beginning 90 days after the + date on which the regulation involved becomes final. + + (c) Start-up Fund.-- + (1) Establishment of fund.-- + (A) In general.--There is established in the + Treasury of the United States a trust fund to be known + as the ``Health Benefit Plan Start-Up Fund'' (referred + to in this section as the ``Start-Up Fund''), that shall + consist of such amounts as may be appropriated or + credited to the Start-Up Fund as provided for in this + subsection to provide loans for the initial operations + of a community health insurance option. Such amounts + shall remain available until expended. + (B) Funding.--There is hereby appropriated to the + Start-Up Fund, out of any moneys in the Treasury not + otherwise appropriated an amount requested by the + Secretary of Health and Human Services as necessary to-- + (i) pay the start-up costs associated with the + initial operations of a community health insurance + option; and + (ii) pay the costs of making payments on + claims submitted during the period that is not + more than 90 days from the date on which such + option is offered. + (2) Use of start-up fund.--The Secretary shall use amounts + contained in the Start-Up Fund to make payments (subject to the + repayment requirements in paragraph (4)) for the purposes + described in paragraph (1)(B). + (3) Pass through of rebates.--The Secretary may establish + procedures for reducing the amount of payments to a contracting + administrator to take into account any rebates or price + concessions. + (4) Repayment.-- + (A) <<NOTE: Deadline.>> In general.--A community + health insurance option shall be required to repay the + Secretary of the Treasury (on such terms as the + Secretary may require) for any payments made under + paragraph (1)(B) by the date that is not later than 9 + years after the date on which the payment is made. The + Secretary may require the payment of interest with + respect to such repayments at rates that do not exceed + the market interest rate (as determined by the + Secretary). + (B) Sanctions in case of for-profit conversion.--In + any case in which the Secretary enters into a contract + with a qualified entity for the offering of a community + health insurance option and such entity is determined to + +[[Page 124 STAT. 196]] + + be a for-profit entity by the Secretary, such entity + shall be-- + (i) immediately liable to the Secretary for + any payments received by such entity from the + Start-Up Fund; and + (ii) permanently ineligible to offer a + qualified health plan. + + (d) State Advisory Council.-- + (1) Establishment.--A State (other than a State that elects + to opt out as provided for in subsection (a)(3)) shall establish + or designate a public or non-profit private entity to serve as + the State Advisory Council to provide recommendations to the + Secretary on the operations and policies of a community health + insurance option in the State. Such Council shall provide + recommendations on at least the following: + (A) policies and procedures to integrate quality + improvement and cost containment mechanisms into the + health care delivery system; + (B) mechanisms to facilitate public awareness of the + availability of a community health insurance option; and + (C) alternative payment structures under a community + health insurance option for health care providers that + encourage quality improvement and cost control. + (2) Members.--The members of the State Advisory Council + shall be representatives of the public and shall include health + care consumers and providers. + (3) Applicability of recommendations.--The Secretary may + apply the recommendations of a State Advisory Council to a + community health insurance option in that State, in any other + State, or in all States. + + (e) Authority To Contract; Terms of Contract.-- + (1) Authority.-- + (A) In general.--The Secretary may enter into a + contract or contracts with one or more qualified + entities for the purpose of performing administrative + functions (including functions described in subsection + (a)(4) of section 1874A of the Social Security Act) with + respect to a community health insurance option in the + same manner as the Secretary may enter into contracts + under subsection (a)(1) of such section. The Secretary + shall have the same authority with respect to a + community health insurance option under this section as + the Secretary has under subsections (a)(1) and (b) of + section 1874A of the Social Security Act with respect to + title XVIII of such Act. + (B) Requirements apply.--If the Secretary enters + into a contract with a qualified entity to offer a + community health insurance option, under such contract + such entity-- + (i) shall meet the criteria established under + paragraph (2); and + (ii) <<NOTE: Fee.>> shall receive an + administrative fee under paragraph (7). + (C) Limitation.--Contracts under this subsection + shall not involve the transfer of insurance risk to the + contracting administrator. + (D) Reference.--An entity with which the Secretary + has entered into a contract under this paragraph shall + be referred to as a ``contracting administrator''. + +[[Page 124 STAT. 197]] + + (2) Qualified entity.--To be qualified to be selected by the + Secretary to offer a community health insurance option, an + entity shall-- + (A) meet the criteria established under section + 1874A(a)(2) of the Social Security Act; + (B) be a nonprofit entity for purposes of offering + such option; + (C) meet the solvency standards applicable under + subsection (b)(7); + (D) be eligible to offer health insurance or health + benefits coverage; + (E) meet quality standards specified by the + Secretary; + (F) have in place effective procedures to control + fraud, abuse, and waste; and + (G) meet such other requirements as the Secretary + may impose. + Procedures described under subparagraph (F) shall include the + implementation of procedures to use beneficiary identifiers to + identify individuals entitled to benefits so that such an + individual's social security account number is not used, and + shall also include procedures for the use of technology + (including front-end, prepayment intelligent data-matching + technology similar to that used by hedge funds, investment + funds, and banks) to provide real-time data analysis of claims + for payment under this title to identify and investigate unusual + billing or order practices under this title that could indicate + fraud or abuse. + (3) Term.--A contract provided for under paragraph (1) shall + be for a term of at least 5 years but not more than 10 years, as + determined by the Secretary. At the end of each such term, the + Secretary shall conduct a competitive bidding process for the + purposes of renewing existing contracts or selecting new + qualified entities with which to enter into contracts under such + paragraph. + (4) <<NOTE: Determination.>> Limitation.--A contract may + not be renewed under this subsection unless the Secretary + determines that the contracting administrator has met + performance requirements established by the Secretary in the + areas described in paragraph (7)(B). + (5) Audits.--The Inspector General shall conduct periodic + audits with respect to contracting administrators under this + subsection to ensure that the administrator involved is in + compliance with this section. + (6) Revocation.-- <<NOTE: Notification.>> A contract awarded + under this subsection shall be revoked by the Secretary, upon + the recommendation of the Inspector General, only after notice + to the contracting administrator involved and an opportunity for + a hearing. The Secretary may revoke such contract if the + Secretary determines that such administrator has engaged in + fraud, deception, waste, abuse of power, negligence, + mismanagement of taxpayer dollars, or gross mismanagement. An + entity that has had a contract revoked under this paragraph + shall not be qualified to enter into a subsequent contract under + this subsection. + (7) Fee for administration.-- + (A) In general.--The Secretary shall pay the + contracting administrator a fee for the management, + administration, and delivery of the benefits under this + section. + +[[Page 124 STAT. 198]] + + (B) Requirement for high quality administration.-- + The Secretary may increase the fee described in + subparagraph (A) by not more than 10 percent, or reduce + the fee described in subparagraph (A) by not more than + 50 percent, based on the extent to which the contracting + administrator, in the determination of the Secretary, + meets performance requirements established by the + Secretary, in at least the following areas: + (i) Maintaining low premium costs and low cost + sharing requirements, provided that such + requirements are consistent with section 1302. + (ii) Reducing administrative costs and + promoting administrative simplification for + beneficiaries. + (iii) Promoting high quality clinical care. + (iv) Providing high quality customer service + to beneficiaries. + (C) Non-renewal.--The Secretary may not renew a + contract to offer a community health insurance option + under this section with any contracting entity that has + been assessed more than one reduction under subparagraph + (B) during the contract period. + (8) Limitation.--Notwithstanding the terms of a contract + under this subsection, the Secretary shall negotiate the + reimbursement rates for purposes of subsection (b)(6). + + (f) Report by HHS and Insolvency Warnings.-- + (1) In general.--On an annual basis, the Secretary shall + conduct a study on the solvency of a community health insurance + option and submit to Congress a report describing the results of + such study. + (2) Result.--If, in any year, the result of the study under + paragraph (1) is that a community health insurance option is + insolvent, such result shall be treated as a community health + insurance option solvency warning. + (3) Submission of plan and procedure.-- + (A) In general <<NOTE: President. Deadline.>> .--If + there is a community health insurance option solvency + warning under paragraph (2) made in a year, the + President shall submit to Congress, within the 15-day + period beginning on the date of the budget submission to + Congress under section 1105(a) of title 31, United + States Code, for the succeeding year, proposed + legislation to respond to such warning. + (B) Procedure.--In the case of a legislative + proposal submitted by the President pursuant to + subparagraph (A), such proposal shall be considered by + Congress using the same procedures described under + sections 803 and 804 of the Medicare Prescription Drug, + Improvement, and Modernization Act of 2003 that shall be + used for a medicare funding warning. + + (g) Marketing Parity.--In a facility controlled by the Federal +Government, or by a State, where marketing or promotional materials +related to a community health insurance option are made available to the +public, making available marketing or promotional materials relating to +private health insurance plans shall not be prohibited. Such materials +include informational pamphlets, guidebooks, enrollment forms, or other +materials determined reasonable for display. + +[[Page 124 STAT. 199]] + + (h) Authorization of Appropriations.--There is authorized to be +appropriated such sums as may be necessary to carry out this section. + +SEC. 1324. <<NOTE: 42 USC 18044.>> LEVEL PLAYING FIELD. + + (a) In General.--Notwithstanding any other provision of law, any +health insurance coverage offered by a private health insurance issuer +shall not be subject to any Federal or State law described in subsection +(b) if a qualified health plan offered under the Consumer Operated and +Oriented Plan program under section 1322, a community health insurance +option under section 1323, or a nationwide qualified health plan under +section 1333(b), is not subject to such law. + (b) Laws Described.--The Federal and State laws described in this +subsection are those Federal and State laws relating to-- + (1) guaranteed renewal; + (2) rating; + (3) preexisting conditions; + (4) non-discrimination; + (5) quality improvement and reporting; + (6) fraud and abuse; + (7) solvency and financial requirements; + (8) market conduct; + (9) prompt payment; + (10) appeals and grievances; + (11) privacy and confidentiality; + (12) licensure; and + (13) benefit plan material or information. + + PART IV--STATE FLEXIBILITY TO ESTABLISH ALTERNATIVE PROGRAMS + +SEC. 1331. <<NOTE: 42 USC 18051.>> STATE FLEXIBILITY TO ESTABLISH BASIC + HEALTH PROGRAMS FOR LOW-INCOME INDIVIDUALS NOT ELIGIBLE FOR + MEDICAID. + + (a) Establishment of Program.-- + (1) In general.--The Secretary shall establish a basic + health program meeting the requirements of this section under + which a State may enter into contracts to offer 1 or more + standard health plans providing at least the essential health + benefits described in section 1302(b) to eligible individuals in + lieu of offering such individuals coverage through an Exchange. + (2) Certifications as to benefit coverage and costs.--Such + program shall provide that a State may not establish a basic + health program under this section unless the State establishes + to the satisfaction of the Secretary, and the Secretary + certifies, that-- + (A) in the case of an eligible individual enrolled + in a standard health plan offered through the program, + the State provides-- + (i) that the amount of the monthly premium an + eligible individual is required to pay for + coverage under the standard health plan for the + individual and the individual's dependents does + not exceed the amount of the monthly premium that + the eligible individual would have been required + to pay (in the rating area in which the individual + resides) if the individual had + +[[Page 124 STAT. 200]] + + enrolled in the applicable second lowest cost + silver plan (as defined in section 36B(b)(3)(B) of + the Internal Revenue Code of 1986) offered to the + individual through an Exchange; and + (ii) that the cost-sharing an eligible + individual is required to pay under the standard + health plan does not exceed-- + (I) the cost-sharing required under + a platinum plan in the case of an + eligible individual with household + income not in excess of 150 percent of + the poverty line for the size of the + family involved; and + (II) the cost-sharing required under + a gold plan in the case of an eligible + individual not described in subclause + (I); and + (B) the benefits provided under the standard health + plans offered through the program cover at least the + essential health benefits described in section 1302(b). + For purposes of subparagraph (A)(i), the amount of the monthly + premium an individual is required to pay under either the + standard health plan or the applicable second lowest cost silver + plan shall be determined after reduction for any premium tax + credits and cost-sharing reductions allowable with respect to + either plan. + + (b) Standard Health Plan. <<NOTE: Definition.>> --In this section, +the term ``standard heath plan'' means a health benefits plan that the +State contracts with under this section-- + (1) under which the only individuals eligible to enroll are + eligible individuals; + (2) that provides at least the essential health benefits + described in section 1302(b); and + (3) in the case of a plan that provides health insurance + coverage offered by a health insurance issuer, that has a + medical loss ratio of at least 85 percent. + + (c) Contracting Process.-- + (1) In general.--A State basic health program shall + establish a competitive process for entering into contracts with + standard health plans under subsection (a), including + negotiation of premiums and cost-sharing and negotiation of + benefits in addition to the essential health benefits described + in section 1302(b). + (2) Specific items to be considered.--A State shall, as part + of its competitive process under paragraph (1), include at least + the following: + (A) Innovation.--Negotiation with offerors of a + standard health plan for the inclusion of innovative + features in the plan, including-- + (i) care coordination and care management for + enrollees, especially for those with chronic + health conditions; + (ii) incentives for use of preventive + services; and + (iii) the establishment of relationships + between providers and patients that maximize + patient involvement in health care decision- + making, including providing incentives for + appropriate utilization under the plan. + +[[Page 124 STAT. 201]] + + (B) Health and resource differences.--Consideration + of, and the making of suitable allowances for, + differences in health care needs of enrollees and + differences in local availability of, and access to, + health care providers. Nothing in this subparagraph + shall be construed as allowing discrimination on the + basis of pre-existing conditions or other health status- + related factors. + (C) Managed care.--Contracting with managed care + systems, or with systems that offer as many of the + attributes of managed care as are feasible in the local + health care market. + (D) Performance measures.--Establishing specific + performance measures and standards for issuers of + standard health plans that focus on quality of care and + improved health outcomes, requiring such plans to report + to the State with respect to the measures and standards, + and making the performance and quality information + available to enrollees in a useful form. + (3) Enhanced availability.-- + (A) Multiple plans.--A State shall, to the maximum + extent feasible, seek to make multiple standard health + plans available to eligible individuals within a State + to ensure individuals have a choice of such plans. + (B) Regional compacts.--A State may negotiate a + regional compact with other States to include coverage + of eligible individuals in all such States in agreements + with issuers of standard health plans. + (4) Coordination with other state programs.--A State shall + seek to coordinate the administration of, and provision of + benefits under, its program under this section with the State + medicaid program under title XIX of the Social Security Act, the + State child health plan under title XXI of such Act, and other + State-administered health programs to maximize the efficiency of + such programs and to improve the continuity of care. + + (d) Transfer of Funds to States.-- + (1) <<NOTE: Determination.>> In general.--If the Secretary + determines that a State electing the application of this section + meets the requirements of the program established under + subsection (a), the Secretary shall transfer to the State for + each fiscal year for which 1 or more standard health plans are + operating within the State the amount determined under paragraph + (3). + (2) Use of funds.--A State shall establish a trust for the + deposit of the amounts received under paragraph (1) and amounts + in the trust fund shall only be used to reduce the premiums and + cost-sharing of, or to provide additional benefits for, eligible + individuals enrolled in standard health plans within the State. + Amounts in the trust fund, and expenditures of such amounts, + shall not be included in determining the amount of any non- + Federal funds for purposes of meeting any matching or + expenditure requirement of any federally-funded program. + (3) Amount of payment.-- + (A) Secretarial determination.-- + (i) In general.--The amount determined under + this paragraph for any fiscal year is the amount + the Secretary determines is equal to 85 percent of + the premium tax credits under section 36B of the + Internal + +[[Page 124 STAT. 202]] + + Revenue Code of 1986, and the cost-sharing + reductions under section 1402, that would have + been provided for the fiscal year to eligible + individuals enrolled in standard health plans in + the State if such eligible individuals were + allowed to enroll in qualified health plans + through an Exchange established under this + subtitle. + (ii) Specific requirements.--The Secretary + shall make the determination under clause (i) on a + per enrollee basis and shall take into account all + relevant factors necessary to determine the value + of the premium tax credits and cost-sharing + reductions that would have been provided to + eligible individuals described in clause (i), + including the age and income of the enrollee, + whether the enrollment is for self-only or family + coverage, geographic differences in average + spending for health care across rating areas, the + health status of the enrollee for purposes of + determining risk adjustment payments and + reinsurance payments that would have been made if + the enrollee had enrolled in a qualified health + plan through an Exchange, and whether any + reconciliation of the credit or cost-sharing + reductions would have occurred if the enrollee had + been so enrolled. This determination shall take + into consideration the experience of other States + with respect to participation in an Exchange and + such credits and reductions provided to residents + of the other States, with a special focus on + enrollees with income below 200 percent of + poverty. + (iii) Certification.--The Chief Actuary of the + Centers for Medicare & Medicaid Services, in + consultation with the Office of Tax Analysis of + the Department of the Treasury, shall certify + whether the methodology used to make + determinations under this subparagraph, and such + determinations, meet the requirements of clause + (ii). Such certifications shall be based on + sufficient data from the State and from comparable + States about their experience with programs + created by this Act. + (B) Corrections.--The Secretary shall adjust the + payment for any fiscal year to reflect any error in the + determinations under subparagraph (A) for any preceding + fiscal year. + (4) Application of special rules.--The provisions of section + 1303 shall apply to a State basic health program, and to + standard health plans offered through such program, in the same + manner as such rules apply to qualified health plans. + + (e) Eligible Individual.-- + (1) <<NOTE: Definition.>> In general.--In this section, the + term ``eligible individual'' means, with respect to any State, + an individual-- + (A) who a resident of the State who is not eligible + to enroll in the State's medicaid program under title + XIX of the Social Security Act for benefits that at a + minimum consist of the essential health benefits + described in section 1302(b); + +[[Page 124 STAT. 203]] + + (B) whose household income exceeds 133 percent but + does not exceed 200 percent of the poverty line for the + size of the family involved; + (C) who is not eligible for minimum essential + coverage (as defined in section 5000A(f) of the Internal + Revenue Code of 1986) or is eligible for an employer- + sponsored plan that is not affordable coverage (as + determined under section 5000A(e)(2) of such Code); and + (D) who has not attained age 65 as of the beginning + of the plan year. + Such term shall not include any individual who is not a + qualified individual under section 1312 who is eligible to be + covered by a qualified health plan offered through an Exchange. + (2) Eligible individuals may not use exchange.--An eligible + individual shall not be treated as a qualified individual under + section 1312 eligible for enrollment in a qualified health plan + offered through an Exchange established under section 1311. + + (f) Secretarial Oversight <<NOTE: Review.>> .--The Secretary shall +each year conduct a review of each State program to ensure compliance +with the requirements of this section, including ensuring that the State +program meets-- + (1) eligibility verification requirements for participation + in the program; + (2) the requirements for use of Federal funds received by + the program; and + (3) the quality and performance standards under this + section. + + (g) Standard Health Plan Offerors.--A State may provide that persons +eligible to offer standard health plans under a basic health program +established under this section may include a licensed health maintenance +organization, a licensed health insurance insurer, or a network of +health care providers established to offer services under the program. + (h) Definitions.--Any term used in this section which is also used +in section 36B of the Internal Revenue Code of 1986 shall have the +meaning given such term by such section. + +SEC. 1332. <<NOTE: 42 USC 18052.>> WAIVER FOR STATE INNOVATION. + + (a) Application.-- + (1) <<NOTE: Effective date.>> In general.--A State may + apply to the Secretary for the waiver of all or any requirements + described in paragraph (2) with respect to health insurance + coverage within that State for plan years beginning on or after + January 1, 2017. Such application shall-- + (A) be filed at such time and in such manner as the + Secretary may require; + (B) contain such information as the Secretary may + require, including-- + (i) a comprehensive description of the State + legislation and program to implement a plan + meeting the requirements for a waiver under this + section; and + (ii) a 10-year budget plan for such plan that + is budget neutral for the Federal Government; and + (C) provide an assurance that the State has enacted + the law described in subsection (b)(2). + +[[Page 124 STAT. 204]] + + (2) Requirements.-- <<NOTE: Effective date.>> The + requirements described in this paragraph with respect to health + insurance coverage within the State for plan years beginning on + or after January 1, 2014, are as follows: + (A) Part I of subtitle D. + (B) Part II of subtitle D. + (C) Section 1402. + (D) Sections 36B, 4980H, and 5000A of the Internal + Revenue Code of 1986. + (3) Pass through of funding.--With respect to a State waiver + under paragraph (1), under which, due to the structure of the + State plan, individuals and small employers in the State would + not qualify for the premium tax credits, cost-sharing + reductions, or small business credits under sections 36B of the + Internal Revenue Code of 1986 or under part I of subtitle E for + which they would otherwise be eligible, the Secretary shall + provide for an alternative means by which the aggregate amount + of such credits or reductions that would have been paid on + behalf of participants in the Exchanges established under this + title had the State not received such waiver, shall be paid to + the State for purposes of implementing the State plan under the + waiver. Such amount shall be determined annually by the + Secretary, taking into consideration the experience of other + States with respect to participation in an Exchange and credits + and reductions provided under such provisions to residents of + the other States. + (4) Waiver consideration and transparency.-- + (A) In general.--An application for a waiver under + this section shall be considered by the Secretary in + accordance with the regulations described in + subparagraph (B). + (B) Regulations <<NOTE: Deadline.>> .--Not later + than 180 days after the date of enactment of this Act, + the Secretary shall promulgate regulations relating to + waivers under this section that provide-- + (i) a process for public notice and comment at + the State level, including public hearings, + sufficient to ensure a meaningful level of public + input; + (ii) a process for the submission of an + application that ensures the disclosure of-- + (I) the provisions of law that the + State involved seeks to waive; and + (II) the specific plans of the State + to ensure that the waiver will be in + compliance with subsection (b); + (iii) a process for providing public notice + and comment after the application is received by + the Secretary, that is sufficient to ensure a + meaningful level of public input and that does not + impose requirements that are in addition to, or + duplicative of, requirements imposed under the + Administrative Procedures Act, or requirements + that are unreasonable or unnecessarily burdensome + with respect to State compliance; + (iv) a process for the submission to the + Secretary of periodic reports by the State + concerning the implementation of the program under + the waiver; and + (v) a process for the periodic evaluation by + the Secretary of the program under the waiver. + +[[Page 124 STAT. 205]] + + (C) Report.--The Secretary shall annually report to + Congress concerning actions taken by the Secretary with + respect to applications for waivers under this section. + (5) Coordinated waiver process.--The Secretary shall develop + a process for coordinating and consolidating the State waiver + processes applicable under the provisions of this section, and + the existing waiver processes applicable under titles XVIII, + XIX, and XXI of the Social Security Act, and any other Federal + law relating to the provision of health care items or services. + Such process shall permit a State to submit a single application + for a waiver under any or all of such provisions. + (6) Definition.--In this section, the term ``Secretary'' + means-- + (A) the Secretary of Health and Human Services with + respect to waivers relating to the provisions described + in subparagraph (A) through (C) of paragraph (2); and + (B) the Secretary of the Treasury with respect to + waivers relating to the provisions described in + paragraph (2)(D). + + (b) Granting of Waivers.-- + (1) In general.--The Secretary may grant a request for a + waiver under subsection (a)(1) only if the Secretary determines + that the State plan-- + (A) will provide coverage that is at least as + comprehensive as the coverage defined in section 1302(b) + and offered through Exchanges established under this + title as certified by Office of the Actuary of the + Centers for Medicare & Medicaid Services based on + sufficient data from the State and from comparable + States about their experience with programs created by + this Act and the provisions of this Act that would be + waived; + (B) will provide coverage and cost sharing + protections against excessive out-of-pocket spending + that are at least as affordable as the provisions of + this title would provide; + (C) will provide coverage to at least a comparable + number of its residents as the provisions of this title + would provide; and + (D) will not increase the Federal deficit. + (2) Requirement to enact a law.-- + (A) In general.--A law described in this paragraph + is a State law that provides for State actions under a + waiver under this section, including the implementation + of the State plan under subsection (a)(1)(B). + (B) Termination of opt out.--A State may repeal a + law described in subparagraph (A) and terminate the + authority provided under the waiver with respect to the + State. + + (c) Scope of Waiver.-- + (1) <<NOTE: Determination.>> In general.--The Secretary + shall determine the scope of a waiver of a requirement described + in subsection (a)(2) granted to a State under subsection (a)(1). + (2) Limitation.--The Secretary may not waive under this + section any Federal law or requirement that is not within the + authority of the Secretary. + + (d) Determinations by Secretary.-- + (1) Time for determination.-- <<NOTE: Deadline.>> The + Secretary shall make a determination under subsection (a)(1) not + later than 180 + +[[Page 124 STAT. 206]] + + days after the receipt of an application from a State under such + subsection. + (2) Effect of determination.-- <<NOTE: Notification.>> + (A) Granting of waivers.--If the Secretary + determines to grant a waiver under subsection (a)(1), + the Secretary shall notify the State involved of such + determination and the terms and effectiveness of such + waiver. + (B) Denial of waiver.--If the Secretary determines a + waiver should not be granted under subsection (a)(1), + the Secretary shall notify the State involved, and the + appropriate committees of Congress of such determination + and the reasons therefore. + + (e) <<NOTE: Deadline. Notification.>> Term of Waiver.--No waiver +under this section may extend over a period of longer than 5 years +unless the State requests continuation of such waiver, and such request +shall be deemed granted unless the Secretary, within 90 days after the +date of its submission to the Secretary, either denies such request in +writing or informs the State in writing with respect to any additional +information which is needed in order to make a final determination with +respect to the request. + +SEC. 1333. <<NOTE: 42 USC 18053.>> PROVISIONS RELATING TO OFFERING OF + PLANS IN MORE THAN ONE STATE. + + (a) Health Care Choice Compacts.-- + (1) In general.-- <<NOTE: Deadline. Regulations.>> Not later + than July 1, 2013, the Secretary shall, in consultation with the + National Association of Insurance Commissioners, issue + regulations for the creation of health care choice compacts + under which 2 or more States may enter into an agreement under + which-- + (A) 1 or more qualified health plans could be + offered in the individual markets in all such States + but, except as provided in subparagraph (B), only be + subject to the laws and regulations of the State in + which the plan was written or issued; + (B) the issuer of any qualified health plan to which + the compact applies-- + (i) would continue to be subject to market + conduct, unfair trade practices, network adequacy, + and consumer protection standards (including + standards relating to rating), including + addressing disputes as to the performance of the + contract, of the State in which the purchaser + resides; + (ii) would be required to be licensed in each + State in which it offers the plan under the + compact or to submit to the jurisdiction of each + such State with regard to the standards described + in clause (i) (including allowing access to + records as if the insurer were licensed in the + State); and + (iii) <<NOTE: Notification.>> must clearly + notify consumers that the policy may not be + subject to all the laws and regulations of the + State in which the purchaser resides. + (2) State authority.--A State may not enter into an + agreement under this subsection unless the State enacts a law + after the date of the enactment of this title that specifically + authorizes the State to enter into such agreements. + (3) Approval of compacts.--The Secretary may approve + interstate health care choice compacts under paragraph (1) + +[[Page 124 STAT. 207]] + + only if the Secretary determines that such health care choice + compact-- + (A) will provide coverage that is at least as + comprehensive as the coverage defined in section 1302(b) + and offered through Exchanges established under this + title; + (B) will provide coverage and cost sharing + protections against excessive out-of-pocket spending + that are at least as affordable as the provisions of + this title would provide; + (C) will provide coverage to at least a comparable + number of its residents as the provisions of this title + would provide; + (D) will not increase the Federal deficit; and + (E) will not weaken enforcement of laws and + regulations described in paragraph (1)(B)(i) in any + State that is included in such compact. + (4) Effective date.--A health care choice compact described + in paragraph (1) shall not take effect before January 1, 2016. + + (b) Authority for Nationwide Plans.-- + (1) In general.--Except as provided in paragraph (2), if an + issuer (including a group of health insurance issuers affiliated + either by common ownership and control or by the common use of a + nationally licensed service mark) of a qualified health plan in + the individual or small group market meets the requirements of + this subsection (in this subsection a ``nationwide qualified + health plan'')-- + (A) the issuer of the plan may offer the nationwide + qualified health plan in the individual or small group + market in more than 1 State; and + (B) <<NOTE: Applicability.>> with respect to State + laws mandating benefit coverage by a health plan, only + the State laws of the State in which such plan is + written or issued shall apply to the nationwide + qualified health plan. + (2) State opt-out.--A State may, by specific reference in a + law enacted after the date of enactment of this title, provide + that this subsection shall not apply to that State. Such opt-out + shall be effective until such time as the State by law revokes + it. + (3) Plan requirements.--An issuer meets the requirements of + this subsection with respect to a nationwide qualified health + plan if, in the determination of the Secretary-- + (A) the plan offers a benefits package that is + uniform in each State in which the plan is offered and + meets the requirements set forth in paragraphs (4) + through (6); + (B) the issuer is licensed in each State in which it + offers the plan and is subject to all requirements of + State law not inconsistent with this section, including + but not limited to, the standards and requirements that + a State imposes that do not prevent the application of a + requirement of part A of title XXVII of the Public + Health Service Act or a requirement of this title; + (C) the issuer meets all requirements of this title + with respect to a qualified health plan, including the + requirement to offer the silver and gold levels of the + plan in each Exchange in the State for the market in + which the plan is offered; + +[[Page 124 STAT. 208]] + + (D) the issuer determines the premiums for the plan + in any State on the basis of the rating rules in effect + in that State for the rating areas in which it is + offered; + (E) the issuer offers the nationwide qualified + health plan in at least 60 percent of the participating + States in the first year in which the plan is offered, + 65 percent of such States in the second year, 70 percent + of such States in the third year, 75 percent of such + States in the fourth year, and 80 percent of such States + in the fifth and subsequent years; + (F) the issuer shall offer the plan in participating + States across the country, in all geographic regions, + and in all States that have adopted adjusted community + rating before the date of enactment of this Act; and + (G) the issuer clearly notifies consumers that the + policy may not contain some benefits otherwise mandated + for plans in the State in which the purchaser resides + and provides a detailed statement of the benefits + offered and the benefit differences in that State, in + accordance with rules promulgated by the Secretary. + (4) <<NOTE: Deadline.>> Form review for nationwide plans.-- + Notwithstanding any contrary provision of State law, at least 3 + months before any nationwide qualified health plan is offered, + the issuer shall file all nationwide qualified health plan forms + with the regulator in each participating State in which the plan + will be offered. An issuer may appeal the disapproval of a + nationwide qualified health plan form to the Secretary. + (5) Applicable rules.--The Secretary shall, in consultation + with the National Association of Insurance Commissioners, issue + rules for the offering of nationwide qualified health plans + under this subsection. Nationwide qualified health plans may be + offered only after such rules have taken effect. + (6) Coverage.--The Secretary shall provide that the health + benefits coverage provided to an individual through a nationwide + qualified health plan under this subsection shall include at + least the essential benefits package described in section 1302. + (7) State law mandating benefit coverage by a health + benefits plan.--For the purposes of this subsection, a State law + mandating benefit coverage by a health plan is a law that + mandates health insurance coverage or the offer of health + insurance coverage for specific health services or specific + diseases. A law that mandates health insurance coverage or + reimbursement for services provided by certain classes of + providers of health care services, or a law that mandates that + certain classes of individuals must be covered as a group or as + dependents, is not a State law mandating benefit coverage by a + health benefits plan. + + PART V--REINSURANCE AND RISK ADJUSTMENT + +SEC. 1341. <<NOTE: 42 USC 18061.>> TRANSITIONAL REINSURANCE PROGRAM FOR + INDIVIDUAL AND SMALL GROUP MARKETS IN EACH STATE. + + (a) In General <<NOTE: Deadline.>> .--Each State shall, not later +than January 1, 2014-- + +[[Page 124 STAT. 209]] + + (1) include in the Federal standards or State law or + regulation the State adopts and has in effect under section + 1321(b) the provisions described in subsection (b); and + (2) <<NOTE: Contracts.>> establish (or enter into a contract + with) 1 or more applicable reinsurance entities to carry out the + reinsurance program under this section. + + (b) Model Regulation.-- + (1) In general.--In establishing the Federal standards under + section 1321(a), the Secretary, in consultation with the + National Association of Insurance Commissioners (the ``NAIC''), + shall include provisions that enable States to establish and + maintain a program under which-- + (A) <<NOTE: Effective date. Time period.>> health + insurance issuers, and third party administrators on + behalf of group health plans, are required to make + payments to an applicable reinsurance entity for any + plan year beginning in the 3-year period beginning + January 1, 2014 (as specified in paragraph (3); and + (B) the applicable reinsurance entity collects + payments under subparagraph (A) and uses amounts so + collected to make reinsurance payments to health + insurance issuers described in subparagraph (A) that + cover high risk individuals in the individual market + (excluding grandfathered health plans) for any plan year + beginning in such 3-year period. + (2) High-risk individual; payment amounts.--The Secretary + shall include the following in the provisions under paragraph + (1): + (A) Determination of high-risk individuals.--The + method by which individuals will be identified as high + risk individuals for purposes of the reinsurance program + established under this section. Such method shall + provide for identification of individuals as high-risk + individuals on the basis of-- + (i) a list of at least 50 but not more than + 100 medical conditions that are identified as + high-risk conditions and that may be based on the + identification of diagnostic and procedure codes + that are indicative of individuals with pre- + existing, high-risk conditions; or + (ii) any other comparable objective method of + identification recommended by the American Academy + of Actuaries. + (B) Payment amount.--The formula for determining the + amount of payments that will be paid to health insurance + issuers described in paragraph (1)(A) that insure high- + risk individuals. Such formula shall provide for the + equitable allocation of available funds through + reconciliation and may be designed-- + (i) to provide a schedule of payments that + specifies the amount that will be paid for each of + the conditions identified under subparagraph (A); + or + (ii) to use any other comparable method for + determining payment amounts that is recommended by + the American Academy of Actuaries and that + encourages the use of care coordination and care + management programs for high risk conditions. + (3) Determination of required contributions.-- + +[[Page 124 STAT. 210]] + + (A) In general <<NOTE: Effective date. Time + period.>> .--The Secretary shall include in the + provisions under paragraph (1) the method for + determining the amount each health insurance issuer and + group health plan described in paragraph (1)(A) + contributing to the reinsurance program under this + section is required to contribute under such paragraph + for each plan year beginning in the 36-month period + beginning January 1, 2014. The contribution amount for + any plan year may be based on the percentage of revenue + of each issuer and the total costs of providing benefits + to enrollees in self-insured plans or on a specified + amount per enrollee and may be required to be paid in + advance or periodically throughout the plan year. + (B) Specific requirements.--The method under this + paragraph shall be designed so that-- + (i) the contribution amount for each issuer + proportionally reflects each issuer's fully + insured commercial book of business for all major + medical products and the total value of all fees + charged by the issuer and the costs of coverage + administered by the issuer as a third party + administrator; + (ii) the contribution amount can include an + additional amount to fund the administrative + expenses of the applicable reinsurance entity; + (iii) the aggregate contribution amounts for + all States shall, based on the best estimates of + the NAIC and without regard to amounts described + in clause (ii), equal $10,000,000,000 for plan + years beginning in 2014, $6,000,000,000 for plan + years beginning 2015, and $4,000,000,000 for plan + years beginning in 2016; and + (iv) in addition to the aggregate contribution + amounts under clause (iii), each issuer's + contribution amount for any calendar year under + clause (iii) reflects its proportionate share of + an additional $2,000,000,000 for 2014, an + additional $2,000,000,000 for 2015, and an + additional $1,000,000,000 for 2016. + Nothing in this subparagraph shall be construed to + preclude a State from collecting additional amounts from + issuers on a voluntary basis. + (4) Expenditure of funds.--The provisions under paragraph + (1) shall provide that-- + (A) the contribution amounts collected for any + calendar year may be allocated and used in any of the + three calendar years for which amounts are collected + based on the reinsurance needs of a particular period or + to reflect experience in a prior period; and + (B) <<NOTE: Time period. Effective date.>> amounts + remaining unexpended as of December, 2016, may be used + to make payments under any reinsurance program of a + State in the individual market in effect in the 2-year + period beginning on January 1, 2017. + Notwithstanding the preceding sentence, any contribution amounts + described in paragraph (3)(B)(iv) shall be deposited into the + general fund of the Treasury of the United States and may not be + used for the program established under this section. + +[[Page 124 STAT. 211]] + + (c) Applicable Reinsurance Entity.--For purposes of this section-- + (1) In general.-- <<NOTE: Definition.>> The term + ``applicable reinsurance entity'' means a not-for-profit + organization-- + (A) the purpose of which is to help stabilize + premiums for coverage in the individual and small group + markets in a State during the first 3 years of operation + of an Exchange for such markets within the State when + the risk of adverse selection related to new rating + rules and market changes is greatest; and + (B) the duties of which shall be to carry out the + reinsurance program under this section by coordinating + the funding and operation of the risk-spreading + mechanisms designed to implement the reinsurance + program. + (2) State discretion.--A State may have more than 1 + applicable reinsurance entity to carry out the reinsurance + program under this section within the State and 2 or more States + may enter into agreements to provide for an applicable + reinsurance entity to carry out such program in all such States. + (3) Entities are tax-exempt.--An applicable reinsurance + entity established under this section shall be exempt from + taxation under chapter 1 of the Internal Revenue Code of 1986. + The preceding sentence shall not apply to the tax imposed by + section 511 such Code (relating to tax on unrelated business + taxable income of an exempt organization). + + (d) Coordination With State High-risk Pools.--The State shall +eliminate or modify any State high-risk pool to the extent necessary to +carry out the reinsurance program established under this section. The +State may coordinate the State high-risk pool with such program to the +extent not inconsistent with the provisions of this section. + +SEC. 1342. <<NOTE: 42 USC 18062.>> ESTABLISHMENT OF RISK CORRIDORS FOR + PLANS IN INDIVIDUAL AND SMALL GROUP MARKETS. + + (a) In General.--The Secretary shall establish and administer a +program of risk corridors for calendar years 2014, 2015, and 2016 under +which a qualified health plan offered in the individual or small group +market shall participate in a payment adjustment system based on the +ratio of the allowable costs of the plan to the plan's aggregate +premiums. Such program shall be based on the program for regional +participating provider organizations under part D of title XVIII of the +Social Security Act. + (b) Payment Methodology.-- + (1) Payments out.--The Secretary shall provide under the + program established under subsection (a) that if-- + (A) a participating plan's allowable costs for any + plan year are more than 103 percent but not more than + 108 percent of the target amount, the Secretary shall + pay to the plan an amount equal to 50 percent of the + target amount in excess of 103 percent of the target + amount; and + (B) a participating plan's allowable costs for any + plan year are more than 108 percent of the target + amount, the Secretary shall pay to the plan an amount + equal to the sum of 2.5 percent of the target amount + plus 80 percent of allowable costs in excess of 108 + percent of the target amount. + +[[Page 124 STAT. 212]] + + (2) Payments in.--The Secretary shall provide under the + program established under subsection (a) that if-- + (A) a participating plan's allowable costs for any + plan year are less than 97 percent but not less than 92 + percent of the target amount, the plan shall pay to the + Secretary an amount equal to 50 percent of the excess of + 97 percent of the target amount over the allowable + costs; and + (B) a participating plan's allowable costs for any + plan year are less than 92 percent of the target amount, + the plan shall pay to the Secretary an amount equal to + the sum of 2.5 percent of the target amount plus 80 + percent of the excess of 92 percent of the target amount + over the allowable costs. + + (c) Definitions.--In this section: + (1) Allowable costs.-- + (A) In general.--The amount of allowable costs of a + plan for any year is an amount equal to the total costs + (other than administrative costs) of the plan in + providing benefits covered by the plan. + (B) Reduction for risk adjustment and reinsurance + payments.--Allowable costs shall reduced by any risk + adjustment and reinsurance payments received under + section 1341 and 1343. + (2) Target amount.--The target amount of a plan for any year + is an amount equal to the total premiums (including any premium + subsidies under any governmental program), reduced by the + administrative costs of the plan. + +SEC. 1343. <<NOTE: 42 USC 18063.>> RISK ADJUSTMENT. + + (a) In General.-- + (1) Low actuarial risk plans.--Using the criteria and + methods developed under subsection (b), each State shall assess + a charge on health plans and health insurance issuers (with + respect to health insurance coverage) described in subsection + (c) if the actuarial risk of the enrollees of such plans or + coverage for a year is less than the average actuarial risk of + all enrollees in all plans or coverage in such State for such + year that are not self-insured group health plans (which are + subject to the provisions of the Employee Retirement Income + Security Act of 1974). + (2) High actuarial risk plans.--Using the criteria and + methods developed under subsection (b), each State shall provide + a payment to health plans and health insurance issuers (with + respect to health insurance coverage) described in subsection + (c) if the actuarial risk of the enrollees of such plans or + coverage for a year is greater than the average actuarial risk + of all enrollees in all plans and coverage in such State for + such year that are not self-insured group health plans (which + are subject to the provisions of the Employee Retirement Income + Security Act of 1974). + + (b) Criteria and Methods.--The Secretary, in consultation with +States, shall establish criteria and methods to be used in carrying out +the risk adjustment activities under this section. The Secretary may +utilize criteria and methods similar to the criteria and methods +utilized under part C or D of title XVIII of the Social Security Act. +Such criteria and methods shall be included + +[[Page 124 STAT. 213]] + +in the standards and requirements the Secretary prescribes under section +1321. + (c) Scope.--A health plan or a health insurance issuer is described +in this subsection if such health plan or health insurance issuer +provides coverage in the individual or small group market within the +State. This subsection shall not apply to a grandfathered health plan or +the issuer of a grandfathered health plan with respect to that plan. + + Subtitle E--Affordable Coverage Choices for All Americans + + PART I--PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS + + Subpart A--Premium Tax Credits and Cost-sharing Reductions + +SEC. 1401. REFUNDABLE TAX CREDIT PROVIDING PREMIUM ASSISTANCE FOR + COVERAGE UNDER A QUALIFIED HEALTH PLAN. + + (a) In General.--Subpart C of part IV of subchapter A of chapter 1 +of the Internal Revenue Code of 1986 (relating to refundable credits) is +amended by inserting after section 36A the following new section: + +``SEC. 36B. <<NOTE: 26 USC 36.>> REFUNDABLE CREDIT FOR COVERAGE UNDER A + QUALIFIED HEALTH PLAN. + + ``(a) In General.--In the case of an applicable taxpayer, there +shall be allowed as a credit against the tax imposed by this subtitle +for any taxable year an amount equal to the premium assistance credit +amount of the taxpayer for the taxable year. + ``(b) Premium Assistance Credit Amount.--For purposes of this +section-- + ``(1) In general.-- <<NOTE: Definition.>> The term `premium + assistance credit amount' means, with respect to any taxable + year, the sum of the premium assistance amounts determined under + paragraph (2) with respect to all coverage months of the + taxpayer occurring during the taxable year. + ``(2) Premium assistance amount.--The premium assistance + amount determined under this subsection with respect to any + coverage month is the amount equal to the lesser of-- + ``(A) the monthly premiums for such month for 1 or + more qualified health plans offered in the individual + market within a State which cover the taxpayer, the + taxpayer's spouse, or any dependent (as defined in + section 152) of the taxpayer and which were enrolled in + through an Exchange established by the State under 1311 + of the Patient Protection and Affordable Care Act, or + ``(B) the excess (if any) of-- + ``(i) the adjusted monthly premium for such + month for the applicable second lowest cost silver + plan with respect to the taxpayer, over + +[[Page 124 STAT. 214]] + + ``(ii) an amount equal to 1/12 of the product + of the applicable percentage and the taxpayer's + household income for the taxable year. + ``(3) Other terms and rules relating to premium assistance + amounts.--For purposes of paragraph (2)-- + ``(A) Applicable percentage.-- + ``(i) In general.--Except as provided in + clause (ii), the applicable percentage with + respect to any taxpayer for any taxable year is + equal to 2.8 percent, increased by the number of + percentage points (not greater than 7) which bears + the same ratio to 7 percentage points as-- + ``(I) the taxpayer's household + income for the taxable year in excess of + 100 percent of the poverty line for a + family of the size involved, bears to + ``(II) an amount equal to 200 + percent of the poverty line for a family + of the size involved. + ``(ii) Special rule for taxpayers under 133 + percent of poverty line.--If a taxpayer's + household income for the taxable year is in excess + of 100 percent, but not more than 133 percent, of + the poverty line for a family of the size + involved, the taxpayer's applicable percentage + shall be 2 percent. + ``(iii) Indexing.--In the case of taxable + years beginning in any calendar year after 2014, + the Secretary shall adjust the initial and final + applicable percentages under clause (i), and the 2 + percent under clause (ii), for the calendar year + to reflect the excess of the rate of premium + growth between the preceding calendar year and + 2013 over the rate of income growth for such + period. + ``(B) Applicable second lowest cost silver plan.-- + The applicable second lowest cost silver plan with + respect to any applicable taxpayer is the second lowest + cost silver plan of the individual market in the rating + area in which the taxpayer resides which-- + ``(i) is offered through the same Exchange + through which the qualified health plans taken + into account under paragraph (2)(A) were offered, + and + ``(ii) provides-- + ``(I) self-only coverage in the case + of an applicable taxpayer-- + ``(aa) whose tax for the + taxable year is determined under + section 1(c) (relating to + unmarried individuals other than + surviving spouses and heads of + households) and who is not + allowed a deduction under + section 151 for the taxable year + with respect to a dependent, or + ``(bb) who is not described + in item (aa) but who purchases + only self-only coverage, and + ``(II) family coverage in the case + of any other applicable taxpayer. + If a taxpayer files a joint return and no credit is + allowed under this section with respect to 1 of the + spouses by reason of subsection (e), the taxpayer shall + be treated as described in clause (ii)(I) unless a + deduction is allowed + +[[Page 124 STAT. 215]] + + under section 151 for the taxable year with respect to a + dependent other than either spouse and subsection (e) + does not apply to the dependent. + ``(C) Adjusted monthly premium.--The adjusted + monthly premium for an applicable second lowest cost + silver plan is the monthly premium which would have been + charged (for the rating area with respect to which the + premiums under paragraph (2)(A) were determined) for the + plan if each individual covered under a qualified health + plan taken into account under paragraph (2)(A) were + covered by such silver plan and the premium was adjusted + only for the age of each such individual in the manner + allowed under section 2701 of the Public Health Service + Act. In the case of a State participating in the + wellness discount demonstration project under section + 2705(d) of the Public Health Service Act, the adjusted + monthly premium shall be determined without regard to + any premium discount or rebate under such project. + ``(D) Additional benefits.--If-- + ``(i) a qualified health plan under section + 1302(b)(5) of the Patient Protection and + Affordable Care Act offers benefits in addition to + the essential health benefits required to be + provided by the plan, or + ``(ii) a State requires a qualified health + plan under section 1311(d)(3)(B) of such Act to + cover benefits in addition to the essential health + benefits required to be provided by the plan, + the portion of the premium for the plan properly + allocable (under rules prescribed by the Secretary of + Health and Human Services) to such additional benefits + shall not be taken into account in determining either + the monthly premium or the adjusted monthly premium + under paragraph (2). + ``(E) Special rule for pediatric dental coverage.-- + For purposes of determining the amount of any monthly + premium, if an individual enrolls in both a qualified + health plan and a plan described in section + 1311(d)(2)(B)(ii)(I) of the Patient Protection and + Affordable Care Act for any plan year, the portion of + the premium for the plan described in such section that + (under regulations prescribed by the Secretary) is + properly allocable to pediatric dental benefits which + are included in the essential health benefits required + to be provided by a qualified health plan under section + 1302(b)(1)(J) of such Act shall be treated as a premium + payable for a qualified health plan. + + ``(c) Definition and Rules Relating to Applicable Taxpayers, +Coverage Months, and Qualified Health Plan.--For purposes of this +section-- + ``(1) Applicable taxpayer.-- + ``(A) In general.--The term `applicable taxpayer' + means, with respect to any taxable year, a taxpayer + whose household income for the taxable year exceeds 100 + percent but does not exceed 400 percent of an amount + equal to the poverty line for a family of the size + involved. + ``(B) Special rule for certain individuals lawfully + present in the united states.--If-- + +[[Page 124 STAT. 216]] + + ``(i) a taxpayer has a household income which + is not greater than 100 percent of an amount equal + to the poverty line for a family of the size + involved, and + ``(ii) the taxpayer is an alien lawfully + present in the United States, but is not eligible + for the medicaid program under title XIX of the + Social Security Act by reason of such alien + status, + the taxpayer shall, for purposes of the credit under + this section, be treated as an applicable taxpayer with + a household income which is equal to 100 percent of the + poverty line for a family of the size involved. + ``(C) Married couples must file joint return.--If + the taxpayer is married (within the meaning of section + 7703) at the close of the taxable year, the taxpayer + shall be treated as an applicable taxpayer only if the + taxpayer and the taxpayer's spouse file a joint return + for the taxable year. + ``(D) Denial of credit to dependents.--No credit + shall be allowed under this section to any individual + with respect to whom a deduction under section 151 is + allowable to another taxpayer for a taxable year + beginning in the calendar year in which such + individual's taxable year begins. + ``(2) Coverage month.--For purposes of this subsection-- + ``(A) In general.--The term `coverage month' means, + with respect to an applicable taxpayer, any month if-- + ``(i) as of the first day of such month the + taxpayer, the taxpayer's spouse, or any dependent + of the taxpayer is covered by a qualified health + plan described in subsection (b)(2)(A) that was + enrolled in through an Exchange established by the + State under section 1311 of the Patient Protection + and Affordable Care Act, and + ``(ii) the premium for coverage under such + plan for such month is paid by the taxpayer (or + through advance payment of the credit under + subsection (a) under section 1412 of the Patient + Protection and Affordable Care Act). + ``(B) Exception for minimum essential coverage.-- + ``(i) In general.--The term `coverage month' + shall not include any month with respect to an + individual if for such month the individual is + eligible for minimum essential coverage other than + eligibility for coverage described in section + 5000A(f)(1)(C) (relating to coverage in the + individual market). + ``(ii) Minimum essential coverage.--The term + `minimum essential coverage' has the meaning given + such term by section 5000A(f). + ``(C) Special rule for employer-sponsored minimum + essential coverage.--For purposes of subparagraph (B)-- + ``(i) Coverage must be affordable.--Except as + provided in clause (iii), an employee shall not be + treated as eligible for minimum essential coverage + if such coverage-- + ``(I) consists of an eligible + employer-sponsored plan (as defined in + section 5000A(f)(2)), and + ``(II) the employee's required + contribution (within the meaning of + section 5000A(e)(1)(B)) with + +[[Page 124 STAT. 217]] + + respect to the plan exceeds 9.8 percent + of the applicable taxpayer's household + income. + <<NOTE: Applicability.>> This clause shall also + apply to an individual who is eligible to enroll + in the plan by reason of a relationship the + individual bears to the employee. + ``(ii) Coverage must provide minimum value.-- + Except as provided in clause (iii), an employee + shall not be treated as eligible for minimum + essential coverage if such coverage consists of an + eligible employer-sponsored plan (as defined in + section 5000A(f)(2)) and the plan's share of the + total allowed costs of benefits provided under the + plan is less than 60 percent of such costs. + ``(iii) Employee or family must not be covered + under employer plan.--Clauses (i) and (ii) shall + not apply if the employee (or any individual + described in the last sentence of clause (i)) is + covered under the eligible employer-sponsored plan + or the grandfathered health plan. + ``(iv) Indexing.--In the case of plan years + beginning in any calendar year after 2014, the + Secretary shall adjust the 9.8 percent under + clause (i)(II) in the same manner as the + percentages are adjusted under subsection + (b)(3)(A)(ii). + ``(3) Definitions and other rules.-- + ``(A) Qualified health plan.--The term `qualified + health plan' has the meaning given such term by section + 1301(a) of the Patient Protection and Affordable Care + Act, except that such term shall not include a qualified + health plan which is a catastrophic plan described in + section 1302(e) of such Act. + ``(B) Grandfathered health plan.--The term + `grandfathered health plan' has the meaning given such + term by section 1251 of the Patient Protection and + Affordable Care Act. + + ``(d) Terms Relating to Income and Families.--For purposes of this +section-- + ``(1) Family size.--The family size involved with respect to + any taxpayer shall be equal to the number of individuals for + whom the taxpayer is allowed a deduction under section 151 + (relating to allowance of deduction for personal exemptions) for + the taxable year. + ``(2) Household income.-- + ``(A) Household income.--The term `household income' + means, with respect to any taxpayer, an amount equal to + the sum of-- + ``(i) the modified gross income of the + taxpayer, plus + ``(ii) the aggregate modified gross incomes of + all other individuals who-- + ``(I) were taken into account in + determining the taxpayer's family size + under paragraph (1), and + ``(II) were required to file a + return of tax imposed by section 1 for + the taxable year. + ``(B) Modified gross income.--The term `modified + gross income' means gross income-- + +[[Page 124 STAT. 218]] + + ``(i) decreased by the amount of any deduction + allowable under paragraph (1), (3), (4), or (10) + of section 62(a), + ``(ii) increased by the amount of interest + received or accrued during the taxable year which + is exempt from tax imposed by this chapter, and + ``(iii) determined without regard to sections + 911, 931, and 933. + ``(3) Poverty line.-- + ``(A) In general.--The term `poverty line' has the + meaning given that term in section 2110(c)(5) of the + Social Security Act (42 U.S.C. 1397jj(c)(5)). + ``(B) Poverty line used.--In the case of any + qualified health plan offered through an Exchange for + coverage during a taxable year beginning in a calendar + year, the poverty line used shall be the most recently + published poverty line as of the 1st day of the regular + enrollment period for coverage during such calendar + year. + + ``(e) Rules for Individuals Not Lawfully Present.-- + ``(1) In general.--If 1 or more individuals for whom a + taxpayer is allowed a deduction under section 151 (relating to + allowance of deduction for personal exemptions) for the taxable + year (including the taxpayer or his spouse) are individuals who + are not lawfully present-- + ``(A) the aggregate amount of premiums otherwise + taken into account under clauses (i) and (ii) of + subsection (b)(2)(A) shall be reduced by the portion (if + any) of such premiums which is attributable to such + individuals, and + ``(B) for purposes of applying this section, the + determination as to what percentage a taxpayer's + household income bears to the poverty level for a family + of the size involved shall be made under one of the + following methods: + ``(i) A method under which-- + ``(I) the taxpayer's family size is + determined by not taking such + individuals into account, and + ``(II) the taxpayer's household + income is equal to the product of the + taxpayer's household income (determined + without regard to this subsection) and a + fraction-- + ``(aa) the numerator of + which is the poverty line for + the taxpayer's family size + determined after application of + subclause (I), and + ``(bb) the denominator of + which is the poverty line for + the taxpayer's family size + determined without regard to + subclause (I). + ``(ii) A comparable method reaching the same + result as the method under clause (i). + ``(2) Lawfully present.--For purposes of this section, an + individual shall be treated as lawfully present only if the + individual is, and is reasonably expected to be for the entire + period of enrollment for which the credit under this section is + being claimed, a citizen or national of the United States or an + alien lawfully present in the United States. + ``(3) Secretarial authority.-- <<NOTE: Regulations.>> The + Secretary of Health and Human Services, in consultation with the + Secretary, shall prescribe rules setting forth the methods by + which calculations of family size and household income are made + for purposes + +[[Page 124 STAT. 219]] + + of this subsection. Such rules shall be designed to ensure that + the least burden is placed on individuals enrolling in qualified + health plans through an Exchange and taxpayers eligible for the + credit allowable under this section. + + ``(f) Reconciliation of Credit and Advance Credit.-- + ``(1) In general.--The amount of the credit allowed under + this section for any taxable year shall be reduced (but not + below zero) by the amount of any advance payment of such credit + under section 1412 of the Patient Protection and Affordable Care + Act. + ``(2) Excess advance payments.-- + ``(A) In general.--If the advance payments to a + taxpayer under section 1412 of the Patient Protection + and Affordable Care Act for a taxable year exceed the + credit allowed by this section (determined without + regard to paragraph (1)), the tax imposed by this + chapter for the taxable year shall be increased by the + amount of such excess. + ``(B) Limitation on increase where income less than + 400 percent of poverty line.-- + ``(i) In general.--In the case of an + applicable taxpayer whose household income is less + than 400 percent of the poverty line for the size + of the family involved for the taxable year, the + amount of the increase under subparagraph (A) + shall in no event exceed $400 ($250 in the case of + a taxpayer whose tax is determined under section + 1(c) for the taxable year). + ``(ii) Indexing of amount.--In the case of any + calendar year beginning after 2014, each of the + dollar amounts under clause (i) shall be increased + by an amount equal to-- + ``(I) such dollar amount, multiplied + by + ``(II) the cost-of-living adjustment + determined under section 1(f)(3) for the + calendar year, determined by + substituting `calendar year 2013' for + `calendar year 1992' in subparagraph (B) + thereof. + If the amount of any increase under clause (i) is + not a multiple of $50, such increase shall be + rounded to the next lowest multiple of $50. + + ``(g) Regulations.--The Secretary shall prescribe such regulations +as may be necessary to carry out the provisions of this section, +including regulations which provide for-- + ``(1) the coordination of the credit allowed under this + section with the program for advance payment of the credit under + section 1412 of the Patient Protection and Affordable Care Act, + and + ``(2) the application of subsection (f) where the filing + status of the taxpayer for a taxable year is different from such + status used for determining the advance payment of the + credit.''. + + (b) Disallowance of Deduction.--Section 280C of the Internal Revenue +Code of 1986 <<NOTE: 26 USC 280C.>> is amended by adding at the end the +following new subsection: + + ``(g) Credit for Health Insurance Premiums.--No deduction shall be +allowed for the portion of the premiums paid by the taxpayer for +coverage of 1 or more individuals under a qualified health plan which is +equal to the amount of the credit determined for the taxable year under +section 36B(a) with respect to such premiums.''. + +[[Page 124 STAT. 220]] + + (c) Study on Affordable Coverage.-- + (1) Study and report.-- + (A) In general.--Not later than 5 years after the + date of the enactment of this Act, the Comptroller + General shall conduct a study on the affordability of + health insurance coverage, including-- + (i) the impact of the tax credit for qualified + health insurance coverage of individuals under + section 36B of the Internal Revenue Code of 1986 + and the tax credit for employee health insurance + expenses of small employers under section 45R of + such Code on maintaining and expanding the health + insurance coverage of individuals; + (ii) the availability of affordable health + benefits plans, including a study of whether the + percentage of household income used for purposes + of section 36B(c)(2)(C) of the Internal Revenue + Code of 1986 (as added by this section) is the + appropriate level for determining whether + employer-provided coverage is affordable for an + employee and whether such level may be lowered + without significantly increasing the costs to the + Federal Government and reducing employer-provided + coverage; and + (iii) the ability of individuals to maintain + essential health benefits coverage (as defined in + section 5000A(f) of the Internal Revenue Code of + 1986). + (B) Report.--The Comptroller General shall submit to + the appropriate committees of Congress a report on the + study conducted under subparagraph (A), together with + legislative recommendations relating to the matters + studied under such subparagraph. + (2) Appropriate committees of congress.--In this subsection, + the term ``appropriate committees of Congress'' means the + Committee on Ways and Means, the Committee on Education and + Labor, and the Committee on Energy and Commerce of the House of + Representatives and the Committee on Finance and the Committee + on Health, Education, Labor and Pensions of the Senate. + + (d) Conforming Amendments.-- + (1) Paragraph (2) of section 1324(b) of title 31, United + States Code, is amended by inserting ``36B,'' after ``36A,''. + (2) The table of sections for subpart C of part IV of + subchapter A of chapter 1 of the Internal Revenue Code of 1986 + is amended by inserting after the item relating to section 36A + the following new item: + +``Sec. 36B. Refundable credit for coverage under a qualified health + plan.''. + + (e) <<NOTE: 26 USC 36B note.>> Effective Date.--The amendments made +by this section shall apply to taxable years ending after December 31, +2013. + +SEC. 1402. <<NOTE: 42 USC 18071.>> REDUCED COST-SHARING FOR INDIVIDUALS + ENROLLING IN QUALIFIED HEALTH PLANS. + + (a) In General.--In the case of an eligible insured enrolled in a +qualified health plan-- + (1) <<NOTE: Notification.>> the Secretary shall notify the + issuer of the plan of such eligibility; and + (2) the issuer shall reduce the cost-sharing under the plan + at the level and in the manner specified in subsection (c). + +[[Page 124 STAT. 221]] + + (b) Eligible Insured.--In this section, the term ``eligible +insured'' means an individual-- + (1) who enrolls in a qualified health plan in the silver + level of coverage in the individual market offered through an + Exchange; and + (2) whose household income exceeds 100 percent but does not + exceed 400 percent of the poverty line for a family of the size + involved. + +In the case of an individual described in section 36B(c)(1)(B) of the +Internal Revenue Code of 1986, the individual shall be treated as having +household income equal to 100 percent for purposes of applying this +section. + (c) Determination of Reduction in Cost-sharing.-- + (1) Reduction in out-of-pocket limit.-- + (A) In general.--The reduction in cost-sharing under + this subsection shall first be achieved by reducing the + applicable out-of pocket limit under section 1302(c)(1) + in the case of-- + (i) an eligible insured whose household income + is more than 100 percent but not more than 200 + percent of the poverty line for a family of the + size involved, by two-thirds; + (ii) an eligible insured whose household + income is more than 200 percent but not more than + 300 percent of the poverty line for a family of + the size involved, by one-half; and + (iii) an eligible insured whose household + income is more than 300 percent but not more than + 400 percent of the poverty line for a family of + the size involved, by one-third. + (B) Coordination with actuarial value limits.-- + (i) In general.--The Secretary shall ensure + the reduction under this paragraph shall not + result in an increase in the plan's share of the + total allowed costs of benefits provided under the + plan above-- + (I) 90 percent in the case of an + eligible insured described in paragraph + (2)(A); + (II) 80 percent in the case of an + eligible insured described in paragraph + (2)(B); and + (III) 70 percent in the case of an + eligible insured described in clause + (ii) or (iii) of subparagraph (A). + (ii) Adjustment.--The Secretary shall adjust + the out-of pocket limits under paragraph (1) if + necessary to ensure that such limits do not cause + the respective actuarial values to exceed the + levels specified in clause (i). + (2) Additional reduction for lower income insureds.-- + The <<NOTE: Procedures.>> Secretary shall establish procedures + under which the issuer of a qualified health plan to which this + section applies shall further reduce cost-sharing under the plan + in a manner sufficient to-- + (A) in the case of an eligible insured whose + household income is not less than 100 percent but not + more than 150 percent of the poverty line for a family + of the size involved, increase the plan's share of the + total allowed + +[[Page 124 STAT. 222]] + + costs of benefits provided under the plan to 90 percent + of such costs; and + (B) in the case of an eligible insured whose + household income is more than 150 percent but not more + than 200 percent of the poverty line for a family of the + size involved, increase the plan's share of the total + allowed costs of benefits provided under the plan to 80 + percent of such costs. + (3) Methods for reducing cost-sharing.-- + (A) <<NOTE: Notification.>> In general.--An issuer + of a qualified health plan making reductions under this + subsection shall notify the Secretary of such reductions + and the Secretary shall make periodic and timely + payments to the issuer equal to the value of the + reductions. + (B) Capitated payments.--The Secretary may establish + a capitated payment system to carry out the payment of + cost-sharing reductions under this section. Any such + system shall take into account the value of the + reductions and make appropriate risk adjustments to such + payments. + (4) Additional benefits.--If a qualified health plan under + section 1302(b)(5) offers benefits in addition to the essential + health benefits required to be provided by the plan, or a State + requires a qualified health plan under section 1311(d)(3)(B) to + cover benefits in addition to the essential health benefits + required to be provided by the plan, the reductions in cost- + sharing under this section shall not apply to such additional + benefits. + (5) Special rule for pediatric dental plans.--If an + individual enrolls in both a qualified health plan and a plan + described in section 1311(d)(2)(B)(ii)(I) for any plan year, + subsection (a) shall not apply to that portion of any reduction + in cost-sharing under subsection (c) that (under regulations + prescribed by the Secretary) is properly allocable to pediatric + dental benefits which are included in the essential health + benefits required to be provided by a qualified health plan + under section 1302(b)(1)(J). + + (d) Special Rules for Indians.-- + (1) Indians under 300 percent of poverty.--If an individual + enrolled in any qualified health plan in the individual market + through an Exchange is an Indian (as defined in section 4(d) of + the Indian Self-Determination and Education Assistance Act (25 + U.S.C. 450b(d))) whose household income is not more than 300 + percent of the poverty line for a family of the size involved, + then, for purposes of this section-- + (A) such individual shall be treated as an eligible + insured; and + (B) the issuer of the plan shall eliminate any cost- + sharing under the plan. + (2) Items or services furnished through indian health + providers.--If an Indian (as so defined) enrolled in a qualified + health plan is furnished an item or service directly by the + Indian Health Service, an Indian Tribe, Tribal Organization, or + Urban Indian Organization or through referral under contract + health services-- + (A) no cost-sharing under the plan shall be imposed + under the plan for such item or service; and + (B) the issuer of the plan shall not reduce the + payment to any such entity for such item or service by + the amount + +[[Page 124 STAT. 223]] + + of any cost-sharing that would be due from the Indian + but for subparagraph (A). + (3) Payment.--The Secretary shall pay to the issuer of a + qualified health plan the amount necessary to reflect the + increase in actuarial value of the plan required by reason of + this subsection. + + (e) Rules for Individuals Not Lawfully Present.-- + (1) In general.--If an individual who is an eligible insured + is not lawfully present-- + (A) no cost-sharing reduction under this section + shall apply with respect to the individual; and + (B) for purposes of applying this section, the + determination as to what percentage a taxpayer's + household income bears to the poverty level for a family + of the size involved shall be made under one of the + following methods: + (i) A method under which-- + (I) the taxpayer's family size is + determined by not taking such + individuals into account, and + (II) the taxpayer's household income + is equal to the product of the + taxpayer's household income (determined + without regard to this subsection) and a + fraction-- + (aa) the numerator of which + is the poverty line for the + taxpayer's family size + determined after application of + subclause (I), and + (bb) the denominator of + which is the poverty line for + the taxpayer's family size + determined without regard to + subclause (I). + (ii) A comparable method reaching the same + result as the method under clause (i). + (2) Lawfully present.--For purposes of this section, an + individual shall be treated as lawfully present only if the + individual is, and is reasonably expected to be for the entire + period of enrollment for which the cost-sharing reduction under + this section is being claimed, a citizen or national of the + United States or an alien lawfully present in the United States. + (3) <<NOTE: Regulations.>> Secretarial authority.--The + Secretary, in consultation with the Secretary of the Treasury, + shall prescribe rules setting forth the methods by which + calculations of family size and household income are made for + purposes of this subsection. Such rules shall be designed to + ensure that the least burden is placed on individuals enrolling + in qualified health plans through an Exchange and taxpayers + eligible for the credit allowable under this section. + + (f) Definitions and Special Rules.--In this section: + (1) In general.--Any term used in this section which is also + used in section 36B of the Internal Revenue Code of 1986 shall + have the meaning given such term by such section. + (2) Limitations on reduction.--No cost-sharing reduction + shall be allowed under this section with respect to coverage for + any month unless the month is a coverage month with respect to + which a credit is allowed to the insured (or an applicable + taxpayer on behalf of the insured) under section 36B of such + Code. + (3) Data used for eligibility.--Any determination under this + section shall be made on the basis of the taxable year for which + the advance determination is made under section + +[[Page 124 STAT. 224]] + + 1412 and not the taxable year for which the credit under section + 36B of such Code is allowed. + + Subpart B--Eligibility Determinations + +SEC. 1411. <<NOTE: 42 USC 18081.>> PROCEDURES FOR DETERMINING + ELIGIBILITY FOR EXCHANGE PARTICIPATION, PREMIUM TAX CREDITS + AND REDUCED COST-SHARING, AND INDIVIDUAL RESPONSIBILITY + EXEMPTIONS. + + (a) Establishment of Program.--The Secretary shall establish a +program meeting the requirements of this section for determining-- + (1) whether an individual who is to be covered in the + individual market by a qualified health plan offered through an + Exchange, or who is claiming a premium tax credit or reduced + cost-sharing, meets the requirements of sections 1312(f)(3), + 1402(e), and 1412(d) of this title and section 36B(e) of the + Internal Revenue Code of 1986 that the individual be a citizen + or national of the United States or an alien lawfully present in + the United States; + (2) in the case of an individual claiming a premium tax + credit or reduced cost-sharing under section 36B of such Code or + section 1402-- + (A) whether the individual meets the income and + coverage requirements of such sections; and + (B) the amount of the tax credit or reduced cost- + sharing; + (3) whether an individual's coverage under an employer- + sponsored health benefits plan is treated as unaffordable under + sections 36B(c)(2)(C) and 5000A(e)(2); and + (4) whether to grant a certification under section + 1311(d)(4)(H) attesting that, for purposes of the individual + responsibility requirement under section 5000A of the Internal + Revenue Code of 1986, an individual is entitled to an exemption + from either the individual responsibility requirement or the + penalty imposed by such section. + + (b) Information Required To Be Provided by Applicants.-- + (1) In general.--An applicant for enrollment in a qualified + health plan offered through an Exchange in the individual market + shall provide-- + (A) the name, address, and date of birth of each + individual who is to be covered by the plan (in this + subsection referred to as an ``enrollee''); and + (B) the information required by any of the following + paragraphs that is applicable to an enrollee. + (2) Citizenship or immigration status.--The following + information shall be provided with respect to every enrollee: + (A) In the case of an enrollee whose eligibility is + based on an attestation of citizenship of the enrollee, + the enrollee's social security number. + (B) In the case of an individual whose eligibility + is based on an attestation of the enrollee's immigration + status, the enrollee's social security number (if + applicable) and such identifying information with + respect to the enrollee's immigration status as the + Secretary, after consultation with the Secretary of + Homeland Security, determines appropriate. + +[[Page 124 STAT. 225]] + + (3) Eligibility and amount of tax credit or reduced cost- + sharing.--In the case of an enrollee with respect to whom a + premium tax credit or reduced cost-sharing under section 36B of + such Code or section 1402 is being claimed, the following + information: + (A) Information regarding income and family size.-- + The information described in section 6103(l)(21) for the + taxable year ending with or within the second calendar + year preceding the calendar year in which the plan year + begins. + (B) Changes in circumstances.--The information + described in section 1412(b)(2), including information + with respect to individuals who were not required to + file an income tax return for the taxable year described + in subparagraph (A) or individuals who experienced + changes in marital status or family size or significant + reductions in income. + (4) Employer-sponsored coverage.--In the case of an enrollee + with respect to whom eligibility for a premium tax credit under + section 36B of such Code or cost-sharing reduction under section + 1402 is being established on the basis that the enrollee's (or + related individual's) employer is not treated under section + 36B(c)(2)(C) of such Code as providing minimum essential + coverage or affordable minimum essential coverage, the following + information: + (A) The name, address, and employer identification + number (if available) of the employer. + (B) Whether the enrollee or individual is a full- + time employee and whether the employer provides such + minimum essential coverage. + (C) If the employer provides such minimum essential + coverage, the lowest cost option for the enrollee's or + individual's enrollment status and the enrollee's or + individual's required contribution (within the meaning + of section 5000A(e)(1)(B) of such Code) under the + employer-sponsored plan. + (D) If an enrollee claims an employer's minimum + essential coverage is unaffordable, the information + described in paragraph (3). + If an enrollee changes employment or obtains additional + employment while enrolled in a qualified health plan for which + such credit or reduction is allowed, the enrollee shall notify + the Exchange of such change or additional employment and provide + the information described in this paragraph with respect to the + new employer. + (5) Exemptions from individual responsibility + requirements.--In the case of an individual who is seeking an + exemption certificate under section 1311(d)(4)(H) from any + requirement or penalty imposed by section 5000A, the following + information: + (A) In the case of an individual seeking exemption + based on the individual's status as a member of an + exempt religious sect or division, as a member of a + health care sharing ministry, as an Indian, or as an + individual eligible for a hardship exemption, such + information as the Secretary shall prescribe. + +[[Page 124 STAT. 226]] + + (B) In the case of an individual seeking exemption + based on the lack of affordable coverage or the + individual's status as a taxpayer with household income + less than 100 percent of the poverty line, the + information described in paragraphs (3) and (4), as + applicable. + + (c) Verification of Information Contained in Records of Specific +Federal Officials.-- + (1) Information transferred to secretary.--An Exchange shall + submit the information provided by an applicant under subsection + (b) to the Secretary for verification in accordance with the + requirements of this subsection and subsection (d). + (2) Citizenship or immigration status.-- + (A) Commissioner of social security.--The Secretary + shall submit to the Commissioner of Social Security the + following information for a determination as to whether + the information provided is consistent with the + information in the records of the Commissioner: + (i) The name, date of birth, and social + security number of each individual for whom such + information was provided under subsection (b)(2). + (ii) The attestation of an individual that the + individual is a citizen. + (B) Secretary of homeland security.-- + (i) <<NOTE: Submission.>> In general.--In the + case of an individual-- + (I) who attests that the individual + is an alien lawfully present in the + United States; or + (II) who attests that the individual + is a citizen but with respect to whom + the Commissioner of Social Security has + notified the Secretary under subsection + (e)(3) that the attestation is + inconsistent with information in the + records maintained by the Commissioner; + the Secretary shall submit to the Secretary of + Homeland Security the information described in + clause (ii) for a determination as to whether the + information provided is consistent with the + information in the records of the Secretary of + Homeland Security. + (ii) Information.--The information described + in clause (ii) is the following: + (I) The name, date of birth, and any + identifying information with respect to + the individual's immigration status + provided under subsection (b)(2). + (II) The attestation that the + individual is an alien lawfully present + in the United States or in the case of + an individual described in clause + (i)(II), the attestation that the + individual is a citizen. + (3) Eligibility for tax credit and cost-sharing reduction.-- + The Secretary shall submit the information described in + subsection (b)(3)(A) provided under paragraph (3), (4), or (5) + of subsection (b) to the Secretary of the Treasury for + verification of household income and family size for purposes of + eligibility. + (4) Methods.-- + (A) <<NOTE: Electronic submission.>> In general.-- + The Secretary, in consultation with the Secretary of the + Treasury, the Secretary of Homeland + +[[Page 124 STAT. 227]] + + Security, and the Commissioner of Social Security, shall + provide that verifications and determinations under this + subsection shall be done-- + (i) through use of an on-line system or + otherwise for the electronic submission of, and + response to, the information submitted under this + subsection with respect to an applicant; or + (ii) by determining the consistency of the + information submitted with the information + maintained in the records of the Secretary of the + Treasury, the Secretary of Homeland Security, or + the Commissioner of Social Security through such + other method as is approved by the Secretary. + (B) Flexibility.--The Secretary may modify the + methods used under the program established by this + section for the Exchange and verification of information + if the Secretary determines such modifications would + reduce the administrative costs and burdens on the + applicant, including allowing an applicant to request + the Secretary of the Treasury to provide the information + described in paragraph (3) directly to the Exchange or + to the Secretary. The Secretary shall not make any such + modification unless the Secretary determines that any + applicable requirements under this section and section + 6103 of the Internal Revenue Code of 1986 with respect + to the confidentiality, disclosure, maintenance, or use + of information will be met. + + (d) Verification by Secretary.--In the case of information provided +under subsection (b) that is not required under subsection (c) to be +submitted to another person for verification, the Secretary shall verify +the accuracy of such information in such manner as the Secretary +determines appropriate, including delegating responsibility for +verification to the Exchange. + (e) Actions Relating to Verification.-- + (1) In general.--Each person to whom the Secretary provided + information under subsection (c) shall report to the Secretary + under the method established under subsection (c)(4) the results + of its verification and the Secretary shall notify the Exchange + of such results. <<NOTE: Reports.>> Each person to whom the + Secretary provided information under subsection (d) shall report + to the Secretary in such manner as the Secretary determines + appropriate. + (2) Verification.-- + (A) Eligibility for enrollment and premium tax + credits and cost-sharing reductions.--If information + provided by an applicant under paragraphs (1), (2), (3), + and (4) of subsection (b) is verified under subsections + (c) and (d)-- + (i) the individual's eligibility to enroll + through the Exchange and to apply for premium tax + credits and cost-sharing reductions shall be + satisfied; and + (ii) <<NOTE: Notification.>> the Secretary + shall, if applicable, notify the Secretary of the + Treasury under section 1412(c) of the amount of + any advance payment to be made. + (B) Exemption from individual responsibility.--If + information provided by an applicant under subsection + (b)(5) is verified under subsections (c) and (d), the + Secretary + +[[Page 124 STAT. 228]] + + shall issue the certification of exemption described in + section 1311(d)(4)(H). + (3) Inconsistencies involving attestation of citizenship or + lawful presence.--If the information provided by any applicant + under subsection (b)(2) is inconsistent with information in the + records maintained by the Commissioner of Social Security or + Secretary of Homeland Security, whichever is applicable, the + applicant's eligibility will be determined in the same manner as + an individual's eligibility under the medicaid program is + determined under section 1902(ee) of the Social Security Act (as + in effect on January 1, 2010). + (4) <<NOTE: Notifications.>> Inconsistencies involving + other information.-- + (A) In general.--If the information provided by an + applicant under subsection (b) (other than subsection + (b)(2)) is inconsistent with information in the records + maintained by persons under subsection (c) or is not + verified under subsection (d), the Secretary shall + notify the Exchange and the Exchange shall take the + following actions: + (i) Reasonable effort.--The Exchange shall + make a reasonable effort to identify and address + the causes of such inconsistency, including + through typographical or other clerical errors, by + contacting the applicant to confirm the accuracy + of the information, and by taking such additional + actions as the Secretary, through regulation or + other guidance, may identify. + (ii) Notice and opportunity to correct.--In + the case the inconsistency or inability to verify + is not resolved under subparagraph (A), the + Exchange shall-- + (I) notify the applicant of such + fact; + (II) <<NOTE: Time period.>> provide + the applicant an opportunity to either + present satisfactory documentary + evidence or resolve the inconsistency + with the person verifying the + information under subsection (c) or (d) + during the 90-day period beginning the + date on which the notice required under + subclause (I) is sent to the applicant. + The Secretary may extend the 90-day period under + subclause (II) for enrollments occurring during + 2014. + (B) Specific actions not involving citizenship or + lawful presence.-- + (i) In general.--Except as provided in + paragraph (3), the Exchange shall, during any + period before the close of the period under + subparagraph (A)(ii)(II), make any determination + under paragraphs (2), (3), and (4) of subsection + (a) on the basis of the information contained on + the application. + (ii) Eligibility or amount of credit or + reduction.--If an inconsistency involving the + eligibility for, or amount of, any premium tax + credit or cost-sharing reduction is unresolved + under this subsection as of the close of the + period under subparagraph (A)(ii)(II), the + Exchange shall notify the applicant of the amount + (if any) of the credit or reduction that is + determined on the basis of the records maintained + by persons under subsection (c). + (iii) Employer affordability.--If the + Secretary notifies an Exchange that an enrollee is + eligible for + +[[Page 124 STAT. 229]] + + a premium tax credit under section 36B of such + Code or cost-sharing reduction under section 1402 + because the enrollee's (or related individual's) + employer does not provide minimum essential + coverage through an employer-sponsored plan or + that the employer does provide that coverage but + it is not affordable coverage, the Exchange shall + notify the employer of such fact and that the + employer may be liable for the payment assessed + under section 4980H of such Code. + (iv) Exemption.--In any case where the + inconsistency involving, or inability to verify, + information provided under subsection (b)(5) is + not resolved as of the close of the period under + subparagraph (A)(ii)(II), the Exchange shall + notify an applicant that no certification of + exemption from any requirement or payment under + section 5000A of such Code will be issued. + (C) Appeals process.--The Exchange shall also notify + each person receiving notice under this paragraph of the + appeals processes established under subsection (f). + + (f) Appeals and Redeterminations.-- + (1) <<NOTE: Procedures.>> In general.--The Secretary, in + consultation with the Secretary of the Treasury, the Secretary + of Homeland Security, and the Commissioner of Social Security, + shall establish procedures by which the Secretary or one of such + other Federal officers-- + (A) hears and makes decisions with respect to + appeals of any determination under subsection (e); and + (B) redetermines eligibility on a periodic basis in + appropriate circumstances. + (2) Employer liability.-- + (A) In general.--The Secretary shall establish a + separate appeals process for employers who are notified + under subsection (e)(4)(C) that the employer may be + liable for a tax imposed by section 4980H of the + Internal Revenue Code of 1986 with respect to an + employee because of a determination that the employer + does not provide minimum essential coverage through an + employer-sponsored plan or that the employer does + provide that coverage but it is not affordable coverage + with respect to an employee. Such process shall provide + an employer the opportunity to-- + (i) present information to the Exchange for + review of the determination either by the Exchange + or the person making the determination, including + evidence of the employer-sponsored plan and + employer contributions to the plan; and + (ii) have access to the data used to make the + determination to the extent allowable by law. + Such process shall be in addition to any rights of + appeal the employer may have under subtitle F of such + Code. + (B) Confidentiality.--Notwithstanding any provision + of this title (or the amendments made by this title) or + section 6103 of the Internal Revenue Code of 1986, an + employer shall not be entitled to any taxpayer return + information with respect to an employee for purposes of + determining whether the employer is subject to the + penalty under section 4980H of such Code with respect to + the employee, except that-- + +[[Page 124 STAT. 230]] + + (i) the employer may be notified as to the + name of an employee and whether or not the + employee's income is above or below the threshold + by which the affordability of an employer's health + insurance coverage is measured; and + (ii) this subparagraph shall not apply to an + employee who provides a waiver (at such time and + in such manner as the Secretary may prescribe) + authorizing an employer to have access to the + employee's taxpayer return information. + + (g) Confidentiality of Applicant Information.-- + (1) In general.--An applicant for insurance coverage or for + a premium tax credit or cost-sharing reduction shall be required + to provide only the information strictly necessary to + authenticate identity, determine eligibility, and determine the + amount of the credit or reduction. + (2) Receipt of information.--Any person who receives + information provided by an applicant under subsection (b) + (whether directly or by another person at the request of the + applicant), or receives information from a Federal agency under + subsection (c), (d), or (e), shall-- + (A) use the information only for the purposes of, + and to the extent necessary in, ensuring the efficient + operation of the Exchange, including verifying the + eligibility of an individual to enroll through an + Exchange or to claim a premium tax credit or cost- + sharing reduction or the amount of the credit or + reduction; and + (B) not disclose the information to any other person + except as provided in this section. + + (h) Penalties.-- + (1) False or fraudulent information.-- + (A) Civil penalty.-- + (i) In general.--If-- + (I) any person fails to provides + correct information under subsection + (b); and + (II) such failure is attributable to + negligence or disregard of any rules or + regulations of the Secretary, + such person shall be subject, in addition to any + other penalties that may be prescribed by law, to + a civil penalty of not more than $25,000 with + respect to any failures involving an application + for a plan year. For purposes of this + subparagraph, the terms ``negligence'' and + ``disregard'' shall have the same meanings as when + used in section 6662 of the Internal Revenue Code + of 1986. + (ii) Reasonable cause exception.--No penalty + shall be imposed under clause (i) if the Secretary + determines that there was a reasonable cause for + the failure and that the person acted in good + faith. + (B) Knowing and willful violations.--Any person who + knowingly and willfully provides false or fraudulent + information under subsection (b) shall be subject, in + addition to any other penalties that may be prescribed + by law, to a civil penalty of not more than $250,000. + +[[Page 124 STAT. 231]] + + (2) Improper use or disclosure of information.--Any person + who knowingly and willfully uses or discloses information in + violation of subsection (g) shall be subject, in addition to any + other penalties that may be prescribed by law, to a civil + penalty of not more than $25,000. + (3) Limitations on liens and levies.--The Secretary (or, if + applicable, the Attorney General of the United States) shall + not-- + (A) file notice of lien with respect to any property + of a person by reason of any failure to pay the penalty + imposed by this subsection; or + (B) levy on any such property with respect to such + failure. + + (i) Study of Administration of Employer Responsibility.-- + (1) In general.--The Secretary of Health and Human Services + shall, in consultation with the Secretary of the Treasury, + conduct a study of the procedures that are necessary to ensure + that in the administration of this title and section 4980H of + the Internal Revenue Code of 1986 (as added by section 1513) + that the following rights are protected: + (A) The rights of employees to preserve their right + to confidentiality of their taxpayer return information + and their right to enroll in a qualified health plan + through an Exchange if an employer does not provide + affordable coverage. + (B) The rights of employers to adequate due process + and access to information necessary to accurately + determine any payment assessed on employers. + (2) Report.--Not later than January 1, 2013, the Secretary + of Health and Human Services shall report the results of the + study conducted under paragraph (1), including any + recommendations for legislative changes, to the Committees on + Finance and Health, Education, Labor and Pensions of the Senate + and the Committees of Education and Labor and Ways and Means of + the House of Representatives. + +SEC. 1412. <<NOTE: 42 USC 18082.>> ADVANCE DETERMINATION AND PAYMENT OF + PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS. + + (a) In General.--The Secretary, in consultation with the Secretary +of the Treasury, shall establish a program under which-- + (1) upon request of an Exchange, advance determinations are + made under section 1411 with respect to the income eligibility + of individuals enrolling in a qualified health plan in the + individual market through the Exchange for the premium tax + credit allowable under section 36B of the Internal Revenue Code + of 1986 and the cost-sharing reductions under section 1402; + (2) <<NOTE: Notification.>> the Secretary notifies-- + (A) the Exchange and the Secretary of the Treasury + of the advance determinations; and + (B) the Secretary of the Treasury of the name and + employer identification number of each employer with + respect to whom 1 or more employee of the employer were + determined to be eligible for the premium tax credit + under section 36B of the Internal Revenue Code of 1986 + and the cost-sharing reductions under section 1402 + because-- + +[[Page 124 STAT. 232]] + + (i) the employer did not provide minimum + essential coverage; or + (ii) the employer provided such minimum + essential coverage but it was determined under + section 36B(c)(2)(C) of such Code to either be + unaffordable to the employee or not provide the + required minimum actuarial value; and + (3) the Secretary of the Treasury makes advance payments of + such credit or reductions to the issuers of the qualified health + plans in order to reduce the premiums payable by individuals + eligible for such credit. + + (b) Advance Determinations.-- + (1) In general.--The Secretary shall provide under the + program established under subsection (a) that advance + determination of eligibility with respect to any individual + shall be made-- + (A) during the annual open enrollment period + applicable to the individual (or such other enrollment + period as may be specified by the Secretary); and + (B) on the basis of the individual's household + income for the most recent taxable year for which the + Secretary, after consultation with the Secretary of the + Treasury, determines information is available. + (2) Changes in circumstances.--The Secretary shall provide + procedures for making advance determinations on the basis of + information other than that described in paragraph (1)(B) in + cases where information included with an application form + demonstrates substantial changes in income, changes in family + size or other household circumstances, change in filing status, + the filing of an application for unemployment benefits, or other + significant changes affecting eligibility, including-- + (A) allowing an individual claiming a decrease of 20 + percent or more in income, or filing an application for + unemployment benefits, to have eligibility for the + credit determined on the basis of household income for a + later period or on the basis of the individual's + estimate of such income for the taxable year; and + (B) the determination of household income in cases + where the taxpayer was not required to file a return of + tax imposed by this chapter for the second preceding + taxable year. + + (c) <<NOTE: Notifications.>> Payment of Premium Tax Credits and +Cost-sharing Reductions.-- + (1) In general.--The Secretary shall notify the Secretary of + the Treasury and the Exchange through which the individual is + enrolling of the advance determination under section 1411. + (2) Premium tax credit.-- + (A) In general.--The Secretary of the Treasury shall + make the advance payment under this section of any + premium tax credit allowed under section 36B of the + Internal Revenue Code of 1986 to the issuer of a + qualified health plan on a monthly basis (or such other + periodic basis as the Secretary may provide). + (B) Issuer responsibilities.--An issuer of a + qualified health plan receiving an advance payment with + respect to an individual enrolled in the plan shall-- + +[[Page 124 STAT. 233]] + + (i) reduce the premium charged the insured for + any period by the amount of the advance payment + for the period; + (ii) notify the Exchange and the Secretary of + such reduction; + (iii) include with each billing statement the + amount by which the premium for the plan has been + reduced by reason of the advance payment; and + (iv) in the case of any nonpayment of premiums + by the insured-- + (I) notify the Secretary of such + nonpayment; and + (II) allow a 3-month grace period + for nonpayment of premiums before + discontinuing coverage. + (3) Cost-sharing reductions.--The Secretary shall also + notify the Secretary of the Treasury and the Exchange under + paragraph (1) if an advance payment of the cost-sharing + reductions under section 1402 is to be made to the issuer of any + qualified health plan with respect to any individual enrolled in + the plan. The Secretary of the Treasury shall make such advance + payment at such time and in such amount as the Secretary + specifies in the notice. + + (d) No Federal Payments for Individuals Not Lawfully Present.-- +Nothing in this subtitle or the amendments made by this subtitle allows +Federal payments, credits, or cost-sharing reductions for individuals +who are not lawfully present in the United States. + (e) State Flexibility.--Nothing in this subtitle or the amendments +made by this subtitle shall be construed to prohibit a State from making +payments to or on behalf of an individual for coverage under a qualified +health plan offered through an Exchange that are in addition to any +credits or cost-sharing reductions allowable to the individual under +this subtitle and such amendments. + +SEC. 1413. <<NOTE: 42 USC 18083.>> STREAMLINING OF PROCEDURES FOR + ENROLLMENT THROUGH AN EXCHANGE AND STATE MEDICAID, CHIP, AND + HEALTH SUBSIDY PROGRAMS. + + (a) In General.--The Secretary shall establish a system meeting the +requirements of this section under which residents of each State may +apply for enrollment in, receive a determination of eligibility for +participation in, and continue participation in, applicable State health +subsidy programs. Such system shall ensure that if an individual +applying to an Exchange is found through screening to be eligible for +medical assistance under the State medicaid plan under title XIX, or +eligible for enrollment under a State children's health insurance +program (CHIP) under title XXI of such Act, the individual is enrolled +for assistance under such plan or program. + (b) Requirements Relating to Forms and Notice.-- + (1) Requirements relating to forms.-- + (A) In general.--The Secretary shall develop and + provide to each State a single, streamlined form that-- + (i) may be used to apply for all applicable + State health subsidy programs within the State; + (ii) may be filed online, in person, by mail, + or by telephone; + +[[Page 124 STAT. 234]] + + (iii) may be filed with an Exchange or with + State officials operating one of the other + applicable State health subsidy programs; and + (iv) is structured to maximize an applicant's + ability to complete the form satisfactorily, + taking into account the characteristics of + individuals who qualify for applicable State + health subsidy programs. + (B) State authority to establish form.--A State may + develop and use its own single, streamlined form as an + alternative to the form developed under subparagraph (A) + if the alternative form is consistent with standards + promulgated by the Secretary under this section. + (C) Supplemental eligibility forms.--The Secretary + may allow a State to use a supplemental or alternative + form in the case of individuals who apply for + eligibility that is not determined on the basis of the + household income (as defined in section 36B of the + Internal Revenue Code of 1986). + (2) Notice.--The Secretary shall provide that an applicant + filing a form under paragraph (1) shall receive notice of + eligibility for an applicable State health subsidy program + without any need to provide additional information or paperwork + unless such information or paperwork is specifically required by + law when information provided on the form is inconsistent with + data used for the electronic verification under paragraph (3) or + is otherwise insufficient to determine eligibility. + + (c) Requirements Relating to Eligibility Based on Data Exchanges.-- + (1) Development of secure interfaces.--Each State shall + develop for all applicable State health subsidy programs a + secure, electronic interface allowing an exchange of data + (including information contained in the application forms + described in subsection (b)) that allows a determination of + eligibility for all such programs based on a single application. + Such interface shall be compatible with the method established + for data verification under section 1411(c)(4). + (2) Data matching program.--Each applicable State health + subsidy program shall participate in a data matching arrangement + for determining eligibility for participation in the program + under paragraph (3) that-- + (A) provides access to data described in paragraph + (3); + (B) applies only to individuals who-- + (i) receive assistance from an applicable + State health subsidy program; or + (ii) apply for such assistance-- + (I) by filing a form described in + subsection (b); or + (II) by requesting a determination + of eligibility and authorizing + disclosure of the information described + in paragraph (3) to applicable State + health coverage subsidy programs for + purposes of determining and establishing + eligibility; and + (C) consistent with standards promulgated by the + Secretary, including the privacy and data security + safeguards described in section 1942 of the Social + Security Act or that are otherwise applicable to such + programs. + +[[Page 124 STAT. 235]] + + (3) Determination of eligibility.-- + (A) In general.--Each applicable State health + subsidy program shall, to the maximum extent + practicable-- + (i) establish, verify, and update eligibility + for participation in the program using the data + matching arrangement under paragraph (2); and + (ii) determine such eligibility on the basis + of reliable, third party data, including + information described in sections 1137, 453(i), + and 1942(a) of the Social Security Act, obtained + through such arrangement. + (B) Exception.--This paragraph shall not apply in + circumstances with respect to which the Secretary + determines that the administrative and other costs of + use of the data matching arrangement under paragraph (2) + outweigh its expected gains in accuracy, efficiency, and + program participation. + (4) Secretarial standards.--The Secretary shall, after + consultation with persons in possession of the data to be + matched and representatives of applicable State health subsidy + programs, promulgate standards governing the timing, contents, + and procedures for data matching described in this subsection. + Such standards shall take into account administrative and other + costs and the value of data matching to the establishment, + verification, and updating of eligibility for applicable State + health subsidy programs. + + (d) Administrative Authority.-- + (1) Agreements.--Subject to section 1411 and section + 6103(l)(21) of the Internal Revenue Code of 1986 and any other + requirement providing safeguards of privacy and data integrity, + the Secretary may establish model agreements, and enter into + agreements, for the sharing of data under this section. + (2) Authority of exchange to contract out.--Nothing in this + section shall be construed to-- + (A) prohibit contractual arrangements through which + a State medicaid agency determines eligibility for all + applicable State health subsidy programs, but only if + such agency complies with the Secretary's requirements + ensuring reduced administrative costs, eligibility + errors, and disruptions in coverage; or + (B) change any requirement under title XIX that + eligibility for participation in a State's medicaid + program must be determined by a public agency. + + (e) Applicable State Health Subsidy Program.--In this section, the +term ``applicable State health subsidy program'' means-- + (1) the program under this title for the enrollment in + qualified health plans offered through an Exchange, including + the premium tax credits under section 36B of the Internal + Revenue Code of 1986 and cost-sharing reductions under section + 1402; + (2) a State medicaid program under title XIX of the Social + Security Act; + (3) a State children's health insurance program (CHIP) under + title XXI of such Act; and + (4) a State program under section 1331 establishing + qualified basic health plans. + +[[Page 124 STAT. 236]] + +SEC. 1414. DISCLOSURES TO CARRY OUT ELIGIBILITY REQUIREMENTS FOR CERTAIN + PROGRAMS. + + (a) Disclosure of Taxpayer Return Information and Social Security +Numbers.-- + (1) Taxpayer return information.--Subsection (l) of section + 6103 of the Internal Revenue Code of 1986 <<NOTE: 26 USC + 6103.>> is amended by adding at the end the following new + paragraph: + ``(21) Disclosure of return information to carry out + eligibility requirements for certain programs.-- + ``(A) In general.--The Secretary, upon written + request from the Secretary of Health and Human Services, + shall disclose to officers, employees, and contractors + of the Department of Health and Human Services return + information of any taxpayer whose income is relevant in + determining any premium tax credit under section 36B or + any cost-sharing reduction under section 1402 of the + Patient Protection and Affordable Care Act or + eligibility for participation in a State medicaid + program under title XIX of the Social Security Act, a + State's children's health insurance program under title + XXI of the Social Security Act, or a basic health + program under section 1331 of Patient Protection and + Affordable Care Act. Such return information shall be + limited to-- + ``(i) taxpayer identity information with + respect to such taxpayer, + ``(ii) the filing status of such taxpayer, + ``(iii) the number of individuals for whom a + deduction is allowed under section 151 with + respect to the taxpayer (including the taxpayer + and the taxpayer's spouse), + ``(iv) the modified gross income (as defined + in section 36B) of such taxpayer and each of the + other individuals included under clause (iii) who + are required to file a return of tax imposed by + chapter 1 for the taxable year, + ``(v) such other information as is prescribed + by the Secretary by regulation as might indicate + whether the taxpayer is eligible for such credit + or reduction (and the amount thereof), and + ``(vi) the taxable year with respect to which + the preceding information relates or, if + applicable, the fact that such information is not + available. + ``(B) Information to exchange and state agencies.-- + The Secretary of Health and Human Services may disclose + to an Exchange established under the Patient Protection + and Affordable Care Act or its contractors, or to a + State agency administering a State program described in + subparagraph (A) or its contractors, any inconsistency + between the information provided by the Exchange or + State agency to the Secretary and the information + provided to the Secretary under subparagraph (A). + ``(C) Restriction on use of disclosed information.-- + Return information disclosed under subparagraph (A) or + (B) may be used by officers, employees, and contractors + of the Department of Health and Human Services, an + Exchange, or a State agency only for the purposes of, + and to the extent necessary in-- + +[[Page 124 STAT. 237]] + + ``(i) establishing eligibility for + participation in the Exchange, and verifying the + appropriate amount of, any credit or reduction + described in subparagraph (A), + ``(ii) determining eligibility for + participation in the State programs described in + subparagraph (A).''. + (2) Social security numbers.--Section 205(c)(2)(C) of the + Social Security Act <<NOTE: 42 USC 405.>> is amended by adding + at the end the following new clause: + ``(x) The Secretary of Health and Human + Services, and the Exchanges established under + section 1311 of the Patient Protection and + Affordable Care Act, are authorized to collect and + use the names and social security account numbers + of individuals as required to administer the + provisions of, and the amendments made by, the + such Act.''. + + (b) Confidentiality and Disclosure.--Paragraph (3) of section +6103(a) of such Code <<NOTE: 26 USC 6103.>> is amended by striking ``or +(20)'' and inserting ``(20), or (21)''. + + (c) Procedures and Recordkeeping Related to Disclosures.--Paragraph +(4) of section 6103(p) of such Code is amended-- + (1) by inserting ``, or any entity described in subsection + (l)(21),'' after ``or (20)'' in the matter preceding + subparagraph (A), + (2) by inserting ``or any entity described in subsection + (l)(21),'' after ``or (o)(1)(A)'' in subparagraph (F)(ii), and + (3) by inserting ``or any entity described in subsection + (l)(21),'' after ``or (20)'' both places it appears in the + matter after subparagraph (F). + + (d) Unauthorized Disclosure or Inspection.--Paragraph (2) of section +7213(a) of such Code is amended by striking ``or (20)'' and inserting +``(20), or (21)''. + +SEC. 1415. <<NOTE: 42 USC 18084.>> PREMIUM TAX CREDIT AND COST-SHARING + REDUCTION PAYMENTS DISREGARDED FOR FEDERAL AND FEDERALLY- + ASSISTED PROGRAMS. + + For purposes of determining the eligibility of any individual for +benefits or assistance, or the amount or extent of benefits or +assistance, under any Federal program or under any State or local +program financed in whole or in part with Federal funds-- + (1) any credit or refund allowed or made to any individual + by reason of section 36B of the Internal Revenue Code of 1986 + (as added by section 1401) shall not be taken into account as + income and shall not be taken into account as resources for the + month of receipt and the following 2 months; and + (2) any cost-sharing reduction payment or advance payment of + the credit allowed under such section 36B that is made under + section 1402 or 1412 shall be treated as made to the qualified + health plan in which an individual is enrolled and not to that + individual. + + PART II--SMALL BUSINESS TAX CREDIT + +SEC. 1421. CREDIT FOR EMPLOYEE HEALTH INSURANCE EXPENSES OF SMALL + BUSINESSES. + + (a) In General.--Subpart D of part IV of subchapter A of chapter 1 +of the Internal Revenue Code of 1986 (relating to business- + +[[Page 124 STAT. 238]] + +related credits) is amended by inserting after section 45Q the +following: + +``SEC. 45R. <<NOTE: 26 USC 45R.>> EMPLOYEE HEALTH INSURANCE EXPENSES OF + SMALL EMPLOYERS. + + ``(a) General Rule.--For purposes of section 38, in the case of an +eligible small employer, the small employer health insurance credit +determined under this section for any taxable year in the credit period +is the amount determined under subsection (b). + ``(b) Health Insurance Credit Amount.--Subject to subsection (c), +the amount determined under this subsection with respect to any eligible +small employer is equal to 50 percent (35 percent in the case of a tax- +exempt eligible small employer) of the lesser of-- + ``(1) the aggregate amount of nonelective contributions the + employer made on behalf of its employees during the taxable year + under the arrangement described in subsection (d)(4) for + premiums for qualified health plans offered by the employer to + its employees through an Exchange, or + ``(2) the aggregate amount of nonelective contributions + which the employer would have made during the taxable year under + the arrangement if each employee taken into account under + paragraph (1) had enrolled in a qualified health plan which had + a premium equal to the average premium (as determined by the + Secretary of Health and Human Services) for the small group + market in the rating area in which the employee enrolls for + coverage. + + ``(c) Phaseout of Credit Amount Based on Number of Employees and +Average Wages.--The amount of the credit determined under subsection (b) +without regard to this subsection shall be reduced (but not below zero) +by the sum of the following amounts: + ``(1) Such amount multiplied by a fraction the numerator of + which is the total number of full-time equivalent employees of + the employer in excess of 10 and the denominator of which is 15. + ``(2) Such amount multiplied by a fraction the numerator of + which is the average annual wages of the employer in excess of + the dollar amount in effect under subsection (d)(3)(B) and the + denominator of which is such dollar amount. + + ``(d) Eligible Small Employer.--For purposes of this section-- + ``(1) In general.--The term `eligible small employer' means, + with respect to any taxable year, an employer-- + ``(A) which has no more than 25 full-time equivalent + employees for the taxable year, + ``(B) the average annual wages of which do not + exceed an amount equal to twice the dollar amount in + effect under paragraph (3)(B) for the taxable year, and + ``(C) which has in effect an arrangement described + in paragraph (4). + ``(2) Full-time equivalent employees.-- + ``(A) In general.--The term `full-time equivalent + employees' means a number of employees equal to the + number determined by dividing-- + ``(i) the total number of hours of service for + which wages were paid by the employer to employees + during the taxable year, by + ``(ii) 2,080. + +[[Page 124 STAT. 239]] + + Such number shall be rounded to the next lowest whole + number if not otherwise a whole number. + ``(B) Excess hours not counted.--If an employee + works in excess of 2,080 hours of service during any + taxable year, such excess shall not be taken into + account under subparagraph (A). + ``(C) <<NOTE: Regulations.>> Hours of service.--The + Secretary, in consultation with the Secretary of Labor, + shall prescribe such regulations, rules, and guidance as + may be necessary to determine the hours of service of an + employee, including rules for the application of this + paragraph to employees who are not compensated on an + hourly basis. + ``(3) Average annual wages.-- + ``(A) In general.--The average annual wages of an + eligible small employer for any taxable year is the + amount determined by dividing-- + ``(i) the aggregate amount of wages which were + paid by the employer to employees during the + taxable year, by + ``(ii) the number of full-time equivalent + employees of the employee determined under + paragraph (2) for the taxable year. + Such amount shall be rounded to the next lowest multiple + of $1,000 if not otherwise such a multiple. + ``(B) Dollar amount.--For purposes of paragraph + (1)(B)-- + ``(i) 2011, 2012, and 2013.--The dollar amount + in effect under this paragraph for taxable years + beginning in 2011, 2012, or 2013 is $20,000. + ``(ii) Subsequent years.--In the case of a + taxable year beginning in a calendar year after + 2013, the dollar amount in effect under this + paragraph shall be equal to $20,000, multiplied by + the cost-of-living adjustment determined under + section 1(f)(3) for the calendar year, determined + by substituting `calendar year 2012' for `calendar + year 1992' in subparagraph (B) thereof. + ``(4) Contribution arrangement.--An arrangement is described + in this paragraph if it requires an eligible small employer to + make a nonelective contribution on behalf of each employee who + enrolls in a qualified health plan offered to employees by the + employer through an exchange in an amount equal to a uniform + percentage (not less than 50 percent) of the premium cost of the + qualified health plan. + ``(5) Seasonal worker hours and wages not counted.--For + purposes of this subsection-- + ``(A) In general.--The number of hours of service + worked by, and wages paid to, a seasonal worker of an + employer shall not be taken into account in determining + the full-time equivalent employees and average annual + wages of the employer unless the worker works for the + employer on more than 120 days during the taxable year. + ``(B) Definition of seasonal worker.--The term + `seasonal worker' means a worker who performs labor or + services on a seasonal basis as defined by the Secretary + of Labor, including workers covered by section + 500.20(s)(1) of title 29, Code of Federal Regulations + and retail workers employed exclusively during holiday + seasons. + +[[Page 124 STAT. 240]] + + ``(e) Other Rules and Definitions.--For purposes of this section-- + ``(1) Employee.-- + ``(A) Certain employees excluded.--The term + `employee' shall not include-- + ``(i) an employee within the meaning of + section 401(c)(1), + ``(ii) any 2-percent shareholder (as defined + in section 1372(b)) of an eligible small business + which is an S corporation, + ``(iii) any 5-percent owner (as defined in + section 416(i)(1)(B)(i)) of an eligible small + business, or + ``(iv) any individual who bears any of the + relationships described in subparagraphs (A) + through (G) of section 152(d)(2) to, or is a + dependent described in section 152(d)(2)(H) of, an + individual described in clause (i), (ii), or + (iii). + ``(B) Leased employees.--The term `employee' shall + include a leased employee within the meaning of section + 414(n). + ``(2) Credit period.--The term `credit period' means, with + respect to any eligible small employer, the 2-consecutive- + taxable year period beginning with the 1st taxable year in which + the employer (or any predecessor) offers 1 or more qualified + health plans to its employees through an Exchange. + ``(3) Nonelective contribution.--The term `nonelective + contribution' means an employer contribution other than an + employer contribution pursuant to a salary reduction + arrangement. + ``(4) Wages.--The term `wages' has the meaning given such + term by section 3121(a) (determined without regard to any dollar + limitation contained in such section). + ``(5) Aggregation and other rules made applicable.-- + ``(A) Aggregation rules.--All employers treated as a + single employer under subsection (b), (c), (m), or (o) + of section 414 shall be treated as a single employer for + purposes of this section. + ``(B) <<NOTE: Applicability.>> Other rules.--Rules + similar to the rules of subsections (c), (d), and (e) of + section 52 shall apply. + + ``(f) Credit Made Available to Tax-exempt Eligible Small +Employers.-- + ``(1) In general.--In the case of a tax-exempt eligible + small employer, there shall be treated as a credit allowable + under subpart C (and not allowable under this subpart) the + lesser of-- + ``(A) the amount of the credit determined under this + section with respect to such employer, or + ``(B) the amount of the payroll taxes of the + employer during the calendar year in which the taxable + year begins. + ``(2) Tax-exempt eligible small employer.--For purposes of + this section, the term `tax-exempt eligible small employer' + means an eligible small employer which is any organization + described in section 501(c) which is exempt from taxation under + section 501(a). + ``(3) Payroll taxes.--For purposes of this subsection-- + ``(A) In general.--The term `payroll taxes' means-- + +[[Page 124 STAT. 241]] + + ``(i) amounts required to be withheld from the + employees of the tax-exempt eligible small + employer under section 3401(a), + ``(ii) amounts required to be withheld from + such employees under section 3101(b), and + ``(iii) amounts of the taxes imposed on the + tax-exempt eligible small employer under section + 3111(b). + ``(B) <<NOTE: Applicability.>> Special rule.--A + rule similar to the rule of section 24(d)(2)(C) shall + apply for purposes of subparagraph (A). + + ``(g) Application of Section for Calendar Years 2011, 2012, and +2013.--In the case of any taxable year beginning in 2011, 2012, or 2013, +the following modifications to this section shall apply in determining +the amount of the credit under subsection (a): + ``(1) No credit period required.--The credit shall be + determined without regard to whether the taxable year is in a + credit period and for purposes of applying this section to + taxable years beginning after 2013, no credit period shall be + treated as beginning with a taxable year beginning before 2014. + ``(2) Amount of credit.--The amount of the credit determined + under subsection (b) shall be determined-- + ``(A) by substituting `35 percent (25 percent in the + case of a tax-exempt eligible small employer)' for `50 + percent (35 percent in the case of a tax-exempt eligible + small employer)', + ``(B) by reference to an eligible small employer's + nonelective contributions for premiums paid for health + insurance coverage (within the meaning of section + 9832(b)(1)) of an employee, and + ``(C) <<NOTE: Determination.>> by substituting for + the average premium determined under subsection (b)(2) + the amount the Secretary of Health and Human Services + determines is the average premium for the small group + market in the State in which the employer is offering + health insurance coverage (or for such area within the + State as is specified by the Secretary). + ``(3) Contribution arrangement.--An arrangement shall not + fail to meet the requirements of subsection (d)(4) solely + because it provides for the offering of insurance outside of an + Exchange. + + ``(h) Insurance Definitions.--Any term used in this section which is +also used in the Public Health Service Act or subtitle A of title I of +the Patient Protection and Affordable Care Act shall have the meaning +given such term by such Act or subtitle. + ``(i) Regulations.--The Secretary shall prescribe such regulations +as may be necessary to carry out the provisions of this section, +including regulations to prevent the avoidance of the 2-year limit on +the credit period through the use of successor entities and the +avoidance of the limitations under subsection (c) through the use of +multiple entities.''. + (b) Credit To Be Part of General Business Credit.--Section 38(b) of +the Internal Revenue Code of 1986 <<NOTE: 26 USC 38.>> (relating to +current year business credit) is amended by striking ``plus'' at the end +of paragraph (34), by striking the period at the end of paragraph (35) +and inserting ``, plus'', and by inserting after paragraph (35) the +following: + +[[Page 124 STAT. 242]] + + ``(36) the small employer health insurance credit determined + under section 45R.''. + + (c) Credit Allowed Against Alternative Minimum Tax.--Section +38(c)(4)(B) of the Internal Revenue Code of 1986 (defining specified +credits) <<NOTE: 26 USC 38.>> is amended by redesignating clauses (vi), +(vii), and (viii) as clauses (vii), (viii), and (ix), respectively, and +by inserting after clause (v) the following new clause: + ``(vi) the credit determined under section + 45R,''. + + (d) Disallowance of Deduction for Certain Expenses for Which Credit +Allowed.-- + (1) In general.--Section 280C of the Internal Revenue Code + of 1986 (relating to disallowance of deduction for certain + expenses for which credit allowed), as amended by section + 1401(b), is amended by adding at the end the following new + subsection: + + ``(h) Credit for Employee Health Insurance Expenses of Small +Employers.--No deduction shall be allowed for that portion of the +premiums for qualified health plans (as defined in section 1301(a) of +the Patient Protection and Affordable Care Act), or for health insurance +coverage in the case of taxable years beginning in 2011, 2012, or 2013, +paid by an employer which is equal to the amount of the credit +determined under section 45R(a) with respect to the premiums.''. + (2) Deduction for expiring credits.--Section 196(c) of such + Code is amended by striking ``and'' at the end of paragraph + (12), by striking the period at the end of paragraph (13) and + inserting ``, and'', and by adding at the end the following new + paragraph: + ``(14) the small employer health insurance credit determined + under section 45R(a).''. + + (e) Clerical Amendment.--The table of sections for subpart D of part +IV of subchapter A of chapter 1 of the Internal Revenue Code of 1986 is +amended by adding at the end the following: + +``Sec. 45R. Employee health insurance expenses of small employers.''. + + (f) <<NOTE: Applicability. 26 USC 38 note.>> Effective Dates.-- + (1) In general.--The amendments made by this section shall + apply to amounts paid or incurred in taxable years beginning + after December 31, 2010. + (2) Minimum tax.--The amendments made by subsection (c) + shall apply to credits determined under section 45R of the + Internal Revenue Code of 1986 in taxable years beginning after + December 31, 2010, and to carrybacks of such credits. + + Subtitle F--Shared Responsibility for Health Care + + PART I--INDIVIDUAL RESPONSIBILITY + +SEC. 1501. <<NOTE: 42 USC 18091.>> REQUIREMENT TO MAINTAIN MINIMUM + ESSENTIAL COVERAGE. + + (a) Findings.--Congress makes the following findings: + (1) In general.--The individual responsibility requirement + provided for in this section (in this subsection referred to as + the ``requirement'') is commercial and economic in nature, and + substantially affects interstate commerce, as a result of the + effects described in paragraph (2). + +[[Page 124 STAT. 243]] + + (2) Effects on the national economy and interstate + commerce.--The effects described in this paragraph are the + following: + (A) The requirement regulates activity that is + commercial and economic in nature: economic and + financial decisions about how and when health care is + paid for, and when health insurance is purchased. + (B) Health insurance and health care services are a + significant part of the national economy. National + health spending is projected to increase from + $2,500,000,000,000, or 17.6 percent of the economy, in + 2009 to $4,700,000,000,000 in 2019. Private health + insurance spending is projected to be $854,000,000,000 + in 2009, and pays for medical supplies, drugs, and + equipment that are shipped in interstate commerce. Since + most health insurance is sold by national or regional + health insurance companies, health insurance is sold in + interstate commerce and claims payments flow through + interstate commerce. + (C) The requirement, together with the other + provisions of this Act, will add millions of new + consumers to the health insurance market, increasing the + supply of, and demand for, health care services. + According to the Congressional Budget Office, the + requirement will increase the number and share of + Americans who are insured. + (D) The requirement achieves near-universal coverage + by building upon and strengthening the private employer- + based health insurance system, which covers 176,000,000 + Americans nationwide. In Massachusetts, a similar + requirement has strengthened private employer-based + coverage: despite the economic downturn, the number of + workers offered employer-based coverage has actually + increased. + (E) Half of all personal bankruptcies are caused in + part by medical expenses. By significantly increasing + health insurance coverage, the requirement, together + with the other provisions of this Act, will improve + financial security for families. + (F) Under the Employee Retirement Income Security + Act of 1974 (29 U.S.C. 1001 et seq.), the Public Health + Service Act (42 U.S.C. 201 et seq.), and this Act, the + Federal Government has a significant role in regulating + health insurance which is in interstate commerce. + (G) Under sections 2704 and 2705 of the Public + Health Service Act (as added by section 1201 of this + Act), if there were no requirement, many individuals + would wait to purchase health insurance until they + needed care. By significantly increasing health + insurance coverage, the requirement, together with the + other provisions of this Act, will minimize this adverse + selection and broaden the health insurance risk pool to + include healthy individuals, which will lower health + insurance premiums. The requirement is essential to + creating effective health insurance markets in which + improved health insurance products that are guaranteed + issue and do not exclude coverage of pre-existing + conditions can be sold. + (H) Administrative costs for private health + insurance, which were $90,000,000,000 in 2006, are 26 to + 30 percent of premiums in the current individual and + small group + +[[Page 124 STAT. 244]] + + markets. By significantly increasing health insurance + coverage and the size of purchasing pools, which will + increase economies of scale, the requirement, together + with the other provisions of this Act, will + significantly reduce administrative costs and lower + health insurance premiums. The requirement is essential + to creating effective health insurance markets that do + not require underwriting and eliminate its associated + administrative costs. + (3) Supreme court ruling.--In United States v. South-Eastern + Underwriters Association (322 U.S. 533 (1944)), the Supreme + Court of the United States ruled that insurance is interstate + commerce subject to Federal regulation. + + (b) In General.--Subtitle D of the Internal Revenue Code of 1986 is +amended by adding at the end the following new chapter: + + ``CHAPTER 48--MAINTENANCE OF MINIMUM ESSENTIAL COVERAGE + +``Sec. 5000A. Requirement to maintain minimum essential coverage. + +``SEC. 5000A. <<NOTE: 26 USC 5000A.>> REQUIREMENT TO MAINTAIN MINIMUM + ESSENTIAL COVERAGE. + + ``(a) Requirement To Maintain Minimum Essential Coverage.--An +applicable individual shall for each month beginning after 2013 ensure +that the individual, and any dependent of the individual who is an +applicable individual, is covered under minimum essential coverage for +such month. + ``(b) Shared Responsibility Payment.-- + ``(1) In general.-- <<NOTE: Penalty.>> If an applicable + individual fails to meet the requirement of subsection (a) for 1 + or more months during any calendar year beginning after 2013, + then, except as provided in subsection (d), there is hereby + imposed a penalty with respect to the individual in the amount + determined under subsection (c). + ``(2) Inclusion with return.--Any penalty imposed by this + section with respect to any month shall be included with a + taxpayer's return under chapter 1 for the taxable year which + includes such month. + ``(3) Payment of penalty.--If an individual with respect to + whom a penalty is imposed by this section for any month-- + ``(A) is a dependent (as defined in section 152) of + another taxpayer for the other taxpayer's taxable year + including such month, such other taxpayer shall be + liable for such penalty, or + ``(B) files a joint return for the taxable year + including such month, such individual and the spouse of + such individual shall be jointly liable for such + penalty. + + ``(c) Amount of Penalty.-- + ``(1) In general.--The penalty determined under this + subsection for any month with respect to any individual is an + amount equal to \1/12\ of the applicable dollar amount for the + calendar year. + ``(2) Dollar limitation.--The amount of the penalty imposed + by this section on any taxpayer for any taxable year with + respect to all individuals for whom the taxpayer is liable under + subsection (b)(3) shall not exceed an amount equal to 300 + percent the applicable dollar amount (determined without + +[[Page 124 STAT. 245]] + + regard to paragraph (3)(C)) for the calendar year with or within + which the taxable year ends. + ``(3) Applicable dollar amount.--For purposes of paragraph + (1)-- + ``(A) In general.--Except as provided in + subparagraphs (B) and (C), the applicable dollar amount + is $750. + ``(B) Phase in.--The applicable dollar amount is $95 + for 2014 and $350 for 2015. + ``(C) Special rule for individuals under age 18.--If + an applicable individual has not attained the age of 18 + as of the beginning of a month, the applicable dollar + amount with respect to such individual for the month + shall be equal to one-half of the applicable dollar + amount for the calendar year in which the month occurs. + ``(D) Indexing of amount.--In the case of any + calendar year beginning after 2016, the applicable + dollar amount shall be equal to $750, increased by an + amount equal to-- + ``(i) $750, multiplied by + ``(ii) the cost-of-living adjustment + determined under section 1(f)(3) for the calendar + year, determined by substituting `calendar year + 2015' for `calendar year 1992' in subparagraph (B) + thereof. + If the amount of any increase under clause (i) is not a + multiple of $50, such increase shall be rounded to the + next lowest multiple of $50. + ``(4) Terms relating to income and families.--For purposes + of this section-- + ``(A) Family size.--The family size involved with + respect to any taxpayer shall be equal to the number of + individuals for whom the taxpayer is allowed a deduction + under section 151 (relating to allowance of deduction + for personal exemptions) for the taxable year. + ``(B) Household income.--The term `household income' + means, with respect to any taxpayer for any taxable + year, an amount equal to the sum of-- + ``(i) the modified gross income of the + taxpayer, plus + ``(ii) the aggregate modified gross incomes of + all other individuals who-- + ``(I) were taken into account in + determining the taxpayer's family size + under paragraph (1), and + ``(II) were required to file a + return of tax imposed by section 1 for + the taxable year. + ``(C) Modified gross income.--The term `modified + gross income' means gross income-- + ``(i) decreased by the amount of any deduction + allowable under paragraph (1), (3), (4), or (10) + of section 62(a), + ``(ii) increased by the amount of interest + received or accrued during the taxable year which + is exempt from tax imposed by this chapter, and + ``(iii) determined without regard to sections + 911, 931, and 933. + ``(D) Poverty line.-- + +[[Page 124 STAT. 246]] + + ``(i) In general.--The term `poverty line' has + the meaning given that term in section 2110(c)(5) + of the Social Security Act (42 U.S.C. + 1397jj(c)(5)). + ``(ii) Poverty line used.--In the case of any + taxable year ending with or within a calendar + year, the poverty line used shall be the most + recently published poverty line as of the 1st day + of such calendar year. + + ``(d) Applicable Individual.--For purposes of this section-- + ``(1) In general.--The term `applicable individual' means, + with respect to any month, an individual other than an + individual described in paragraph (2), (3), or (4). + ``(2) Religious exemptions.-- + ``(A) Religious conscience exemption.--Such term + shall not include any individual for any month if such + individual has in effect an exemption under section + 1311(d)(4)(H) of the Patient Protection and Affordable + Care Act which certifies that such individual is a + member of a recognized religious sect or division + thereof described in section 1402(g)(1) and an adherent + of established tenets or teachings of such sect or + division as described in such section. + ``(B) Health care sharing ministry.-- + ``(i) In general.--Such term shall not include + any individual for any month if such individual is + a member of a health care sharing ministry for the + month. + ``(ii) Health care sharing ministry.--The term + `health care sharing ministry' means an + organization-- + ``(I) which is described in section + 501(c)(3) and is exempt from taxation + under section 501(a), + ``(II) members of which share a + common set of ethical or religious + beliefs and share medical expenses among + members in accordance with those beliefs + and without regard to the State in which + a member resides or is employed, + ``(III) members of which retain + membership even after they develop a + medical condition, + ``(IV) which (or a predecessor of + which) has been in existence at all + times since December 31, 1999, and + medical expenses of its members have + been shared continuously and without + interruption since at least December 31, + 1999, and + ``(V) which conducts an annual audit + which is performed by an independent + certified public accounting firm in + accordance with generally accepted + accounting principles and which is made + available to the public upon request. + ``(3) Individuals not lawfully present.--Such term shall not + include an individual for any month if for the month the + individual is not a citizen or national of the United States or + an alien lawfully present in the United States. + ``(4) Incarcerated individuals.--Such term shall not include + an individual for any month if for the month the individual is + incarcerated, other than incarceration pending the disposition + of charges. + + ``(e) Exemptions.--No penalty shall be imposed under subsection (a) +with respect to-- + ``(1) Individuals who cannot afford coverage.-- + +[[Page 124 STAT. 247]] + + ``(A) In general.--Any applicable individual for any + month if the applicable individual's required + contribution (determined on an annual basis) for + coverage for the month exceeds 8 percent of such + individual's household income for the taxable year + described in section 1412(b)(1)(B) of the Patient + Protection and Affordable Care Act. For purposes of + applying this subparagraph, the taxpayer's household + income shall be increased by any exclusion from gross + income for any portion of the required contribution made + through a salary reduction arrangement. + ``(B) <<NOTE: Definition.>> Required + contribution.--For purposes of this paragraph, the term + `required contribution' means-- + ``(i) in the case of an individual eligible to + purchase minimum essential coverage consisting of + coverage through an eligible-employer-sponsored + plan, the portion of the annual premium which + would be paid by the individual (without regard to + whether paid through salary reduction or + otherwise) for self-only coverage, or + ``(ii) in the case of an individual eligible + only to purchase minimum essential coverage + described in subsection (f)(1)(C), the annual + premium for the lowest cost bronze plan available + in the individual market through the Exchange in + the State in the rating area in which the + individual resides (without regard to whether the + individual purchased a qualified health plan + through the Exchange), reduced by the amount of + the credit allowable under section 36B for the + taxable year (determined as if the individual was + covered by a qualified health plan offered through + the Exchange for the entire taxable year). + ``(C) Special rules for individuals related to + employees.--For purposes of subparagraph (B)(i), if an + applicable individual is eligible for minimum essential + coverage through an employer by reason of a relationship + to an employee, the determination shall be made by + reference to the affordability of the coverage to the + employee. + ``(D) <<NOTE: Applicability. Determination.>> + Indexing.--In the case of plan years beginning in any + calendar year after 2014, subparagraph (A) shall be + applied by substituting for `8 percent' the percentage + the Secretary of Health and Human Services determines + reflects the excess of the rate of premium growth + between the preceding calendar year and 2013 over the + rate of income growth for such period. + ``(2) Taxpayers with income under 100 percent of poverty + line.--Any applicable individual for any month during a calendar + year if the individual's household income for the taxable year + described in section 1412(b)(1)(B) of the Patient Protection and + Affordable Care Act is less than 100 percent of the poverty line + for the size of the family involved (determined in the same + manner as under subsection (b)(4)). + ``(3) Members of indian tribes.--Any applicable individual + for any month during which the individual is a member of an + Indian tribe (as defined in section 45A(c)(6)). + ``(4) Months during short coverage gaps.-- + ``(A) In general.--Any month the last day of which + occurred during a period in which the applicable + individual + +[[Page 124 STAT. 248]] + + was not covered by minimum essential coverage for a + continuous period of less than 3 months. + ``(B) <<NOTE: Applicability.>> Special rules.--For + purposes of applying this paragraph-- + ``(i) the length of a continuous period shall + be determined without regard to the calendar years + in which months in such period occur, + ``(ii) if a continuous period is greater than + the period allowed under subparagraph (A), no + exception shall be provided under this paragraph + for any month in the period, and + ``(iii) if there is more than 1 continuous + period described in subparagraph (A) covering + months in a calendar year, the exception provided + by this paragraph shall only apply to months in + the first of such periods. + The Secretary shall prescribe rules for the collection + of the penalty imposed by this section in cases where + continuous periods include months in more than 1 taxable + year. + ``(5) Hardships.--Any applicable individual who for any + month is determined by the Secretary of Health and Human + Services under section 1311(d)(4)(H) to have suffered a hardship + with respect to the capability to obtain coverage under a + qualified health plan. + + ``(f) Minimum Essential Coverage.--For purposes of this section-- + ``(1) <<NOTE: Definition.>> In general.--The term `minimum + essential coverage' means any of the following: + ``(A) Government sponsored programs.--Coverage + under-- + ``(i) the Medicare program under part A of + title XVIII of the Social Security Act, + ``(ii) the Medicaid program under title XIX of + the Social Security Act, + ``(iii) the CHIP program under title XXI of + the Social Security Act, + ``(iv) the TRICARE for Life program, + ``(v) the veteran's health care program under + chapter 17 of title 38, United States Code, or + ``(vi) a health plan under section 2504(e) of + title 22, United States Code (relating to Peace + Corps volunteers). + ``(B) Employer-sponsored plan.--Coverage under an + eligible employer-sponsored plan. + ``(C) Plans in the individual market.--Coverage + under a health plan offered in the individual market + within a State. + ``(D) Grandfathered health plan.--Coverage under a + grandfathered health plan. + ``(E) Other coverage.--Such other health benefits + coverage, such as a State health benefits risk pool, as + the Secretary of Health and Human Services, in + coordination with the Secretary, recognizes for purposes + of this subsection. + ``(2) Eligible employer-sponsored plan.--The term `eligible + employer-sponsored plan' means, with respect to any + +[[Page 124 STAT. 249]] + + employee, a group health plan or group health insurance coverage + offered by an employer to the employee which is-- + ``(A) a governmental plan (within the meaning of + section 2791(d)(8) of the Public Health Service Act), or + ``(B) any other plan or coverage offered in the + small or large group market within a State. + Such term shall include a grandfathered health plan described in + paragraph (1)(D) offered in a group market. + ``(3) Excepted benefits not treated as minimum essential + coverage.--The term `minimum essential coverage' shall not + include health insurance coverage which consists of coverage of + excepted benefits-- + ``(A) described in paragraph (1) of subsection (c) + of section 2791 of the Public Health Service Act; or + ``(B) described in paragraph (2), (3), or (4) of + such subsection if the benefits are provided under a + separate policy, certificate, or contract of insurance. + ``(4) Individuals residing outside united states or + residents of territories.--Any applicable individual shall be + treated as having minimum essential coverage for any month-- + ``(A) if such month occurs during any period + described in subparagraph (A) or (B) of section + 911(d)(1) which is applicable to the individual, or + ``(B) if such individual is a bona fide resident of + any possession of the United States (as determined under + section 937(a)) for such month. + ``(5) Insurance-related terms.--Any term used in this + section which is also used in title I of the Patient Protection + and Affordable Care Act shall have the same meaning as when used + in such title. + + ``(g) Administration and Procedure.-- + ``(1) In general.--The penalty provided by this section + shall be paid upon notice and demand by the Secretary, and + except as provided in paragraph (2), shall be assessed and + collected in the same manner as an assessable penalty under + subchapter B of chapter 68. + ``(2) Special rules.--Notwithstanding any other provision of + law-- + ``(A) Waiver of criminal penalties.--In the case of + any failure by a taxpayer to timely pay any penalty + imposed by this section, such taxpayer shall not be + subject to any criminal prosecution or penalty with + respect to such failure. + ``(B) Limitations on liens and levies.--The + Secretary shall not-- + ``(i) file notice of lien with respect to any + property of a taxpayer by reason of any failure to + pay the penalty imposed by this section, or + ``(ii) levy on any such property with respect + to such failure.''. + + (c) Clerical Amendment.--The table of chapters for subtitle D of the +Internal Revenue Code of 1986 is amended by inserting after the item +relating to chapter 47 the following new item: + + ``Chapter 48--Maintenance of Minimum Essential Coverage.''. + + (d) <<NOTE: 26 USC 5000A note.>> Effective Date.--The amendments +made by this section shall apply to taxable years ending after December +31, 2013. + +[[Page 124 STAT. 250]] + +SEC. 1502. REPORTING OF HEALTH INSURANCE COVERAGE. + + (a) In General.--Part III of subchapter A of chapter 61 of the +Internal Revenue Code of 1986 is amended by inserting after subpart C +the following new subpart: + + ``Subpart D--Information Regarding Health Insurance Coverage + +``Sec. 6055. Reporting of health insurance coverage. + +``SEC. 6055. <<NOTE: 26 USC 6055.>> REPORTING OF HEALTH INSURANCE + COVERAGE. + + ``(a) In General.--Every person who provides minimum essential +coverage to an individual during a calendar year shall, at such time as +the Secretary may prescribe, make a return described in subsection (b). + ``(b) Form and Manner of Return.-- + ``(1) In general.--A return is described in this subsection + if such return-- + ``(A) is in such form as the Secretary may + prescribe, and + ``(B) contains-- + ``(i) the name, address and TIN of the primary + insured and the name and TIN of each other + individual obtaining coverage under the policy, + ``(ii) the dates during which such individual + was covered under minimum essential coverage + during the calendar year, + ``(iii) in the case of minimum essential + coverage which consists of health insurance + coverage, information concerning-- + ``(I) whether or not the coverage is + a qualified health plan offered through + an Exchange established under section + 1311 of the Patient Protection and + Affordable Care Act, and + ``(II) in the case of a qualified + health plan, the amount (if any) of any + advance payment under section 1412 of + the Patient Protection and Affordable + Care Act of any cost-sharing reduction + under section 1402 of such Act or of any + premium tax credit under section 36B + with respect to such coverage, and + ``(iv) such other information as the Secretary + may require. + ``(2) Information relating to employer-provided coverage.-- + If minimum essential coverage provided to an individual under + subsection (a) consists of health insurance coverage of a health + insurance issuer provided through a group health plan of an + employer, a return described in this subsection shall include-- + ``(A) the name, address, and employer identification + number of the employer maintaining the plan, + ``(B) the portion of the premium (if any) required + to be paid by the employer, and + ``(C) if the health insurance coverage is a + qualified health plan in the small group market offered + through an Exchange, such other information as the + Secretary may require for administration of the credit + under section 45R + +[[Page 124 STAT. 251]] + + (relating to credit for employee health insurance + expenses of small employers). + + ``(c) Statements To Be Furnished to Individuals With Respect to Whom +Information Is Reported.-- + ``(1) In general.--Every person required to make a return + under subsection (a) shall furnish to each individual whose name + is required to be set forth in such return a written statement + showing-- + ``(A) the name and address of the person required to + make such return and the phone number of the information + contact for such person, and + ``(B) the information required to be shown on the + return with respect to such individual. + ``(2) Time for furnishing statements.--The written statement + required under paragraph (1) shall be furnished on or before + January 31 of the year following the calendar year for which the + return under subsection (a) was required to be made. + + ``(d) Coverage Provided by Governmental Units.--In the case of +coverage provided by any governmental unit or any agency or +instrumentality thereof, the officer or employee who enters into the +agreement to provide such coverage (or the person appropriately +designated for purposes of this section) shall make the returns and +statements required by this section. + ``(e) Minimum Essential Coverage.--For purposes of this section, the +term `minimum essential coverage' has the meaning given such term by +section 5000A(f).''. + (b) Assessable Penalties.-- + (1) Subparagraph (B) of section 6724(d)(1) of the Internal + Revenue Code of 1986 <<NOTE: 26 USC 6724.>> (relating to + definitions) is amended by striking ``or'' at the end of clause + (xxii), by striking ``and'' at the end of clause (xxiii) and + inserting ``or'', and by inserting after clause (xxiii) the + following new clause: + ``(xxiv) section 6055 (relating to returns + relating to information regarding health insurance + coverage), and''. + (2) Paragraph (2) of section 6724(d) of such Code is amended + by striking ``or'' at the end of subparagraph (EE), by striking + the period at the end of subparagraph (FF) and inserting ``, + or'' and by inserting after subparagraph (FF) the following new + subparagraph: + ``(GG) section 6055(c) (relating to statements + relating to information regarding health insurance + coverage).''. + + (c) Notification of Nonenrollment.-- <<NOTE: Deadline. 42 USC +18092.>> Not later than June 30 of each year, the Secretary of the +Treasury, acting through the Internal Revenue Service and in +consultation with the Secretary of Health and Human Services, shall send +a notification to each individual who files an individual income tax +return and who is not enrolled in minimum essential coverage (as defined +in section 5000A of the Internal Revenue Code of 1986). Such +notification shall contain information on the services available through +the Exchange operating in the State in which such individual resides. + + (d) Conforming Amendment.--The table of subparts for part III of +subchapter A of chapter 61 of such Code is amended by inserting after +the item relating to subpart C the following new item: + +[[Page 124 STAT. 252]] + + ``subpart d--information regarding health insurance coverage''. + + (e) <<NOTE: 26 USC 6055 note.>> Effective Date.--The amendments +made by this section shall apply to calendar years beginning after 2013. + + PART II--EMPLOYER RESPONSIBILITIES + +SEC. 1511. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF LARGE EMPLOYERS. + + The Fair Labor Standards Act of 1938 is amended by inserting after +section 18 (29 U.S.C. 218) the following: + +``SEC. 18A. <<NOTE: 29 USC 218A.>> AUTOMATIC ENROLLMENT FOR EMPLOYEES + OF LARGE EMPLOYERS. + + ``In accordance with regulations promulgated by the Secretary, an +employer to which this Act applies that has more than 200 full-time +employees and that offers employees enrollment in 1 or more health +benefits plans shall automatically enroll new full-time employees in one +of the plans offered (subject to any waiting period authorized by law) +and to continue the enrollment of current employees in a health benefits +plan offered through the employer. Any automatic enrollment program +shall include adequate notice and the opportunity for an employee to opt +out of any coverage the individual or employee were automatically +enrolled in. Nothing in this section shall be construed to supersede any +State law which establishes, implements, or continues in effect any +standard or requirement relating to employers in connection with payroll +except to the extent that such standard or requirement prevents an +employer from instituting the automatic enrollment program under this +section.''. + +SEC. 1512. EMPLOYER REQUIREMENT TO INFORM EMPLOYEES OF COVERAGE OPTIONS. + + The Fair Labor Standards Act of 1938 is amended by inserting after +section 18A (as added by section 1513) the following: + +``SEC. 18B. <<NOTE: 29 USC 218B.>> NOTICE TO EMPLOYEES. + + ``(a) In General.-- <<NOTE: Deadline.>> In accordance with +regulations promulgated by the Secretary, an employer to which this Act +applies, shall provide to each employee at the time of hiring (or with +respect to current employees, not later than March 1, 2013), written +notice-- + ``(1) informing the employee of the existence of an + Exchange, including a description of the services provided by + such Exchange, and the manner in which the employee may contact + the Exchange to request assistance; + ``(2) if the employer plan's share of the total allowed + costs of benefits provided under the plan is less than 60 + percent of such costs, that the employee may be eligible for a + premium tax credit under section 36B of the Internal Revenue + Code of 1986 and a cost sharing reduction under section 1402 of + the Patient Protection and Affordable Care Act if the employee + purchases a qualified health plan through the Exchange; and + ``(3) if the employee purchases a qualified health plan + through the Exchange, the employee will lose the employer + contribution (if any) to any health benefits plan offered by the + employer and that all or a portion of such contribution may be + excludable from income for Federal income tax purposes. + +[[Page 124 STAT. 253]] + + ``(b) Effective Date.--Subsection (a) shall take effect with respect +to employers in a State beginning on March 1, 2013.''. + +SEC. 1513. SHARED RESPONSIBILITY FOR EMPLOYERS. + + (a) In General.--Chapter 43 of the Internal Revenue Code of 1986 is +amended by adding at the end the following: + +``SEC. 4980H. <<NOTE: 26 USC 4980H.>> SHARED RESPONSIBILITY FOR + EMPLOYERS REGARDING HEALTH COVERAGE. + + ``(a) Large Employers Not Offering Health Coverage.--If-- + ``(1) any applicable large employer fails to offer to its + full-time employees (and their dependents) the opportunity to + enroll in minimum essential coverage under an eligible employer- + sponsored plan (as defined in section 5000A(f)(2)) for any + month, and + ``(2) at least one full-time employee of the applicable + large employer has been certified to the employer under section + 1411 of the Patient Protection and Affordable Care Act as having + enrolled for such month in a qualified health plan with respect + to which an applicable premium tax credit or cost-sharing + reduction is allowed or paid with respect to the employee, + +then there is hereby imposed on the employer an assessable payment equal +to the product of the applicable payment amount and the number of +individuals employed by the employer as full-time employees during such +month. + ``(b) Large Employers With Waiting Periods Exceeding 30 Days.-- + ``(1) In general.--In the case of any applicable large + employer which requires an extended waiting period to enroll in + any minimum essential coverage under an employer-sponsored plan + (as defined in section 5000A(f)(2)), there is hereby imposed on + the employer an assessable payment, in the amount specified in + paragraph (2), for each full-time employee of the employer to + whom the extended waiting period applies. + ``(2) Amount.--For purposes of paragraph (1), the amount + specified in this paragraph for a full-time employee is-- + ``(A) in the case of an extended waiting period + which exceeds 30 days but does not exceed 60 days, $400, + and + ``(B) in the case of an extended waiting period + which exceeds 60 days, $600. + ``(3) Extended waiting period.--The term `extended waiting + period' means any waiting period (as defined in section + 2701(b)(4) of the Public Health Service Act) which exceeds 30 + days. + + ``(c) Large Employers Offering Coverage With Employees Who Qualify +for Premium Tax Credits or Cost-sharing Reductions.-- + ``(1) In general.--If-- + ``(A) an applicable large employer offers to its + full-time employees (and their dependents) the + opportunity to enroll in minimum essential coverage + under an eligible employer-sponsored plan (as defined in + section 5000A(f)(2)) for any month, and + ``(B) 1 or more full-time employees of the + applicable large employer has been certified to the + employer under section 1411 of the Patient Protection + and Affordable Care Act as having enrolled for such + month in a qualified health + +[[Page 124 STAT. 254]] + + plan with respect to which an applicable premium tax + credit or cost-sharing reduction is allowed or paid with + respect to the employee, + then there is hereby imposed on the employer an assessable + payment equal to the product of the number of full-time + employees of the applicable large employer described in + subparagraph (B) for such month and 400 percent of the + applicable payment amount. + ``(2) Overall limitation.--The aggregate amount of tax + determined under paragraph (1) with respect to all employees of + an applicable large employer for any month shall not exceed the + product of the applicable payment amount and the number of + individuals employed by the employer as full-time employees + during such month. + + ``(d) Definitions and Special Rules.--For purposes of this section-- + ``(1) Applicable payment amount.--The term `applicable + payment amount' means, with respect to any month, \1/12\ of + $750. + ``(2) Applicable large employer.-- + ``(A) In general.--The term `applicable large + employer' means, with respect to a calendar year, an + employer who employed an average of at least 50 full- + time employees on business days during the preceding + calendar year. + ``(B) Exemption for certain employers.-- + ``(i) In general.--An employer shall not be + considered to employ more than 50 full-time + employees if-- + ``(I) the employer's workforce + exceeds 50 full-time employees for 120 + days or fewer during the calendar year, + and + ``(II) the employees in excess of 50 + employed during such 120-day period were + seasonal workers. + ``(ii) Definition of seasonal workers.--The + term `seasonal worker' means a worker who performs + labor or services on a seasonal basis as defined + by the Secretary of Labor, including workers + covered by section 500.20(s)(1) of title 29, Code + of Federal Regulations and retail workers employed + exclusively during holiday seasons. + ``(C) Rules for determining employer size.--For + purposes of this paragraph-- + ``(i) Application of aggregation rule for + employers.--All persons treated as a single + employer under subsection (b), (c), (m), or (o) of + section 414 of the Internal Revenue Code of 1986 + shall be treated as 1 employer. + ``(ii) Employers not in existence in preceding + year.--In the case of an employer which was not in + existence throughout the preceding calendar year, + the determination of whether such employer is an + applicable large employer shall be based on the + average number of employees that it is reasonably + expected such employer will employ on business + days in the current calendar year. + ``(iii) Predecessors.--Any reference in this + subsection to an employer shall include a + reference to any predecessor of such employer. + +[[Page 124 STAT. 255]] + + ``(3) Applicable premium tax credit and cost-sharing + reduction.--The term `applicable premium tax credit and cost- + sharing reduction' means-- + ``(A) any premium tax credit allowed under section + 36B, + ``(B) any cost-sharing reduction under section 1402 + of the Patient Protection and Affordable Care Act, and + ``(C) any advance payment of such credit or + reduction under section 1412 of such Act. + ``(4) Full-time employee.-- + ``(A) In general.--The term `full-time employee' + means an employee who is employed on average at least 30 + hours of service per week. + ``(B) Hours of service.-- + <<NOTE: Regulations. Guidance.>> The Secretary, in + consultation with the Secretary of Labor, shall + prescribe such regulations, rules, and guidance as may + be necessary to determine the hours of service of an + employee, including rules for the application of this + paragraph to employees who are not compensated on an + hourly basis. + ``(5) Inflation adjustment.-- + ``(A) In general.--In the case of any calendar year + after 2014, each of the dollar amounts in subsection + (b)(2) and (d)(1) shall be increased by an amount equal + to the product of-- + ``(i) such dollar amount, and + ``(ii) the premium adjustment percentage (as + defined in section 1302(c)(4) of the Patient + Protection and Affordable Care Act) for the + calendar year. + ``(B) Rounding.--If the amount of any increase under + subparagraph (A) is not a multiple of $10, such increase + shall be rounded to the next lowest multiple of $10. + ``(6) Other definitions.--Any term used in this section + which is also used in the Patient Protection and Affordable Care + Act shall have the same meaning as when used in such Act. + ``(7) Tax nondeductible.--For denial of deduction for the + tax imposed by this section, see section 275(a)(6). + + ``(e) Administration and Procedure.-- + ``(1) In general.--Any assessable payment provided by this + section shall be paid upon notice and demand by the Secretary, + and shall be assessed and collected in the same manner as an + assessable penalty under subchapter B of chapter 68. + ``(2) Time for payment.--The Secretary may provide for the + payment of any assessable payment provided by this section on an + annual, monthly, or other periodic basis as the Secretary may + prescribe. + ``(3) Coordination with credits, etc..-- + <<NOTE: Regulations. Guidance.>> The Secretary shall prescribe + rules, regulations, or guidance for the repayment of any + assessable payment (including interest) if such payment is based + on the allowance or payment of an applicable premium tax credit + or cost-sharing reduction with respect to an employee, such + allowance or payment is subsequently disallowed, and the + assessable payment would not have been required to be made but + for such allowance or payment.''. + +[[Page 124 STAT. 256]] + + (b) Clerical Amendment.--The table of sections for chapter 43 of +such Code is amended by adding at the end the following new item: + +``Sec. 4980H. Shared responsibility for employers regarding health + coverage.''. + + (c) Study and Report of Effect of Tax on Workers' Wages.-- + (1) In general.--The Secretary of Labor shall conduct a + study to determine whether employees' wages are reduced by + reason of the application of the assessable payments under + section 4980H of the Internal Revenue Code of 1986 (as added by + the amendments made by this section). <<NOTE: Determination.>> + The Secretary shall make such determination on the basis of the + National Compensation Survey published by the Bureau of Labor + Statistics. + (2) Report.--The Secretary shall report the results of the + study under paragraph (1) to the Committee on Ways and Means of + the House of Representatives and to the Committee on Finance of + the Senate. + + (d) <<NOTE: 26 USC 4980H note.>> Effective Date.--The amendments +made by this section shall apply to months beginning after December 31, +2013. + +SEC. 1514. REPORTING OF EMPLOYER HEALTH INSURANCE COVERAGE. + + (a) In General.--Subpart D of part III of subchapter A of chapter 61 +of the Internal Revenue Code of 1986, as added by section 1502, is +amended by inserting after section 6055 the following new section: + +``SEC. 6056. <<NOTE: 26 USC 6056.>> LARGE EMPLOYERS REQUIRED TO REPORT + ON HEALTH INSURANCE COVERAGE. + + ``(a) In General.--Every applicable large employer required to meet +the requirements of section 4980H with respect to its full-time +employees during a calendar year shall, at such time as the Secretary +may prescribe, make a return described in subsection (b). + ``(b) Form and Manner of Return.--A return is described in this +subsection if such return-- + ``(1) is in such form as the Secretary may prescribe, and + ``(2) contains-- + ``(A) the name, date, and employer identification + number of the employer, + ``(B) a certification as to whether the employer + offers to its full-time employees (and their dependents) + the opportunity to enroll in minimum essential coverage + under an eligible employer-sponsored plan (as defined in + section 5000A(f)(2)), + ``(C) <<NOTE: Certification.>> if the employer + certifies that the employer did offer to its full-time + employees (and their dependents) the opportunity to so + enroll-- + ``(i) the length of any waiting period (as + defined in section 2701(b)(4) of the Public Health + Service Act) with respect to such coverage, + ``(ii) the months during the calendar year for + which coverage under the plan was available, + ``(iii) the monthly premium for the lowest + cost option in each of the enrollment categories + under the plan, and + ``(iv) the applicable large employer's share + of the total allowed costs of benefits provided + under the plan, + +[[Page 124 STAT. 257]] + + ``(D) the number of full-time employees for each + month during the calendar year, + ``(E) the name, address, and TIN of each full-time + employee during the calendar year and the months (if + any) during which such employee (and any dependents) + were covered under any such health benefits plans, and + ``(F) such other information as the Secretary may + require. + + ``(c) Statements To Be Furnished to Individuals With Respect to Whom +Information Is Reported.-- + ``(1) In general.--Every person required to make a return + under subsection (a) shall furnish to each full-time employee + whose name is required to be set forth in such return under + subsection (b)(2)(E) a written statement showing-- + ``(A) the name and address of the person required to + make such return and the phone number of the information + contact for such person, and + ``(B) the information required to be shown on the + return with respect to such individual. + ``(2) Time for furnishing statements.--The written statement + required under paragraph (1) shall be furnished on or before + January 31 of the year following the calendar year for which the + return under subsection (a) was required to be made. + + ``(d) Coordination With Other Requirements.--To the maximum extent +feasible, the Secretary may provide that-- + ``(1) any return or statement required to be provided under + this section may be provided as part of any return or statement + required under section 6051 or 6055, and + ``(2) in the case of an applicable large employer offering + health insurance coverage of a health insurance issuer, the + employer may enter into an agreement with the issuer to include + information required under this section with the return and + statement required to be provided by the issuer under section + 6055. + + ``(e) Coverage Provided by Governmental Units.--In the case of any +applicable large employer which is a governmental unit or any agency or +instrumentality thereof, the person appropriately designated for +purposes of this section shall make the returns and statements required +by this section. + ``(f) Definitions.--For purposes of this section, any term used in +this section which is also used in section 4980H shall have the meaning +given such term by section 4980H.''. + (b) Assessable Penalties.-- + (1) Subparagraph (B) of section 6724(d)(1) of the Internal + Revenue Code of 1986 (relating to definitions), as amended by + section 1502, <<NOTE: 26 USC 6724.>> is amended by striking + ``or'' at the end of clause (xxiii), by striking ``and'' at the + end of clause (xxiv) and inserting ``or'', and by inserting + after clause (xxiv) the following new clause: + ``(xxv) section 6056 (relating to returns + relating to large employers required to report on + health insurance coverage), and''. + (2) Paragraph (2) of section 6724(d) of such Code, as so + amended, is amended by striking ``or'' at the end of + subparagraph (FF), by striking the period at the end of + subparagraph + +[[Page 124 STAT. 258]] + + (GG) and inserting ``, or'' and by inserting after subparagraph + (GG) the following new subparagraph: + ``(HH) section 6056(c) (relating to statements + relating to large employers required to report on health + insurance coverage).''. + + (c) Conforming Amendment.--The table of sections for subpart D of +part III of subchapter A of chapter 61 of such Code, as added by section +1502, is amended by adding at the end the following new item: + +``Sec. 6056. Large employers required to report on health insurance + coverage.''. + + (d) <<NOTE: 26 USC 6056 note.>> Effective Date.--The amendments +made by this section shall apply to periods beginning after December 31, +2013. + +SEC. 1515. OFFERING OF EXCHANGE-PARTICIPATING QUALIFIED HEALTH PLANS + THROUGH CAFETERIA PLANS. + + (a) In General.--Subsection (f) of section 125 of the Internal +Revenue Code of 1986 <<NOTE: 26 USC 125.>> is amended by adding at the +end the following new paragraph: + ``(3) Certain exchange-participating qualified health plans + not qualified.-- + ``(A) In general.--The term `qualified benefit' + shall not include any qualified health plan (as defined + in section 1301(a) of the Patient Protection and + Affordable Care Act) offered through an Exchange + established under section 1311 of such Act. + ``(B) Exception for exchange-eligible employers.-- + Subparagraph (A) shall not apply with respect to any + employee if such employee's employer is a qualified + employer (as defined in section 1312(f)(2) of the + Patient Protection and Affordable Care Act) offering the + employee the opportunity to enroll through such an + Exchange in a qualified health plan in a group + market.''. + + (b) Conforming Amendments.--Subsection (f) of section 125 of such +Code is amended-- + (1) by striking ``For purposes of this section, the term'' + and inserting ``For purposes of this section-- + + ``(1) In General.--The term'', and + (2) by striking ``Such term shall not include'' and + inserting the following: + ``(2) Long-term care insurance not qualified.--The term + `qualified benefit' shall not include''. + + (c) <<NOTE: 26 USC 125 note.>> Effective Date.--The amendments made +by this section shall apply to taxable years beginning after December +31, 2013. + + Subtitle G--Miscellaneous Provisions + +SEC. 1551. <<NOTE: Applicability. 42 USC 18111.>> DEFINITIONS. + + Unless specifically provided for otherwise, the definitions +contained in section 2791 of the Public Health Service Act (42 U.S.C. +300gg-91) shall apply with respect to this title. + +SEC. 1552. <<NOTE: 42 USC 18112.>> TRANSPARENCY IN GOVERNMENT. + + <<NOTE: Deadline. Web posting.>> Not later than 30 days after the +date of enactment of this Act, the Secretary of Health and Human +Services shall publish on the Internet website of the Department of +Health and Human Services, a list of all of the authorities provided to +the Secretary under this Act (and the amendments made by this Act). + +[[Page 124 STAT. 259]] + +SEC. 1553. <<NOTE: 42 USC 18113.>> PROHIBITION AGAINST DISCRIMINATION + ON ASSISTED SUICIDE. + + (a) In General.--The Federal Government, and any State or local +government or health care provider that receives Federal financial +assistance under this Act (or under an amendment made by this Act) or +any health plan created under this Act (or under an amendment made by +this Act), may not subject an individual or institutional health care +entity to discrimination on the basis that the entity does not provide +any health care item or service furnished for the purpose of causing, or +for the purpose of assisting in causing, the death of any individual, +such as by assisted suicide, euthanasia, or mercy killing. + (b) Definition.--In this section, the term ``health care entity'' +includes an individual physician or other health care professional, a +hospital, a provider-sponsored organization, a health maintenance +organization, a health insurance plan, or any other kind of health care +facility, organization, or plan. + (c) Construction and Treatment of Certain Services.--Nothing in +subsection (a) shall be construed to apply to, or to affect, any +limitation relating to-- + (1) the withholding or withdrawing of medical treatment or + medical care; + (2) the withholding or withdrawing of nutrition or + hydration; + (3) <<NOTE: Abortion.>> abortion; or + (4) the use of an item, good, benefit, or service furnished + for the purpose of alleviating pain or discomfort, even if such + use may increase the risk of death, so long as such item, good, + benefit, or service is not also furnished for the purpose of + causing, or the purpose of assisting in causing, death, for any + reason. + + (d) Administration.--The Office for Civil Rights of the Department +of Health and Human Services is designated to receive complaints of +discrimination based on this section. + +SEC. 1554. <<NOTE: 42 USC 18114.>> ACCESS TO THERAPIES. + + Notwithstanding any other provision of this Act, the Secretary of +Health and Human Services shall not promulgate any regulation that-- + (1) creates any unreasonable barriers to the ability of + individuals to obtain appropriate medical care; + (2) impedes timely access to health care services; + (3) interferes with communications regarding a full range of + treatment options between the patient and the provider; + (4) restricts the ability of health care providers to + provide full disclosure of all relevant information to patients + making health care decisions; + (5) violates the principles of informed consent and the + ethical standards of health care professionals; or + (6) limits the availability of health care treatment for the + full duration of a patient's medical needs. + +[[Page 124 STAT. 260]] + +SEC. 1555. <<NOTE: 42 USC 18115.>> FREEDOM NOT TO PARTICIPATE IN + FEDERAL HEALTH INSURANCE PROGRAMS. + + No individual, company, business, nonprofit entity, or health +insurance issuer offering group or individual health insurance coverage +shall be required to participate in any Federal health insurance program +created under this Act (or any amendments made by this Act), or in any +Federal health insurance program expanded by this Act (or any such +amendments), and there shall be no penalty or fine imposed upon any such +issuer for choosing not to participate in such programs. + +SEC. 1556. EQUITY FOR CERTAIN ELIGIBLE SURVIVORS. + + (a) Rebuttable Presumption.--Section 411(c)(4) of the Black Lung +Benefits Act (30 U.S.C. 921(c)(4)) is amended by striking the last +sentence. + (b) Continuation of Benefits.--Section 422(l) of the Black Lung +Benefits Act (30 U.S.C. 932(l)) is amended by striking ``, except with +respect to a claim filed under this part on or after the effective date +of the Black Lung Benefits Amendments of 1981''. + (c) <<NOTE: Applicability. 30 USC 921 note.>> Effective Date.--The +amendments made by this section shall apply with respect to claims filed +under part B or part C of the Black Lung Benefits Act (30 U.S.C. 921 et +seq., 931 et seq.) after January 1, 2005, that are pending on or after +the date of enactment of this Act. + +SEC. 1557. <<NOTE: 42 USC 18116.>> NONDISCRIMINATION. + + (a) In General.--Except as otherwise provided for in this title (or +an amendment made by this title), an individual shall not, on the ground +prohibited under title VI of the Civil Rights Act of 1964 (42 U.S.C. +2000d et seq.), title IX of the Education Amendments of 1972 (20 U.S.C. +1681 et seq.), the Age Discrimination Act of 1975 (42 U.S.C. 6101 et +seq.), or section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), +be excluded from participation in, be denied the benefits of, or be +subjected to discrimination under, any health program or activity, any +part of which is receiving Federal financial assistance, including +credits, subsidies, or contracts of insurance, or under any program or +activity that is administered by an Executive Agency or any entity +established under this title (or amendments). <<NOTE: Applicability.>> +The enforcement mechanisms provided for and available under such title +VI, title IX, section 504, or such Age Discrimination Act shall apply +for purposes of violations of this subsection. + + (b) Continued Application of Laws.--Nothing in this title (or an +amendment made by this title) shall be construed to invalidate or limit +the rights, remedies, procedures, or legal standards available to +individuals aggrieved under title VI of the Civil Rights Act of 1964 (42 +U.S.C. 2000d et seq.), title VII of the Civil Rights Act of 1964 (42 +U.S.C. 2000e et seq.), title IX of the Education Amendments of 1972 (20 +U.S.C. 1681 et seq.), section 504 of the Rehabilitation Act of 1973 (29 +U.S.C. 794), or the Age Discrimination Act of 1975 (42 U.S.C. 611 et +seq.), or to supersede State laws that provide additional protections +against discrimination on any basis described in subsection (a). + (c) Regulations.--The Secretary may promulgate regulations to +implement this section. + +[[Page 124 STAT. 261]] + +SEC. 1558. PROTECTIONS FOR EMPLOYEES. + + The Fair Labor Standards Act of 1938 is amended by inserting after +section 18B (as added by section 1512) the following: + +``SEC. 18C. <<NOTE: 29 USC 218C.>> PROTECTIONS FOR EMPLOYEES. + + ``(a) Prohibition.--No employer shall discharge or in any manner +discriminate against any employee with respect to his or her +compensation, terms, conditions, or other privileges of employment +because the employee (or an individual acting at the request of the +employee) has-- + ``(1) received a credit under section 36B of the Internal + Revenue Code of 1986 or a subsidy under section 1402 of this + Act; + ``(2) provided, caused to be provided, or is about to + provide or cause to be provided to the employer, the Federal + Government, or the attorney general of a State information + relating to any violation of, or any act or omission the + employee reasonably believes to be a violation of, any provision + of this title (or an amendment made by this title); + ``(3) testified or is about to testify in a proceeding + concerning such violation; + ``(4) assisted or participated, or is about to assist or + participate, in such a proceeding; or + ``(5) objected to, or refused to participate in, any + activity, policy, practice, or assigned task that the employee + (or other such person) reasonably believed to be in violation of + any provision of this title (or amendment), or any order, rule, + regulation, standard, or ban under this title (or amendment). + + ``(b) Complaint Procedure.-- + ``(1) In general.--An employee who believes that he or she + has been discharged or otherwise discriminated against by any + employer in violation of this section may seek relief in + accordance with the procedures, notifications, burdens of proof, + remedies, and statutes of limitation set forth in section + 2087(b) of title 15, United States Code. + ``(2) No limitation on rights.--Nothing in this section + shall be deemed to diminish the rights, privileges, or remedies + of any employee under any Federal or State law or under any + collective bargaining agreement. The rights and remedies in this + section may not be waived by any agreement, policy, form, or + condition of employment.''. + +SEC. 1559. <<NOTE: 42 USC 18117.>> OVERSIGHT. + + The Inspector General of the Department of Health and Human Services +shall have oversight authority with respect to the administration and +implementation of this title as it relates to such Department. + +SEC. 1560. <<NOTE: 42 USC 18118.>> RULES OF CONSTRUCTION. + + (a) No Effect on Antitrust Laws.--Nothing in this title (or an +amendment made by this title) shall be construed to modify, impair, or +supersede the operation of any of the antitrust laws. For the purposes +of this section, the term ``antitrust laws'' has the meaning given such +term in subsection (a) of the first section of the Clayton Act, except +that such term includes section 5 of the Federal Trade Commission Act to +the extent that such section 5 applies to unfair methods of competition. + +[[Page 124 STAT. 262]] + + (b) Rule of Construction Regarding Hawaii's Prepaid Health Care +Act.--Nothing in this title (or an amendment made by this title) shall +be construed to modify or limit the application of the exemption for +Hawaii's Prepaid Health Care Act (Haw. Rev. Stat. Sec. Sec. 393-1 et +seq.) as provided for under section 514(b)(5) of the Employee Retirement +Income Security Act of 1974 (29 U.S.C. 1144(b)(5)). + (c) Student Health Insurance Plans.--Nothing in this title (or an +amendment made by this title) shall be construed to prohibit an +institution of higher education (as such term is defined for purposes of +the Higher Education Act of 1965) from offering a student health +insurance plan, to the extent that such requirement is otherwise +permitted under applicable Federal, State or local law. + (d) No Effect on Existing Requirements.--Nothing in this title (or +an amendment made by this title, unless specified by direct statutory +reference) shall be construed to modify any existing Federal requirement +concerning the State agency responsible for determining eligibility for +programs identified in section 1413. + +SEC. 1561. HEALTH INFORMATION TECHNOLOGY ENROLLMENT STANDARDS AND + PROTOCOLS. + + Title XXX of the Public Health Service Act (42 U.S.C. 300jj et seq.) +is amended by adding at the end the following: + + ``Subtitle C--Other Provisions + +``SEC. 3021. <<NOTE: 42 USC 300jj-51.>> HEALTH INFORMATION TECHNOLOGY + ENROLLMENT STANDARDS AND PROTOCOLS. + + ``(a) In General.-- + ``(1) Standards and protocols.-- + <<NOTE: Deadline. Determination.>> Not later than 180 days after + the date of enactment of this title, the Secretary, in + consultation with the HIT Policy Committee and the HIT Standards + Committee, shall develop interoperable and secure standards and + protocols that facilitate enrollment of individuals in Federal + and State health and human services programs, as determined by + the Secretary. + ``(2) Methods.--The Secretary shall facilitate enrollment in + such programs through methods determined appropriate by the + Secretary, which shall include providing individuals and third + parties authorized by such individuals and their designees + notification of eligibility and verification of eligibility + required under such programs. + + ``(b) Content.--The standards and protocols for electronic +enrollment in the Federal and State programs described in subsection (a) +shall allow for the following: + ``(1) Electronic matching against existing Federal and State + data, including vital records, employment history, enrollment + systems, tax records, and other data determined appropriate by + the Secretary to serve as evidence of eligibility and in lieu of + paper-based documentation. + ``(2) Simplification and submission of electronic + documentation, digitization of documents, and systems + verification of eligibility. + ``(3) Reuse of stored eligibility information (including + documentation) to assist with retention of eligible individuals. + +[[Page 124 STAT. 263]] + + ``(4) Capability for individuals to apply, recertify and + manage their eligibility information online, including at home, + at points of service, and other community-based locations. + ``(5) Ability to expand the enrollment system to integrate + new programs, rules, and functionalities, to operate at + increased volume, and to apply streamlined verification and + eligibility processes to other Federal and State programs, as + appropriate. + ``(6) Notification of eligibility, recertification, and + other needed communication regarding eligibility, which may + include communication via email and cellular phones. + ``(7) Other functionalities necessary to provide eligibles + with streamlined enrollment process. + + ``(c) Approval and Notification.--With respect to any standard or +protocol developed under subsection (a) that has been approved by the +HIT Policy Committee and the HIT Standards Committee, the Secretary-- + ``(1) shall notify States of such standards or protocols; + and + ``(2) may require, as a condition of receiving Federal funds + for the health information technology investments, that States + or other entities incorporate such standards and protocols into + such investments. + + ``(d) Grants for Implementation of Appropriate Enrollment HIT.-- + ``(1) In general.--The Secretary shall award grant to + eligible entities to develop new, and adapt existing, technology + systems to implement the HIT enrollment standards and protocols + developed under subsection (a) (referred to in this subsection + as `appropriate HIT technology'). + ``(2) Eligible entities.--To be eligible for a grant under + this subsection, an entity shall-- + ``(A) be a State, political subdivision of a State, + or a local governmental entity; and + ``(B) submit to the Secretary an application at such + time, in such manner, and containing-- + ``(i) a plan to adopt and implement + appropriate enrollment technology that includes-- + ``(I) proposed reduction in + maintenance costs of technology systems; + ``(II) elimination or updating of + legacy systems; and + ``(III) demonstrated collaboration + with other entities that may receive a + grant under this section that are + located in the same State, political + subdivision, or locality; + ``(ii) an assurance that the entity will share + such appropriate enrollment technology in + accordance with paragraph (4); and + ``(iii) such other information as the + Secretary may require. + ``(3) Sharing.-- + ``(A) In general.--The Secretary shall ensure that + appropriate enrollment HIT adopted under grants under + this subsection is made available to other qualified + State, qualified political subdivisions of a State, or + other appropriate qualified entities (as described in + subparagraph (B)) at no cost. + +[[Page 124 STAT. 264]] + + ``(B) Qualified entities.--The Secretary shall + determine what entities are qualified to receive + enrollment HIT under subparagraph (A), taking into + consideration the recommendations of the HIT Policy + Committee and the HIT Standards Committee.''. + +SEC. 1562. CONFORMING AMENDMENTS. + + (a) Applicability.--Section 2735 of the Public Health Service Act +(42 U.S.C. 300gg-21), as so redesignated by section 1001(4), is +amended-- + (1) by striking subsection (a); + (2) in subsection (b)-- + (A) in paragraph (1), by striking ``1 through 3'' + and inserting ``1 and 2''; and + (B) in paragraph (2)-- + (i) in subparagraph (A), by striking + ``subparagraph (D)'' and inserting ``subparagraph + (D) or (E)''; + (ii) by striking ``1 through 3'' and inserting + ``1 and 2''; and + (iii) by adding at the end the following: + ``(E) Election not applicable.--The election + described in subparagraph (A) shall not be available + with respect to the provisions of subpart 1.''; + (3) in subsection (c), by striking ``1 through 3 shall not + apply to any group'' and inserting ``1 and 2 shall not apply to + any individual coverage or any group''; and + (4) in subsection (d)-- + (A) in paragraph (1), by striking ``1 through 3 + shall not apply to any group'' and inserting ``1 and 2 + shall not apply to any individual coverage or any + group''; + (B) in paragraph (2)-- + (i) in the matter preceding subparagraph (A), + by striking ``1 through 3 shall not apply to any + group'' and inserting ``1 and 2 shall not apply to + any individual coverage or any group''; and + (ii) in subparagraph (C), by inserting ``or, + with respect to individual coverage, under any + health insurance coverage maintained by the same + health insurance issuer''; and + (C) in paragraph (3), by striking ``any group'' and + inserting ``any individual coverage or any group''. + + (b) Definitions.--Section 2791(d) of the Public Health Service Act +(42 U.S.C. 300gg-91(d)) is amended by adding at the end the following: + ``(20) Qualified health plan.--The term `qualified health + plan' has the meaning given such term in section 1301(a) of the + Patient Protection and Affordable Care Act. + ``(21) Exchange.--The term `Exchange' means an American + Health Benefit Exchange established under section 1311 of the + Patient Protection and Affordable Care Act.''. + + (c) Technical and Conforming Amendments.--Title XXVII of the Public +Health Service Act (42 U.S.C. 300gg et seq.) is amended-- + (1) in section 2704 <<NOTE: 42 USC 300gg-3.>> (42 U.S.C. + 300gg), as so redesignated by section 1201(2)-- + (A) in subsection (c)-- + +[[Page 124 STAT. 265]] + + (i) in paragraph (2), by striking ``group + health plan'' each place that such term appears + and inserting ``group or individual health plan''; + and + (ii) in paragraph (3)-- + (I) by striking ``group health + insurance'' each place that such term + appears and inserting ``group or + individual health insurance''; and + (II) in subparagraph (D), by + striking ``small or large'' and + inserting ``individual or group''; + (B) in subsection (d), by striking ``group health + insurance'' each place that such term appears and + inserting ``group or individual health insurance''; and + (C) in subsection (e)(1)(A), by striking ``group + health insurance'' and inserting ``group or individual + health insurance''; + (2) by striking the second heading for subpart 2 of part A + (relating to other requirements); + (3) in section 2725 <<NOTE: 42 USC 300gg-25.>> (42 U.S.C. + 300gg-4), as so redesignated by section 1001(2)-- + (A) in subsection (a), by striking ``health + insurance issuer offering group health insurance + coverage'' and inserting ``health insurance issuer + offering group or individual health insurance + coverage''; + (B) in subsection (b)-- + (i) by striking ``health insurance issuer + offering group health insurance coverage in + connection with a group health plan'' in the + matter preceding paragraph (1) and inserting + ``health insurance issuer offering group or + individual health insurance coverage''; and + (ii) in paragraph (1), by striking ``plan'' + and inserting ``plan or coverage''; + (C) in subsection (c)-- + (i) in paragraph (2), by striking ``group + health insurance coverage offered by a health + insurance issuer'' and inserting ``health + insurance issuer offering group or individual + health insurance coverage''; and + (ii) in paragraph (3), by striking ``issuer'' + and inserting ``health insurance issuer''; and + (D) in subsection (e), by striking ``health + insurance issuer offering group health insurance + coverage'' and inserting ``health insurance issuer + offering group or individual health insurance + coverage''; + (4) in section 2726 <<NOTE: 42 USC 300gg-26.>> (42 U.S.C. + 300gg-5), as so redesignated by section 1001(2)-- + (A) in subsection (a), by striking ``(or health + insurance coverage offered in connection with such a + plan)'' each place that such term appears and inserting + ``or a health insurance issuer offering group or + individual health insurance coverage''; + (B) in subsection (b), by striking ``(or health + insurance coverage offered in connection with such a + plan)'' each place that such term appears and inserting + ``or a health insurance issuer offering group or + individual health insurance coverage''; and + (C) in subsection (c)-- + +[[Page 124 STAT. 266]] + + (i) in paragraph (1), by striking ``(and group + health insurance coverage offered in connection + with a group health plan)'' and inserting ``and a + health insurance issuer offering group or + individual health insurance coverage''; + (ii) in paragraph (2), by striking ``(or + health insurance coverage offered in connection + with such a plan)'' each place that such term + appears and inserting ``or a health insurance + issuer offering group or individual health + insurance coverage''; + (5) in section 2727 <<NOTE: 42 USC 300gg-27.>> (42 U.S.C. + 300gg-6), as so redesignated by section 1001(2), by striking + ``health insurance issuers providing health insurance coverage + in connection with group health plans'' and inserting ``and + health insurance issuers offering group or individual health + insurance coverage''; + (6) in section 2728 <<NOTE: 42 USC 300gg-28.>> (42 U.S.C. + 300gg-7), as so redesignated by section 1001(2)-- + (A) in subsection (a), by striking ``health + insurance coverage offered in connection with such + plan'' and inserting ``individual health insurance + coverage''; + (B) in subsection (b)-- + (i) in paragraph (1), by striking ``or a + health insurance issuer that provides health + insurance coverage in connection with a group + health plan'' and inserting ``or a health + insurance issuer that offers group or individual + health insurance coverage''; + (ii) in paragraph (2), by striking ``health + insurance coverage offered in connection with the + plan'' and inserting ``individual health insurance + coverage''; and + (iii) in paragraph (3), by striking ``health + insurance coverage offered by an issuer in + connection with such plan'' and inserting + ``individual health insurance coverage''; + (C) in subsection (c), by striking ``health + insurance issuer providing health insurance coverage in + connection with a group health plan'' and inserting + ``health insurance issuer that offers group or + individual health insurance coverage''; and + (D) in subsection (e)(1), by striking ``health + insurance coverage offered in connection with such a + plan'' and inserting ``individual health insurance + coverage''; + (7) by striking the heading for subpart 3; + (8) in section 2731 <<NOTE: 42 USC 300gg-1.>> (42 U.S.C. + 300gg-11), as so redesignated by section 1001(3)-- + (A) by striking the section heading and all that + follows through subsection (b); + (B) in subsection (c)-- + (i) in paragraph (1)-- + (I) in the matter preceding + subparagraph (A), by striking ``small + group'' and inserting ``group and + individual''; and + (II) in subparagraph (B)-- + (aa) in the matter preceding + clause (i), by inserting ``and + individuals'' after + ``employers''; + +[[Page 124 STAT. 267]] + + (bb) in clause (i), by + inserting ``or any additional + individuals'' after ``additional + groups''; and + (cc) in clause (ii), by + striking ``without regard to the + claims experience of those + employers and their employees + (and their dependents) or any + health status-related factor + relating to such'' and inserting + ``and individuals without regard + to the claims experience of + those individuals, employers and + their employees (and their + dependents) or any health + status-related factor relating + to such individuals''; and + (ii) in paragraph (2), by striking ``small + group'' and inserting ``group or individual''; + (C) in subsection (d)-- + (i) by striking ``small group'' each place + that such appears and inserting ``group or + individual''; and + (ii) in paragraph (1)(B)-- + (I) by striking ``all employers'' + and inserting ``all employers and + individuals''; + (II) by striking ``those employers'' + and inserting ``those individuals, + employers''; and + (III) by striking ``such employees'' + and inserting ``such individuals, + employees''; + (D) by striking subsection (e); + (E) by striking subsection (f); and + (F) by transferring such section (as amended by this + paragraph) to appear at the end of section 2702 (as + added by section 1001(4)); + (9) in section 2732 <<NOTE: 42 USC 300gg-2.>> (42 U.S.C. + 300gg-12), as so redesignated by section 1001(3)-- + (A) by striking the section heading and all that + follows through subsection (a); + (B) in subsection (b)-- + (i) in the matter preceding paragraph (1), by + striking ``group health plan in the small or large + group market'' and inserting ``health insurance + coverage offered in the group or individual + market''; + (ii) in paragraph (1), by inserting ``, or + individual, as applicable,'' after ``plan + sponsor''; + (iii) in paragraph (2), by inserting ``, or + individual, as applicable,'' after ``plan + sponsor''; and + (iv) by striking paragraph (3) and inserting + the following: + ``(3) Violation of participation or contribution rates.--In + the case of a group health plan, the plan sponsor has failed to + comply with a material plan provision relating to employer + contribution or group participation rules, pursuant to + applicable State law.''; + (C) in subsection (c)-- + (i) in paragraph (1)-- + (I) in the matter preceding + subparagraph (A), by striking ``group + health insurance coverage offered in the + small or large group market'' and + inserting ``group or individual health + insurance coverage''; + +[[Page 124 STAT. 268]] + + (II) in subparagraph (A), by + inserting ``or individual, as + applicable,'' after ``plan sponsor''; + (III) in subparagraph (B)-- + (aa) by inserting ``or + individual, as applicable,'' + after ``plan sponsor''; and + (bb) by inserting ``or + individual health insurance + coverage''; and + (IV) in subparagraph (C), by + inserting ``or individuals, as + applicable,'' after ``those sponsors''; + and + (ii) in paragraph (2)(A)-- + (I) in the matter preceding clause + (i), by striking ``small group market or + the large group market, or both + markets,'' and inserting ``individual or + group market, or all markets,''; and + (II) in clause (i), by inserting + ``or individual, as applicable,'' after + ``plan sponsor''; and + (D) by transferring such section (as amended by this + paragraph) to appear at the end of section 2703 (as + added by section 1001(4)); + (10) in section 2733 <<NOTE: 42 USC 300gg-9.>> (42 U.S.C. + 300gg-13), as so redesignated by section 1001(4)-- + (A) in subsection (a)-- + (i) in the matter preceding paragraph (1), by + striking ``small employer'' and inserting ``small + employer or an individual''; + (ii) in paragraph (1), by inserting ``, or + individual, as applicable,'' after ``employer'' + each place that such appears; and + (iii) in paragraph (2), by striking ``small + employer'' and inserting ``employer, or + individual, as applicable,''; + (B) in subsection (b)-- + (i) in paragraph (1)-- + (I) in the matter preceding + subparagraph (A), by striking ``small + employer'' and inserting ``employer, or + individual, as applicable,''; + (II) in subparagraph (A), by adding + ``and'' at the end; + (III) by striking subparagraphs (B) + and (C); and + (IV) in subparagraph (D)-- + (aa) by inserting ``, or + individual, as applicable,'' + after ``employer''; and + (bb) by redesignating such + subparagraph as subparagraph + (B); + (ii) in paragraph (2)-- + (I) by striking ``small employers'' + each place that such term appears and + inserting ``employers, or individuals, + as applicable,''; and + (II) by striking ``small employer'' + and inserting ``employer, or individual, + as applicable,''; and + (C) by redesignating such section (as amended by + this paragraph) as section 2709 and transferring such + section to appear after section 2708 (as added by + section 1001(5)); + (11) by redesignating subpart 4 as subpart 2; + (12) in section 2735 (42 U.S.C. 300gg-21), as so + redesignated by section 1001(4)-- + +[[Page 124 STAT. 269]] + + (A) by striking subsection (a); + (B) by striking ``subparts 1 through 3'' each place + that such appears and inserting ``subpart 1''; + (C) by redesignating subsections (b) through (e) as + subsections (a) through (d), respectively; and + (D) by redesignating such section (as amended by + this paragraph) <<NOTE: 42 USC 300gg-21.>> as section + 2722; + (13) in section 2736 (42 U.S.C. 300gg-22), as so + redesignated by section 1001(4)-- + (A) in subsection (a)-- + (i) in paragraph (1), by striking ``small or + large group markets'' and inserting ``individual + or group market''; and + (ii) in paragraph (2), by inserting ``or + individual health insurance coverage'' after + ``group health plans''; + (B) in subsection (b)(1)(B), by inserting + ``individual health insurance coverage or'' after + ``respect to''; and + (C) by redesignating such section (as amended by + this paragraph) <<NOTE: 42 USC 300gg-22.>> as section + 2723; + (14) in section 2737(a)(1) (42 U.S.C. 300gg-23), as so + redesignated by section 1001(4)-- + (A) by inserting ``individual or'' before ``group + health insurance''; and + (B) by redesignating such section(as amended by this + paragraph) <<NOTE: 42 USC 300gg-23.>> as section 2724; + (15) in section 2762 (42 U.S.C. 300gg-62)-- + (A) in the section heading by inserting ``and + application'' before the period; and + (B) by adding at the end the following: + + ``(c) Application of Part A Provisions.-- + ``(1) In general.--The provisions of part A shall apply to + health insurance issuers providing health insurance coverage in + the individual market in a State as provided for in such part. + ``(2) Clarification.--To the extent that any provision of + this part conflicts with a provision of part A with respect to + health insurance issuers providing health insurance coverage in + the individual market in a State, the provisions of such part A + shall apply.''; and + (16) in section 2791(e) (42 U.S.C. 300gg-91(e))-- + (A) in paragraph (2), by striking ``51'' and + inserting ``101''; and + (B) in paragraph (4)-- + (i) by striking ``at least 2'' each place that + such appears and inserting ``at least 1''; and + (ii) by striking ``50'' and inserting ``100''. + + (d) <<NOTE: 42 USC 18120.>> Application.--Notwithstanding any other +provision of the Patient Protection and Affordable Care Act, nothing in +such Act (or an amendment made by such Act) shall be construed to-- + (1) prohibit (or authorize the Secretary of Health and Human + Services to promulgate regulations that prohibit) a group health + plan or health insurance issuer from carrying out utilization + management techniques that are commonly used as of the date of + enactment of this Act; or + (2) restrict the application of the amendments made by this + subtitle. + +[[Page 124 STAT. 270]] + + (e) Technical Amendment to the Employee Retirement Income Security +Act of 1974.--Subpart B of part 7 of subtitle A of title I of the +Employee Retirement Income Security Act of 1974 (29 U.S.C. 1181 et. +seq.) is amended, by adding at the end the following: + +``SEC. 715. <<NOTE: Applicability. 29 USC 1185d.>> ADDITIONAL MARKET + REFORMS. + + ``(a) General Rule.--Except as provided in subsection (b)-- + ``(1) the provisions of part A of title XXVII of the Public + Health Service Act (as amended by the Patient Protection and + Affordable Care Act) shall apply to group health plans, and + health insurance issuers providing health insurance coverage in + connection with group health plans, as if included in this + subpart; and + ``(2) to the extent that any provision of this part + conflicts with a provision of such part A with respect to group + health plans, or health insurance issuers providing health + insurance coverage in connection with group health plans, the + provisions of such part A shall apply. + + ``(b) Exception.--Notwithstanding subsection (a), the provisions of +sections 2716 and 2718 of title XXVII of the Public Health Service Act +(as amended by the Patient Protection and Affordable Care Act) shall not +apply with respect to self-insured group health plans, and the +provisions of this part shall continue to apply to such plans as if such +sections of the Public Health Service Act (as so amended) had not been +enacted.''. + (f) Technical Amendment to the Internal Revenue Code of 1986.-- +Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is +amended by adding at the end the following: + +``SEC. 9815. <<NOTE: Applicability. 29 USC 9815.>> ADDITIONAL MARKET + REFORMS. + + ``(a) General Rule.--Except as provided in subsection (b)-- + ``(1) the provisions of part A of title XXVII of the Public + Health Service Act (as amended by the Patient Protection and + Affordable Care Act) shall apply to group health plans, and + health insurance issuers providing health insurance coverage in + connection with group health plans, as if included in this + subchapter; and + ``(2) to the extent that any provision of this subchapter + conflicts with a provision of such part A with respect to group + health plans, or health insurance issuers providing health + insurance coverage in connection with group health plans, the + provisions of such part A shall apply. + + ``(b) Exception.--Notwithstanding subsection (a), the provisions of +sections 2716 and 2718 of title XXVII of the Public Health Service Act +(as amended by the Patient Protection and Affordable Care Act) shall not +apply with respect to self-insured group health plans, and the +provisions of this subchapter shall continue to apply to such plans as +if such sections of the Public Health Service Act (as so amended) had +not been enacted.''. + +SEC. 1563. SENSE OF THE SENATE PROMOTING FISCAL RESPONSIBILITY. + + (a) Findings.--The Senate makes the following findings: + (1) Based on Congressional Budget Office (CBO) estimates, + this Act will reduce the Federal deficit between 2010 and 2019. + (2) CBO projects this Act will continue to reduce budget + deficits after 2019. + +[[Page 124 STAT. 271]] + + (3) Based on CBO estimates, this Act will extend the + solvency of the Medicare HI Trust Fund. + (4) This Act will increase the surplus in the Social + Security Trust Fund, which should be reserved to strengthen the + finances of Social Security. + (5) The initial net savings generated by the Community + Living Assistance Services and Supports (CLASS) program are + necessary to ensure the long-term solvency of that program. + + (b) Sense of the Senate.--It is the sense of the Senate that-- + (1) the additional surplus in the Social Security Trust Fund + generated by this Act should be reserved for Social Security and + not spent in this Act for other purposes; and + (2) the net savings generated by the CLASS program should be + reserved for the CLASS program and not spent in this Act for + other purposes. + + TITLE II--ROLE OF PUBLIC PROGRAMS + + Subtitle A--Improved Access to Medicaid + +SEC. 2001. MEDICAID COVERAGE FOR THE LOWEST INCOME POPULATIONS. + + (a) Coverage for Individuals With Income at or Below 133 Percent of +the Poverty Line.-- + (1) Beginning 2014.-- <<NOTE: Effective date.>> Section + 1902(a)(10)(A)(i) of the Social Security Act (42 U.S.C. 1396a) + is amended-- + (A) by striking ``or'' at the end of subclause (VI); + (B) by adding ``or'' at the end of subclause (VII); + and + (C) by inserting after subclause (VII) the + following: + ``(VIII) beginning January 1, 2014, + who are under 65 years of age, not + pregnant, not entitled to, or enrolled + for, benefits under part A of title + XVIII, or enrolled for benefits under + part B of title XVIII, and are not + described in a previous subclause of + this clause, and whose income (as + determined under subsection (e)(14)) + does not exceed 133 percent of the + poverty line (as defined in section + 2110(c)(5)) applicable to a family of + the size involved, subject to subsection + (k);''. + (2) Provision of at least minimum essential coverage.-- + (A) In general.--Section 1902 of such Act (42 U.S.C. + 1396a) is amended by inserting after subsection (j) the + following: + + ``(k)(1) The medical assistance provided to an individual described +in subclause (VIII) of subsection (a)(10)(A)(i) shall consist of +benchmark coverage described in section 1937(b)(1) or benchmark +equivalent coverage described in section 1937(b)(2). Such medical +assistance shall be provided subject to the requirements of section +1937, without regard to whether a State otherwise has elected the option +to provide medical assistance through coverage under that section, +unless an individual described in subclause (VIII) of subsection +(a)(10)(A)(i) is also an individual for whom, under subparagraph (B) of +section 1937(a)(2), the State may not require enrollment in benchmark +coverage described in subsection (b)(1) + +[[Page 124 STAT. 272]] + +of section 1937 or benchmark equivalent coverage described in subsection +(b)(2) of that section.''. + (B) Conforming amendment.--Section 1903(i) of the + Social Security Act, as amended by section + 6402(c), <<NOTE: 42 USC 13966.>> is amended-- + (i) in paragraph (24), by striking ``or'' at + the end; + (ii) in paragraph (25), by striking the period + and inserting ``; or''; and + (iii) by adding at the end the following: + ``(26) with respect to any amounts expended for medical + assistance for individuals described in subclause (VIII) of + subsection (a)(10)(A)(i) other than medical assistance provided + through benchmark coverage described in section 1937(b)(1) or + benchmark equivalent coverage described in section + 1937(b)(2).''. + (3) Federal funding for cost of covering newly eligible + individuals.--Section 1905 of the Social Security Act (42 U.S.C. + 1396d), is amended-- + (A) in subsection (b), in the first sentence, by + inserting ``subsection (y) and'' before ``section + 1933(d)''; and + (B) by adding at the end the following new + subsection: + + ``(y) Increased FMAP for Medical Assistance for Newly Eligible +Mandatory Individuals.-- + ``(1) <<NOTE: Time periods.>> Amount of increase.-- + ``(A) 100 percent fmap.--During the period that + begins on January 1, 2014, and ends on December 31, + 2016, notwithstanding subsection (b), the Federal + medical assistance percentage determined for a State + that is one of the 50 States or the District of Columbia + for each fiscal year occurring during that period with + respect to amounts expended for medical assistance for + newly eligible individuals described in subclause (VIII) + of section 1902(a)(10)(A)(i) shall be equal to 100 + percent. + ``(B) 2017 and 2018.-- + ``(i) In general.--During the period that + begins on January 1, 2017, and ends on December + 31, 2018, notwithstanding subsection (b) and + subject to subparagraph (D), the Federal medical + assistance percentage determined for a State that + is one of the 50 States or the District of + Columbia for each fiscal year occurring during + that period with respect to amounts expended for + medical assistance for newly eligible individuals + described in subclause (VIII) of section + 1902(a)(10)(A)(i), shall be increased by the + applicable percentage point increase specified in + clause (ii) for the quarter and the State. + ``(ii) Applicable percentage point increase.-- + ``(I) In general.--For purposes of + clause (i), the applicable percentage + point increase for a quarter is the + following: + +[[Page 124 STAT. 273]] + + + + +------------------------------------------------------------------------ + If the State is an If the State is not an + ``For any fiscal year expansion State, the expansion State, the + quarter occurring in applicable percentage applicable percentage + the calendar year: point increase is: point increase is: +------------------------------------------------------------------------ +2017 30.3 34.3 +------------------------------------------------------------------------ +2018 31.3 33.3 +------------------------------------------------------------------------ + + ``(II) Expansion state defined.--For + purposes of the table in subclause (I), + a State is an expansion State if, on the + date of the enactment of the Patient + Protection and Affordable Care Act, the + State offers health benefits coverage + statewide to parents and nonpregnant, + childless adults whose income is at + least 100 percent of the poverty line, + that is not dependent on access to + employer coverage, employer + contribution, or employment and is not + limited to premium assistance, hospital- + only benefits, a high deductible health + plan, or alternative benefits under a + demonstration program authorized under + section 1938. A State that offers health + benefits coverage to only parents or + only nonpregnant childless adults + described in the preceding sentence + shall not be considered to be an + expansion State. + ``(C) 2019 and succeeding years. <<NOTE: Effective + date.>> --Beginning January 1, 2019, notwithstanding + subsection (b) but subject to subparagraph (D), the + Federal medical assistance percentage determined for a + State that is one of the 50 States or the District of + Columbia for each fiscal year quarter occurring during + that period with respect to amounts expended for medical + assistance for newly eligible individuals described in + subclause (VIII) of section 1902(a)(10)(A)(i), shall be + increased by 32.3 percentage points. + ``(D) Limitation.--The Federal medical assistance + percentage determined for a State under subparagraph (B) + or (C) shall in no case be more than 95 percent. + ``(2) Definitions.--In this subsection: + ``(A) Newly eligible.--The term `newly eligible' + means, with respect to an individual described in + subclause (VIII) of section 1902(a)(10)(A)(i), an + individual who is not under 19 years of age (or such + higher age as the State may have elected) and who, on + the date of enactment of the Patient Protection and + Affordable Care Act, is not eligible under the State + plan or under a waiver of the plan for full benefits or + for benchmark coverage described in subparagraph (A), + (B), or (C) of section 1937(b)(1) or benchmark + equivalent coverage described in section 1937(b)(2) that + has an aggregate actuarial value that is at least + actuarially equivalent to benchmark coverage described + in subparagraph (A), (B), or (C) of section 1937(b)(1), + or is eligible but not enrolled (or is on a waiting + list) for such benefits or coverage through a waiver + under the plan that has a capped or limited enrollment + that is full. + +[[Page 124 STAT. 274]] + + ``(B) Full benefits.--The term `full benefits' + means, with respect to an individual, medical assistance + for all services covered under the State plan under this + title that is not less in amount, duration, or scope, or + is determined by the Secretary to be substantially + equivalent, to the medical assistance available for an + individual described in section 1902(a)(10)(A)(i).''. + (4) State options to offer coverage earlier and presumptive + eligibility; children required to have coverage for parents to + be eligible.-- + (A) In general.--Subsection (k) of section 1902 of + the Social Security Act (as added by paragraph + (2)), <<NOTE: 42 USC 1396a.>> is amended by inserting + after paragraph (1) the following: + + ``(2) <<NOTE: Effective date. Time period.>> Beginning with the +first day of any fiscal year quarter that begins on or after January 1, +2011, and before January 1, 2014, a State may elect through a State plan +amendment to provide medical assistance to individuals who would be +described in subclause (VIII) of subsection (a)(10)(A)(i) if that +subclause were effective before January 1, 2014. A State may elect to +phase-in the extension of eligibility for medical assistance to such +individuals based on income, so long as the State does not extend such +eligibility to individuals described in such subclause with higher +income before making individuals described in such subclause with lower +income eligible for medical assistance. + + ``(3) If an individual described in subclause (VIII) of subsection +(a)(10)(A)(i) is the parent of a child who is under 19 years of age (or +such higher age as the State may have elected) who is eligible for +medical assistance under the State plan or under a waiver of such plan +(under that subclause or under a State plan amendment under paragraph +(2), the individual may not be enrolled under the State plan unless the +individual's child is enrolled under the State plan or under a waiver of +the plan or is enrolled in other health insurance coverage. For purposes +of the preceding sentence, the term `parent' includes an individual +treated as a caretaker relative for purposes of carrying out section +1931.''. + (B) Presumptive eligibility.--Section 1920 of the + Social Security Act (42 U.S.C. 1396r-1) is amended by + adding at the end the following: + + ``(e) <<NOTE: Guidelines.>> If the State has elected the option to +provide a presumptive eligibility period under this section or section +1920A, the State may elect to provide a presumptive eligibility period +(as defined in subsection (b)(1)) for individuals who are eligible for +medical assistance under clause (i)(VIII) of subsection (a)(10)(A) or +section 1931 in the same manner as the State provides for such a period +under this section or section 1920A, subject to such guidance as the +Secretary shall establish.''. + (5) Conforming amendments.-- + (A) Section 1902(a)(10) of such Act (42 U.S.C. + 1396a(a)(10)) is amended in the matter following + subparagraph (G), by striking ``and (XIV)'' and + inserting ``(XIV)'' and by inserting ``and (XV) the + medical assistance made available to an individual + described in subparagraph (A)(i)(VIII) shall be limited + to medical assistance described in subsection (k)(1)'' + before the semicolon. + (B) Section 1902(l)(2)(C) of such Act (42 U.S.C. + 1396a(l)(2)(C)) is amended by striking ``100'' and + inserting ``133''. + +[[Page 124 STAT. 275]] + + (C) Section 1905(a) of such Act (42 U.S.C. 1396d(a)) + is amended in the matter preceding paragraph (1)-- + (i) by striking ``or'' at the end of clause + (xii); + (ii) by inserting ``or'' at the end of clause + (xiii); and + (iii) by inserting after clause (xiii) the + following: + ``(xiv) individuals described in section + 1902(a)(10)(A)(i)(VIII),''. + (D) Section 1903(f)(4) of such Act (42 U.S.C. + 1396b(f)(4)) is amended by inserting + ``1902(a)(10)(A)(i)(VIII),'' after + ``1902(a)(10)(A)(i)(VII),''. + (E) Section 1937(a)(1)(B) of such Act (42 U.S.C. + 1396u-7(a)(1)(B)) is amended by inserting ``subclause + (VIII) of section 1902(a)(10)(A)(i) or under'' after + ``eligible under''. + + (b) Maintenance of Medicaid Income Eligibility.--Section 1902 of the +Social Security Act (42 U.S.C. 1396a) is amended-- + (1) in subsection (a)-- + (A) by striking ``and'' at the end of paragraph + (72); + (B) by striking the period at the end of paragraph + (73) and inserting ``; and''; and + (C) by inserting after paragraph (73) the following + new paragraph: + ``(74) provide for maintenance of effort under the State + plan or under any waiver of the plan in accordance with + subsection (gg).''; and + (2) by adding at the end the following new subsection: + + ``(gg) Maintenance of Effort.-- + ``(1) General requirement to maintain eligibility standards + until state exchange is fully operational.--Subject <<NOTE: Time + period. Determination.>> to the succeeding paragraphs of this + subsection, during the period that begins on the date of + enactment of the Patient Protection and Affordable Care Act and + ends on the date on which the Secretary determines that an + Exchange established by the State under section 1311 of the + Patient Protection and Affordable Care Act is fully operational, + as a condition for receiving any Federal payments under section + 1903(a) for calendar quarters occurring during such period, a + State shall not have in effect eligibility standards, + methodologies, or procedures under the State plan under this + title or under any waiver of such plan that is in effect during + that period, that are more restrictive than the eligibility + standards, methodologies, or procedures, respectively, under the + plan or waiver that are in effect on the date of enactment of + the Patient Protection and Affordable Care Act. + ``(2) Continuation of eligibility standards for children + until october 1, 2019.-- <<NOTE: Applicability.>> The + requirement under paragraph (1) shall continue to apply to a + State through September 30, 2019, with respect to the + eligibility standards, methodologies, and procedures under the + State plan under this title or under any waiver of such plan + that are applicable to determining the eligibility for medical + assistance of any child who is under 19 years of age (or such + higher age as the State may have elected). + ``(3) Nonapplication.-- <<NOTE: Time + period. Deadline. Certification.>> During the period that begins + on January 1, 2011, and ends on December 31, 2013, the + requirement under paragraph (1) shall not apply to a State with + respect to nonpregnant, nondisabled adults who are eligible + +[[Page 124 STAT. 276]] + + for medical assistance under the State plan or under a waiver of + the plan at the option of the State and whose income exceeds 133 + percent of the poverty line (as defined in section 2110(c)(5)) + applicable to a family of the size involved if, on or after + December 31, 2010, the State certifies to the Secretary that, + with respect to the State fiscal year during which the + certification is made, the State has a budget deficit, or with + respect to the succeeding State fiscal year, the State is + projected to have a budget deficit. Upon submission of such a + certification to the Secretary, the requirement under paragraph + (1) shall not apply to the State with respect to any remaining + portion of the period described in the preceding sentence. + ``(4) Determination of compliance.-- + ``(A) States shall apply modified gross income.--A + State's determination of income in accordance with + subsection (e)(14) shall not be considered to be + eligibility standards, methodologies, or procedures that + are more restrictive than the standards, methodologies, + or procedures in effect under the State plan or under a + waiver of the plan on the date of enactment of the + Patient Protection and Affordable Care Act for purposes + of determining compliance with the requirements of + paragraph (1), (2), or (3). + ``(B) States may expand eligibility or move waivered + populations into coverage under the state plan.--With + respect to any period applicable under paragraph (1), + (2), or (3), a State that applies eligibility standards, + methodologies, or procedures under the State plan under + this title or under any waiver of the plan that are less + restrictive than the eligibility standards, + methodologies, or procedures, applied under the State + plan or under a waiver of the plan on the date of + enactment of the Patient Protection and Affordable Care + Act, or that makes individuals who, on such date of + enactment, are eligible for medical assistance under a + waiver of the State plan, after such date of enactment + eligible for medical assistance through a State plan + amendment with an income eligibility level that is not + less than the income eligibility level that applied + under the waiver, or as a result of the application of + subclause (VIII) of section 1902(a)(10)(A)(i), shall not + be considered to have in effect eligibility standards, + methodologies, or procedures that are more restrictive + than the standards, methodologies, or procedures in + effect under the State plan or under a waiver of the + plan on the date of enactment of the Patient Protection + and Affordable Care Act for purposes of determining + compliance with the requirements of paragraph (1), (2), + or (3).''. + + (c) Medicaid Benchmark Benefits Must Consist of at Least Minimum +Essential Coverage.--Section 1937(b) of such Act (42 U.S.C. 1396u-7(b)) +is amended-- + (1) in paragraph (1), in the matter preceding subparagraph + (A), by inserting ``subject to paragraphs (5) and (6),'' before + ``each''; + (2) in paragraph (2)-- + (A) in the matter preceding subparagraph (A), by + inserting ``subject to paragraphs (5) and (6)'' after + ``subsection (a)(1),''; + +[[Page 124 STAT. 277]] + + (B) in subparagraph (A)-- + (i) by redesignating clauses (iv) and (v) as + clauses (vi) and (vii), respectively; and + (ii) by inserting after clause (iii), the + following: + ``(iv) Coverage of prescription drugs. + ``(v) Mental health services.''; and + (C) in subparagraph (C)-- + (i) by striking clauses (i) and (ii); and + (ii) by redesignating clauses (iii) and (iv) + as clauses (i) and (ii), respectively; and + (3) by adding at the end the following new paragraphs: + ``(5) Minimum standards.-- <<NOTE: Effective + date.>> Effective January 1, 2014, any benchmark benefit package + under paragraph (1) or benchmark equivalent coverage under + paragraph (2) must provide at least essential health benefits as + described in section 1302(b) of the Patient Protection and + Affordable Care Act. + ``(6) Mental health services parity.-- + ``(A) In general.--In the case of any benchmark + benefit package under paragraph (1) or benchmark + equivalent coverage under paragraph (2) that is offered + by an entity that is not a medicaid managed care + organization and that provides both medical and surgical + benefits and mental health or substance use disorder + benefits, the entity shall ensure that the financial + requirements and treatment limitations applicable to + such mental health or substance use disorder benefits + comply with the requirements of section 2705(a) of the + Public Health Service Act in the same manner as such + requirements apply to a group health plan. + ``(B) Deemed compliance.--Coverage provided with + respect to an individual described in section + 1905(a)(4)(B) and covered under the State plan under + section 1902(a)(10)(A) of the services described in + section 1905(a)(4)(B) (relating to early and periodic + screening, diagnostic, and treatment services defined in + section 1905(r)) and provided in accordance with section + 1902(a)(43), shall be deemed to satisfy the requirements + of subparagraph (A).''. + + (d) Annual Reports on Medicaid Enrollment.-- + (1) State reports.--Section 1902(a) of the Social Security + Act (42 U.S.C. 1396a(a)), as amended by subsection (b), is + amended-- + (A) by striking ``and'' at the end of paragraph + (73); + (B) by striking the period at the end of paragraph + (74) and inserting ``; and''; and + (C) by inserting after paragraph (74) the following + new paragraph: + ``(75) <<NOTE: Effective date.>> provide that, beginning + January 2015, and annually thereafter, the State shall submit a + report to the Secretary that contains-- + ``(A) the total number of enrolled and newly + enrolled individuals in the State plan or under a waiver + of the plan for the fiscal year ending on September 30 + of the preceding calendar year, disaggregated by + population, including children, parents, nonpregnant + childless adults, disabled individuals, elderly + individuals, and such other + +[[Page 124 STAT. 278]] + + categories or sub-categories of individuals eligible for + medical assistance under the State plan or under a + waiver of the plan as the Secretary may require; + ``(B) a description, which may be specified by + population, of the outreach and enrollment processes + used by the State during such fiscal year; and + ``(C) any other data reporting determined necessary + by the Secretary to monitor enrollment and retention of + individuals eligible for medical assistance under the + State plan or under a waiver of the plan.''. + (2) Reports to congress.-- <<NOTE: Effective date. 42 USC + 1396a note.>> Beginning April 2015, and annually thereafter, the + Secretary of Health and Human Services shall submit a report to + the appropriate committees of Congress on the total enrollment + and new enrollment in Medicaid for the fiscal year ending on + September 30 of the preceding calendar year on a national and + State-by-State basis, and shall include in each such report such + recommendations for administrative or legislative changes to + improve enrollment in the Medicaid program as the Secretary + determines appropriate. + + (e) State Option for Coverage for Individuals With Income That +Exceeds 133 Percent of the Poverty Line.-- + (1) Coverage as optional categorically needy group.--Section + 1902 of the Social Security Act (42 U.S.C. 1396a) is amended-- + (A) in subsection (a)(10)(A)(ii)-- + (i) in subclause (XVIII), by striking ``or'' + at the end; + (ii) in subclause (XIX), by adding ``or'' at + the end; and + (iii) by adding at the end the following new + subclause: + ``(XX) <<NOTE: Effective + date.>> beginning January 1, 2014, who + are under 65 years of age and are not + described in or enrolled under a + previous subclause of this clause, and + whose income (as determined under + subsection (e)(14)) exceeds 133 percent + of the poverty line (as defined in + section 2110(c)(5)) applicable to a + family of the size involved but does not + exceed the highest income eligibility + level established under the State plan + or under a waiver of the plan, subject + to subsection (hh);'' and + (B) by adding at the end the following new + subsection: + + ``(hh)(1) A State may elect to phase-in the extension of eligibility +for medical assistance to individuals described in subclause (XX) of +subsection (a)(10)(A)(ii) based on the categorical group (including +nonpregnant childless adults) or income, so long as the State does not +extend such eligibility to individuals described in such subclause with +higher income before making individuals described in such subclause with +lower income eligible for medical assistance. + ``(2) If an individual described in subclause (XX) of subsection +(a)(10)(A)(ii) is the parent of a child who is under 19 years of age (or +such higher age as the State may have elected) who is eligible for +medical assistance under the State plan or under a waiver of such plan, +the individual may not be enrolled under the State plan unless the +individual's child is enrolled under the State plan or under a waiver of +the plan or is enrolled in other health insurance coverage. For purposes +of the preceding sentence, + +[[Page 124 STAT. 279]] + +the term `parent' includes an individual treated as a caretaker relative +for purposes of carrying out section 1931.''. + (2) Conforming amendments.-- + (A) Section 1905(a) of such Act (42 U.S.C. + 1396d(a)), as amended by subsection (a)(5)(C), is + amended in the matter preceding paragraph (1)-- + (i) by striking ``or'' at the end of clause + (xiii); + (ii) by inserting ``or'' at the end of clause + (xiv); and + (iii) by inserting after clause (xiv) the + following: + ``(xv) individuals described in section + 1902(a)(10)(A)(ii)(XX),''. + (B) Section 1903(f)(4) of such Act (42 U.S.C. + 1396b(f)(4)) is amended by inserting + ``1902(a)(10)(A)(ii)(XX),'' after + ``1902(a)(10)(A)(ii)(XIX),''. + (C) Section 1920(e) of such Act (42 U.S.C. 1396r- + 1(e)), as added by subsection (a)(4)(B), is amended by + inserting ``or clause (ii)(XX)'' after ``clause + (i)(VIII)''. + +SEC. 2002. INCOME ELIGIBILITY FOR NONELDERLY DETERMINED USING MODIFIED + GROSS INCOME. + + (a) In General.--Section 1902(e) of the Social Security Act (42 +U.S.C. 1396a(e)) is amended by adding at the end the following: + ``(14) Income determined using modified gross income.-- + ``(A) In general.--Notwithstanding subsection (r) or + any other provision of this title, except as provided in + subparagraph (D), for purposes of determining income + eligibility for medical assistance under the State plan + or under any waiver of such plan and for any other + purpose applicable under the plan or waiver for which a + determination of income is required, including with + respect to the imposition of premiums and cost-sharing, + a State shall use the modified gross income of an + individual and, in the case of an individual in a family + greater than 1, the household income of such family. A + State shall establish income eligibility thresholds for + populations to be eligible for medical assistance under + the State plan or a waiver of the plan using modified + gross income and household income that are not less than + the effective income eligibility levels that applied + under the State plan or waiver on the date of enactment + of the Patient Protection and Affordable Care Act. For + purposes of complying with the maintenance of effort + requirements under subsection (gg) during the transition + to modified gross income and household income, a State + shall, working with the Secretary, establish an + equivalent income test that ensures individuals eligible + for medical assistance under the State plan or under a + waiver of the plan on the date of enactment of the + Patient Protection and Affordable Care Act, do not lose + coverage under the State plan or under a waiver of the + plan. <<NOTE: Waiver authority.>> The Secretary may + waive such provisions of this title and title XXI as are + necessary to ensure that States establish income and + eligibility determination systems that protect + beneficiaries. + ``(B) No income or expense disregards.--No type of + expense, block, or other income disregard shall be + applied + +[[Page 124 STAT. 280]] + + by a State to determine income eligibility for medical + assistance under the State plan or under any waiver of + such plan or for any other purpose applicable under the + plan or waiver for which a determination of income is + required. + ``(C) No assets test.--A State shall not apply any + assets or resources test for purposes of determining + eligibility for medical assistance under the State plan + or under a waiver of the plan. + ``(D) Exceptions.-- + ``(i) Individuals eligible because of other + aid or assistance, elderly individuals, medically + needy individuals, and individuals eligible for + medicare cost-sharing.--Subparagraphs (A), (B), + and (C) shall not apply to the determination of + eligibility under the State plan or under a waiver + for medical assistance for the following: + ``(I) Individuals who are eligible + for medical assistance under the State + plan or under a waiver of the plan on a + basis that does not require a + determination of income by the State + agency administering the State plan or + waiver, including as a result of + eligibility for, or receipt of, other + Federal or State aid or assistance, + individuals who are eligible on the + basis of receiving (or being treated as + if receiving) supplemental security + income benefits under title XVI, and + individuals who are eligible as a result + of being or being deemed to be a child + in foster care under the responsibility + of the State. + ``(II) Individuals who have attained + age 65. + ``(III) Individuals who qualify for + medical assistance under the State plan + or under any waiver of such plan on the + basis of being blind or disabled (or + being treated as being blind or + disabled) without regard to whether the + individual is eligible for supplemental + security income benefits under title XVI + on the basis of being blind or disabled + and including an individual who is + eligible for medical assistance on the + basis of section 1902(e)(3). + ``(IV) Individuals described in + subsection (a)(10)(C). + ``(V) Individuals described in any + clause of subsection (a)(10)(E). + ``(ii) Express lane agency findings.--In the + case of a State that elects the Express Lane + option under paragraph (13), notwithstanding + subparagraphs (A), (B), and (C), the State may + rely on a finding made by an Express Lane agency + in accordance with that paragraph relating to the + income of an individual for purposes of + determining the individual's eligibility for + medical assistance under the State plan or under a + waiver of the plan. + ``(iii) Medicare prescription drug subsidies + determinations.--Subparagraphs (A), (B), and (C) + shall not apply to any determinations of + eligibility for premium and cost-sharing subsidies + under and in + +[[Page 124 STAT. 281]] + + accordance with section 1860D-14 made by the State + pursuant to section 1935(a)(2). + ``(iv) Long-term care.--Subparagraphs (A), + (B), and (C) shall not apply to any determinations + of eligibility of individuals for purposes of + medical assistance for nursing facility services, + a level of care in any institution equivalent to + that of nursing facility services, home or + community-based services furnished under a waiver + or State plan amendment under section 1915 or a + waiver under section 1115, and services described + in section 1917(c)(1)(C)(ii). + ``(v) Grandfather of current enrollees until + date of next regular redetermination.--An + individual who, on January 1, 2014, is enrolled in + the State plan or under a waiver of the plan and + who would be determined ineligible for medical + assistance solely because of the application of + the modified gross income or household income + standard described in subparagraph (A), shall + remain eligible for medical assistance under the + State plan or waiver (and subject to the same + premiums and cost-sharing as applied to the + individual on that date) through March 31, 2014, + or the date on which the individual's next + regularly scheduled redetermination of eligibility + is to occur, whichever is later. + ``(E) Transition planning and oversight.-- + <<NOTE: Submission.>> Each State shall submit to the + Secretary for the Secretary's approval the income + eligibility thresholds proposed to be established using + modified gross income and household income, the + methodologies and procedures to be used to determine + income eligibility using modified gross income and + household income and, if applicable, a State plan + amendment establishing an optional eligibility category + under subsection (a)(10)(A)(ii)(XX). To the extent + practicable, the State shall use the same methodologies + and procedures for purposes of making such + determinations as the State used on the date of + enactment of the Patient Protection and Affordable Care + Act. The Secretary shall ensure that the income + eligibility thresholds proposed to be established using + modified gross income and household income, including + under the eligibility category established under + subsection (a)(10)(A)(ii)(XX), and the methodologies and + procedures proposed to be used to determine income + eligibility, will not result in children who would have + been eligible for medical assistance under the State + plan or under a waiver of the plan on the date of + enactment of the Patient Protection and Affordable Care + Act no longer being eligible for such assistance. + ``(F) Limitation on secretarial authority.--The + Secretary shall not waive compliance with the + requirements of this paragraph except to the extent + necessary to permit a State to coordinate eligibility + requirements for dual eligible individuals (as defined + in section 1915(h)(2)(B)) under the State plan or under + a waiver of the plan and under title XVIII and + individuals who require the level of care provided in a + hospital, a nursing facility, or an intermediate care + facility for the mentally retarded. + +[[Page 124 STAT. 282]] + + ``(G) Definitions of modified gross income and + household income.--In this paragraph, the terms + `modified gross income' and `household income' have the + meanings given such terms in section 36B(d)(2) of the + Internal Revenue Code of 1986. + ``(H) Continued application of medicaid rules + regarding point-in-time income and sources of income.-- + The requirement under this paragraph for States to use + modified gross income and household income to determine + income eligibility for medical assistance under the + State plan or under any waiver of such plan and for any + other purpose applicable under the plan or waiver for + which a determination of income is required shall not be + construed as affecting or limiting the application of-- + ``(i) the requirement under this title and + under the State plan or a waiver of the plan to + determine an individual's income as of the point + in time at which an application for medical + assistance under the State plan or a waiver of the + plan is processed; or + ``(ii) any rules established under this title + or under the State plan or a waiver of the plan + regarding sources of countable income.''. + + (b) Conforming Amendment.--Section 1902(a)(17) of such Act (42 +U.S.C. 1396a(a)(17)) is amended by inserting ``(e)(14),'' before +``(l)(3)''. + (c) <<NOTE: 42 USC 1396a note.>> Effective Date.--The amendments +made by subsections (a) and (b) take effect on January 1, 2014. + +SEC. 2003. REQUIREMENT TO OFFER PREMIUM ASSISTANCE FOR EMPLOYER- + SPONSORED INSURANCE. + + (a) In General.--Section 1906A of such Act (42 U.S.C. 1396e-1) is +amended-- + (1) in subsection (a)-- + (A) by striking ``may elect to'' and inserting + ``shall''; + (B) by striking ``under age 19''; and + (C) by inserting ``, in the case of an individual + under age 19,'' after ``(and''; + (2) in subsection (c), in the first sentence, by striking + ``under age 19''; and + (3) in subsection (d)-- + (A) in paragraph (2)-- + (i) in the first sentence, by striking ``under + age 19''; and + (ii) by striking the third sentence and + inserting ``A State may not require, as a + condition of an individual (or the individual's + parent) being or remaining eligible for medical + assistance under this title, that the individual + (or the individual's parent) apply for enrollment + in qualified employer-sponsored coverage under + this section.''; and + (B) in paragraph (3), by striking ``the parent of an + individual under age 19'' and inserting ``an individual + (or the parent of an individual)''; and + (4) in subsection (e), by striking ``under age 19'' each + place it appears. + +[[Page 124 STAT. 283]] + + (b) Conforming Amendment.--The heading for section 1906A of such Act +(42 U.S.C. 1396e-1) is amended by striking ``option for children''. + (c) <<NOTE: 42 USC 1396e-1 note.>> Effective Date.--The amendments +made by this section take effect on January 1, 2014. + +SEC. 2004. MEDICAID COVERAGE FOR FORMER FOSTER CARE CHILDREN. + + (a) In General.--Section 1902(a)(10)(A)(i) of the Social Security +Act (42 U.S.C. 1396a), as amended by section 2001(a)(1), is amended-- + (1) by striking ``or'' at the end of subclause (VII); + (2) by adding ``or'' at the end of subclause (VIII); and + (3) by inserting after subclause (VIII) the following: + ``(IX) who were in foster care under + the responsibility of a State for more + than 6 months (whether or not + consecutive) but are no longer in such + care, who are not described in any of + subclauses (I) through (VII) of this + clause, and who are under 25 years of + age;''. + + (b) Option To Provide Presumptive Eligibility.--Section 1920(e) of +such Act (42 U.S.C. 1396r-1(e)), as added by section 2001(a)(4)(B) and +amended by section 2001(e)(2)(C), is amended by inserting ``, clause +(i)(IX),'' after ``clause (i)(VIII)''. + (c) Conforming Amendments.-- + (1) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)), + as amended by section 2001(a)(5)(D), is amended by inserting + ``1902(a)(10)(A)(i)(IX),'' after ``1902(a)(10)(A)(i)(VIII),''. + (2) Section 1937(a)(2)(B)(viii) of such Act (42 U.S.C. + 1396u-7(a)(2)(B)(viii)) is amended by inserting ``, or the + individual qualifies for medical assistance on the basis of + section 1902(a)(10)(A)(i)(IX)'' before the period. + + (d) <<NOTE: 42 USC 1396a note.>> Effective Date.--The amendments +made by this section take effect on January 1, 2019. + +SEC. 2005. PAYMENTS TO TERRITORIES. + + (a) Increase in Limit on Payments.--Section 1108(g) of the Social +Security Act (42 U.S.C. 1308(g)) is amended-- + (1) in paragraph (2), in the matter preceding subparagraph + (A), by striking ``paragraph (3)'' and inserting ``paragraphs + (3) and (5)''; + (2) in paragraph (4), by striking ``and (3)'' and inserting + ``(3), and (4)''; and + (3) by adding at the end the following paragraph: + ``(5) Fiscal year 2011 and thereafter.--The amounts + otherwise determined under this subsection for Puerto Rico, the + Virgin Islands, Guam, the Northern Mariana Islands, and American + Samoa for the second, third, and fourth quarters of fiscal year + 2011, and for each fiscal year after fiscal year 2011 (after the + application of subsection (f) and the preceding paragraphs of + this subsection), shall be increased by 30 percent.''. + + (b) Disregard of Payments for Mandatory Expanded Enrollment.-- +Section 1108(g)(4) of such Act (42 U.S.C. 1308(g)(4)) is amended-- + (1) by striking ``to fiscal years beginning'' and inserting + ``to-- + ``(A) fiscal years beginning''; + +[[Page 124 STAT. 284]] + + (2) by striking the period at the end and inserting ``; + and''; and + (3) by adding at the end the following: + ``(B) fiscal years beginning with fiscal year 2014, + payments made to Puerto Rico, the Virgin Islands, Guam, + the Northern Mariana Islands, or American Samoa with + respect to amounts expended for medical assistance for + newly eligible (as defined in section 1905(y)(2)) + nonpregnant childless adults who are eligible under + subclause (VIII) of section 1902(a)(10)(A)(i) and whose + income (as determined under section 1902(e)(14)) does + not exceed (in the case of each such commonwealth and + territory respectively) the income eligibility level in + effect for that population under title XIX or under a + waiver on the date of enactment of the Patient + Protection and Affordable Care Act, shall not be taken + into account in applying subsection (f) (as increased in + accordance with paragraphs (1), (2), (3), and (5) of + this subsection) to such commonwealth or territory for + such fiscal year.''. + + (c) Increased FMAP.-- + (1) In general.--The first sentence of section 1905(b) of + the Social Security Act (42 U.S.C. 1396d(b)) is amended by + striking ``shall be 50 per centum'' and inserting ``shall be 55 + percent''. + (2) <<NOTE: 42 USC 1396d note.>> Effective date.--The + amendment made by paragraph (1) takes effect on January 1, 2011. + +SEC. 2006. SPECIAL ADJUSTMENT TO FMAP DETERMINATION FOR CERTAIN STATES + RECOVERING FROM A MAJOR DISASTER. + + Section 1905 of the Social Security Act (42 U.S.C. 1396d), as +amended by sections 2001(a)(3) and 2001(b)(2), is amended-- + (1) in subsection (b), in the first sentence, by striking + ``subsection (y)'' and inserting ``subsections (y) and (aa)''; + and + (2) by adding at the end the following new subsection: + + ``(aa)(1) <<NOTE: Effective date.>> Notwithstanding subsection (b), +beginning January 1, 2011, the Federal medical assistance percentage for +a fiscal year for a disaster-recovery FMAP adjustment State shall be +equal to the following: + ``(A) In the case of the first fiscal year (or part of a + fiscal year) for which this subsection applies to the State, the + Federal medical assistance percentage determined for the fiscal + year without regard to this subsection and subsection (y), + increased by 50 percent of the number of percentage points by + which the Federal medical assistance percentage determined for + the State for the fiscal year without regard to this subsection + and subsection (y), is less than the Federal medical assistance + percentage determined for the State for the preceding fiscal + year after the application of only subsection (a) of section + 5001 of Public Law 111-5 (if applicable to the preceding fiscal + year) and without regard to this subsection, subsection (y), and + subsections (b) and (c) of section 5001 of Public Law 111-5. + ``(B) In the case of the second or any succeeding fiscal + year for which this subsection applies to the State, the Federal + medical assistance percentage determined for the preceding + fiscal year under this subsection for the State, increased by 25 + percent of the number of percentage points by which the Federal + medical assistance percentage determined for the State + +[[Page 124 STAT. 285]] + + for the fiscal year without regard to this subsection and + subsection (y), is less than the Federal medical assistance + percentage determined for the State for the preceding fiscal + year under this subsection. + + ``(2) <<NOTE: Definition.>> In this subsection, the term `disaster- +recovery FMAP adjustment State' means a State that is one of the 50 +States or the District of Columbia, for which, at any time during the +preceding 7 fiscal years, the President has declared a major disaster +under section 401 of the Robert T. Stafford Disaster Relief and +Emergency Assistance Act and determined as a result of such disaster +that every county or parish in the State warrant individual and public +assistance or public assistance from the Federal Government under such +Act and for which-- + ``(A) in the case of the first fiscal year (or part of a + fiscal year) for which this subsection applies to the State, the + Federal medical assistance percentage determined for the State + for the fiscal year without regard to this subsection and + subsection (y), is less than the Federal medical assistance + percentage determined for the State for the preceding fiscal + year after the application of only subsection (a) of section + 5001 of Public Law 111-5 (if applicable to the preceding fiscal + year) and without regard to this subsection, subsection (y), and + subsections (b) and (c) of section 5001 of Public Law 111-5, by + at least 3 percentage points; and + ``(B) in the case of the second or any succeeding fiscal + year for which this subsection applies to the State, the Federal + medical assistance percentage determined for the State for the + fiscal year without regard to this subsection and subsection + (y), is less than the Federal medical assistance percentage + determined for the State for the preceding fiscal year under + this subsection by at least 3 percentage points. + + ``(3) <<NOTE: Applicability.>> The Federal medical assistance +percentage determined for a disaster-recovery FMAP adjustment State +under paragraph (1) shall apply for purposes of this title (other than +with respect to disproportionate share hospital payments described in +section 1923 and payments under this title that are based on the +enhanced FMAP described in 2105(b)) and shall not apply with respect to +payments under title IV (other than under part E of title IV) or +payments under title XXI.''. + +SEC. 2007. MEDICAID IMPROVEMENT FUND RESCISSION. + + (a) Rescission.--Any amounts available to the Medicaid Improvement +Fund established under section 1941 of the Social Security Act (42 +U.S.C. 1396w-1) for any of fiscal years 2014 through 2018 that are +available for expenditure from the Fund and that are not so obligated as +of the date of the enactment of this Act are rescinded. + (b) Conforming Amendments.--Section 1941(b)(1) of the Social +Security Act (42 U.S.C. 1396w-1(b)(1)) is amended-- + (1) in subparagraph (A), by striking ``$100,000,000'' and + inserting ``$0''; and + (2) in subparagraph (B), by striking ``$150,000,000'' and + inserting ``$0''. + +[[Page 124 STAT. 286]] + +Subtitle B--Enhanced Support for the Children's Health Insurance Program + +SEC. 2101. ADDITIONAL FEDERAL FINANCIAL PARTICIPATION FOR CHIP. + + (a) In General.-- <<NOTE: Time period.>> Section 2105(b) of the +Social Security Act (42 U.S.C. 1397ee(b)) is amended by adding at the +end the following: ``Notwithstanding the preceding sentence, during the +period that begins on October 1, 2013, and ends on September 30, 2019, +the enhanced FMAP determined for a State for a fiscal year (or for any +portion of a fiscal year occurring during such period) shall be +increased by 23 percentage points, but in no case shall exceed 100 +percent. The increase in the enhanced FMAP under the preceding sentence +shall not apply with respect to determining the payment to a State under +subsection (a)(1) for expenditures described in subparagraph (D)(iv), +paragraphs (8), (9), (11) of subsection (c), or clause (4) of the first +sentence of section 1905(b).''. + + (b) Maintenance of Effort.-- + (1) In general.--Section 2105(d) of the Social Security Act + (42 U.S.C. 1397ee(d)) is amended by adding at the end the + following: + ``(3) Continuation of eligibility standards for children + until october 1, 2019.-- + ``(A) In general.-- <<NOTE: Time period.>> During + the period that begins on the date of enactment of the + Patient Protection and Affordable Care Act and ends on + September 30, 2019, a State shall not have in effect + eligibility standards, methodologies, or procedures + under its State child health plan (including any waiver + under such plan) for children (including children + provided medical assistance for which payment is made + under section 2105(a)(1)(A)) that are more restrictive + than the eligibility standards, methodologies, or + procedures, respectively, under such plan (or waiver) as + in effect on the date of enactment of that Act. The + preceding sentence shall not be construed as preventing + a State during such period from-- + ``(i) applying eligibility standards, + methodologies, or procedures for children under + the State child health plan or under any waiver of + the plan that are less restrictive than the + eligibility standards, methodologies, or + procedures, respectively, for children under the + plan or waiver that are in effect on the date of + enactment of such Act; or + ``(ii) imposing a limitation described in + section 2112(b)(7) for a fiscal year in order to + limit expenditures under the State child health + plan to those for which Federal financial + participation is available under this section for + the fiscal year. + ``(B) Assurance of exchange coverage for targeted + low-income children unable to be provided child health + assistance as a result of funding + shortfalls. <<NOTE: Procedures.>> --In the event that + allotments provided under section 2104 are insufficient + to provide coverage to all children who are eligible to + be targeted low-income children under the State child + health plan under this title, a State shall + +[[Page 124 STAT. 287]] + + establish procedures to ensure that such children are + provided coverage through an Exchange established by the + State under section 1311 of the Patient Protection and + Affordable Care Act.''. + (2) Conforming amendment to title xxi medicaid maintenance + of effort.--Section 2105(d)(1) of the Social Security Act (42 + U.S.C. 1397ee(d)(1)) is amended by adding before the period ``, + except as required under section 1902(e)(14)''. + + (c) No Enrollment Bonus Payments for Children Enrolled After Fiscal +Year 2013.--Section 2105(a)(3)(F)(iii) of the Social Security Act (42 +U.S.C. 1397ee(a)(3)(F)(iii)) is amended by inserting ``or any children +enrolled on or after October 1, 2013'' before the period. + (d) Income Eligibility Determined Using Modified Gross Income.-- + (1) State plan requirement.--Section 2102(b)(1)(B) of the + Social Security Act (42 U.S.C. 1397bb(b)(1)(B)) is amended-- + (A) in clause (iii), by striking ``and'' after the + semicolon; + (B) in clause (iv), by striking the period and + inserting ``; and''; and + (C) by adding at the end the following: + ``(v) <<NOTE: Effective date.>> shall, + beginning January 1, 2014, use modified gross + income and household income (as defined in section + 36B(d)(2) of the Internal Revenue Code of 1986) to + determine eligibility for child health assistance + under the State child health plan or under any + waiver of such plan and for any other purpose + applicable under the plan or waiver for which a + determination of income is required, including + with respect to the imposition of premiums and + cost-sharing, consistent with section + 1902(e)(14).''. + (2) Conforming amendment.--Section 2107(e)(1) of the Social + Security Act (42 U.S.C. 1397gg(e)(1)) is amended-- + (A) by redesignating subparagraphs (E) through (L) + as subparagraphs (F) through (M), respectively; and + (B) by inserting after subparagraph (D), the + following: + ``(E) Section 1902(e)(14) (relating to income + determined using modified gross income and household + income).''. + + (e) Application of Streamlined Enrollment System.--Section +2107(e)(1) of the Social Security Act (42 U.S.C. 1397gg(e)(1)), as +amended by subsection (d)(2), is amended by adding at the end the +following: + ``(N) Section 1943(b) (relating to coordination with + State Exchanges and the State Medicaid agency).''. + + (f) <<NOTE: 42 USC 1397jj note.>> CHIP Eligibility for Children +Ineligible for Medicaid as a Result of Elimination of Disregards.-- +Notwithstanding any other provision of law, a State shall treat any +child who is determined to be ineligible for medical assistance under +the State Medicaid plan or under a waiver of the plan as a result of the +elimination of the application of an income disregard based on expense +or type of income, as required under section 1902(e)(14) of the Social +Security Act (as added by this Act), as a targeted low-income child +under section 2110(b) (unless the child is excluded under paragraph (2) +of that section) and shall provide child health assistance to the child +under the State child health plan (whether + +[[Page 124 STAT. 288]] + +implemented under title XIX or XXI, or both, of the Social Security +Act). + +SEC. 2102. TECHNICAL CORRECTIONS. + + (a) <<NOTE: Effective date. 42 USC 1396b note.>> CHIPRA.--Effective +as if included in the enactment of the Children's Health Insurance +Program Reauthorization Act of 2009 (Public Law 111-3) (in this section +referred to as ``CHIPRA''): + (1) Section 2104(m) of the Social Security Act, as added by + section 102 of CHIPRA, <<NOTE: 42 USC 1397dd.>> is amended-- + (A) by redesignating paragraph (7) as paragraph (8); + and + (B) by inserting after paragraph (6), the following: + ``(7) Adjustment of fiscal year 2010 allotments to account + for changes in projected spending for certain previously + approved expansion programs.--For purposes of recalculating the + fiscal year 2010 allotment, in the case of one of the 50 States + or the District of Columbia that has an approved State plan + amendment effective January 1, 2006, to provide child health + assistance through the provision of benefits under the State + plan under title XIX for children from birth through age 5 whose + family income does not exceed 200 percent of the poverty line, + the Secretary shall increase the allotment by an amount that + would be equal to the Federal share of expenditures that would + have been claimed at the enhanced FMAP rate rather than the + Federal medical assistance percentage matching rate for such + population.''. + (2) Section 605 of CHIPRA <<NOTE: 42 USC 1396 note.>> is + amended by striking ``legal residents'' and insert ``lawfully + residing in the United States''. + (3) Subclauses (I) and (II) of paragraph (3)(C)(i) of + section 2105(a) of the Social Security Act (42 U.S.C. + 1397ee(a)(3)(ii)), as added by section 104 of CHIPRA, are each + amended by striking ``, respectively''. + (4) Section 2105(a)(3)(E)(ii) of the Social Security Act (42 + U.S.C. 1397ee(a)(3)(E)(ii)), as added by section 104 of CHIPRA, + is amended by striking subclause (IV). + (5) Section 2105(c)(9)(B) of the Social Security Act (42 + U.S.C. 1397e(c)(9)(B)), <<NOTE: 42 USC 1397ee.>> as added by + section 211(c)(1) of CHIPRA, is amended by striking ``section + 1903(a)(3)(F)'' and inserting ``section 1903(a)(3)(G)''. + (6) Section 2109(b)(2)(B) of the Social Security Act (42 + U.S.C. 1397ii(b)(2)(B)), as added by section 602 of CHIPRA, is + amended by striking ``the child population growth factor under + section 2104(m)(5)(B)'' and inserting ``a high-performing State + under section 2111(b)(3)(B)''. + (7) Section 2110(c)(9)(B)(v) of the Social Security Act (42 + U.S.C. 1397jj(c)(9)(B)(v)), as added by section 505(b) of + CHIPRA, is amended by striking ``school or school system'' and + inserting ``local educational agency (as defined under section + 9101 of the Elementary and Secondary Education Act of 1965''. + (8) Section 211(a)(1)(B) of CHIPRA <<NOTE: 42 USC 1396b.>> + is amended-- + (A) by striking ``is amended'' and all that follows + through ``adding'' and inserting ``is amended by + adding''; and + (B) by redesignating the new subparagraph to be + added by such section to section 1903(a)(3) of the + Social Security Act as a new subparagraph (H). + +[[Page 124 STAT. 289]] + + (b) <<NOTE: 42 USC 13960-1 note.>> ARRA.--Effective as if included +in the enactment of section 5006(a) of division B of the American +Recovery and Reinvestment Act of 2009 (Public Law 111-5), the second +sentence of section 1916A(a)(1) of the Social Security Act (42 U.S.C. +1396o-1(a)(1)) is amended by striking ``or (i)'' and inserting ``, (i), +or (j)''. + + Subtitle C--Medicaid and CHIP Enrollment Simplification + +SEC. 2201. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH STATE HEALTH + INSURANCE EXCHANGES. + + Title XIX of the Social Security Act (42 U.S.C. 1397aa et seq.) is +amended by adding at the end the following: + +``SEC. 1943. <<NOTE: 42 USC 1396w-3.>> ENROLLMENT SIMPLIFICATION AND + COORDINATION WITH STATE HEALTH INSURANCE EXCHANGES. + + ``(a) Condition for Participation in Medicaid. <<NOTE: Effective +date.>> --As a condition of the State plan under this title and receipt +of any Federal financial assistance under section 1903(a) for calendar +quarters beginning after January 1, 2014, a State shall ensure that the +requirements of subsection (b) is met. + + ``(b) Enrollment Simplification and Coordination With State Health +Insurance Exchanges and Chip.-- + ``(1) In general.-- <<NOTE: Procedures.>> A State shall + establish procedures for-- + ``(A) <<NOTE: Web site.>> enabling individuals, + through an Internet website that meets the requirements + of paragraph (4), to apply for medical assistance under + the State plan or under a waiver of the plan, to be + enrolled in the State plan or waiver, to renew their + enrollment in the plan or waiver, and to consent to + enrollment or reenrollment in the State plan through + electronic signature; + ``(B) enrolling, without any further determination + by the State and through such website, individuals who + are identified by an Exchange established by the State + under section 1311 of the Patient Protection and + Affordable Care Act as being eligible for-- + ``(i) medical assistance under the State plan + or under a waiver of the plan; or + ``(ii) child health assistance under the State + child health plan under title XXI; + ``(C) ensuring that individuals who apply for but + are determined to be ineligible for medical assistance + under the State plan or a waiver or ineligible for child + health assistance under the State child health plan + under title XXI, are screened for eligibility for + enrollment in qualified health plans offered through + such an Exchange and, if applicable, premium assistance + for the purchase of a qualified health plan under + section 36B of the Internal Revenue Code of 1986 (and, + if applicable, advance payment of such assistance under + section 1412 of the Patient Protection and Affordable + Care Act), and, if eligible, enrolled in such a plan + without having to submit an additional or separate + application, and that such individuals receive + information regarding reduced cost-sharing for eligible + individuals under section 1402 of the Patient Protection + and Affordable + +[[Page 124 STAT. 290]] + + Care Act, and any other assistance or subsidies + available for coverage obtained through the Exchange; + ``(D) ensuring that the State agency responsible for + administering the State plan under this title (in this + section referred to as the `State Medicaid agency'), the + State agency responsible for administering the State + child health plan under title XXI (in this section + referred to as the `State CHIP agency') and an Exchange + established by the State under section 1311 of the + Patient Protection and Affordable Care Act utilize a + secure electronic interface sufficient to allow for a + determination of an individual's eligibility for such + medical assistance, child health assistance, or premium + assistance, and enrollment in the State plan under this + title, title XXI, or a qualified health plan, as + appropriate; + ``(E) coordinating, for individuals who are enrolled + in the State plan or under a waiver of the plan and who + are also enrolled in a qualified health plan offered + through such an Exchange, and for individuals who are + enrolled in the State child health plan under title XXI + and who are also enrolled in a qualified health plan, + the provision of medical assistance or child health + assistance to such individuals with the coverage + provided under the qualified health plan in which they + are enrolled, including services described in section + 1905(a)(4)(B) (relating to early and periodic screening, + diagnostic, and treatment services defined in section + 1905(r)) and provided in accordance with the + requirements of section 1902(a)(43); and + ``(F) conducting outreach to and enrolling + vulnerable and underserved populations eligible for + medical assistance under this title XIX or for child + health assistance under title XXI, including children, + unaccompanied homeless youth, children and youth with + special health care needs, pregnant women, racial and + ethnic minorities, rural populations, victims of abuse + or trauma, individuals with mental health or substance- + related disorders, and individuals with HIV/AIDS. + ``(2) Agreements with state health insurance exchanges.--The + State Medicaid agency and the State CHIP agency may enter into + an agreement with an Exchange established by the State under + section 1311 of the Patient Protection and Affordable Care Act + under which the State Medicaid agency or State CHIP agency may + determine whether a State resident is eligible for premium + assistance for the purchase of a qualified health plan under + section 36B of the Internal Revenue Code of 1986 (and, if + applicable, advance payment of such assistance under section + 1412 of the Patient Protection and Affordable Care Act), so long + as the agreement meets such conditions and requirements as the + Secretary of the Treasury may prescribe to reduce administrative + costs and the likelihood of eligibility errors and disruptions + in coverage. + ``(3) Streamlined enrollment system.--The State Medicaid + agency and State CHIP agency shall participate in and comply + with the requirements for the system established under section + 1413 of the Patient Protection and Affordable Care Act (relating + to streamlined procedures for enrollment through an Exchange, + Medicaid, and CHIP). + +[[Page 124 STAT. 291]] + + ``(4) Enrollment website requirements.-- + <<NOTE: Deadline.>> The procedures established by State under + paragraph (1) shall include establishing and having in + operation, not later than January 1, 2014, an Internet website + that is linked to any website of an Exchange established by the + State under section 1311 of the Patient Protection and + Affordable Care Act and to the State CHIP agency (if different + from the State Medicaid agency) and allows an individual who is + eligible for medical assistance under the State plan or under a + waiver of the plan and who is eligible to receive premium credit + assistance for the purchase of a qualified health plan under + section 36B of the Internal Revenue Code of 1986 to compare the + benefits, premiums, and cost-sharing applicable to the + individual under the State plan or waiver with the benefits, + premiums, and cost-sharing available to the individual under a + qualified health plan offered through such an Exchange, + including, in the case of a child, the coverage that would be + provided for the child through the State plan or waiver with the + coverage that would be provided to the child through enrollment + in family coverage under that plan and as supplemental coverage + by the State under the State plan or waiver. + ``(5) Continued need for assessment for home and community- + based services.--Nothing in paragraph (1) shall limit or modify + the requirement that the State assess an individual for purposes + of providing home and community-based services under the State + plan or under any waiver of such plan for individuals described + in subsection (a)(10)(A)(ii)(VI).''. + +SEC. 2202. PERMITTING HOSPITALS TO MAKE PRESUMPTIVE ELIGIBILITY + DETERMINATIONS FOR ALL MEDICAID ELIGIBLE POPULATIONS. + + (a) In General.--Section 1902(a)(47) of the Social Security Act (42 +U.S.C. 1396a(a)(47)) is amended-- + (1) by striking ``at the option of the State, provide'' and + inserting ``provide-- + ``(A) at the option of the State,''; + (2) by inserting ``and'' after the semicolon; and + (3) by adding at the end the following: + ``(B) <<NOTE: Guidelines.>> that any hospital that + is a participating provider under the State plan may + elect to be a qualified entity for purposes of + determining, on the basis of preliminary information, + whether any individual is eligible for medical + assistance under the State plan or under a waiver of the + plan for purposes of providing the individual with + medical assistance during a presumptive eligibility + period, in the same manner, and subject to the same + requirements, as apply to the State options with respect + to populations described in section 1920, 1920A, or + 1920B (but without regard to whether the State has + elected to provide for a presumptive eligibility period + under any such sections), subject to such guidance as + the Secretary shall establish;''. + + (b) Conforming Amendment.--Section 1903(u)(1)(D)(v) of such Act (42 +U.S.C. 1396b(u)(1)(D)v)) is amended-- + (1) by striking ``or for'' and inserting ``for''; and + (2) by inserting before the period at the end the following: + ``, or for medical assistance provided to an individual during a + presumptive eligibility period resulting from a determination + +[[Page 124 STAT. 292]] + + of presumptive eligibility made by a hospital that elects under + section 1902(a)(47)(B) to be a qualified entity for such + purpose''. + + (c) <<NOTE: Applicability. 42 USC 1396a note.>> Effective Date.-- +The amendments made by this section take effect on January 1, 2014, and +apply to services furnished on or after that date. + + Subtitle D--Improvements to Medicaid Services + +SEC. 2301. COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES. + + (a) In General.--Section 1905 of the Social Security Act (42 U.S.C. +1396d), is amended-- + (1) in subsection (a)-- + (A) in paragraph (27), by striking ``and'' at the + end; + (B) by redesignating paragraph (28) as paragraph + (29); and + (C) by inserting after paragraph (27) the following + new paragraph: + ``(28) freestanding birth center services (as defined in + subsection (l)(3)(A)) and other ambulatory services that are + offered by a freestanding birth center (as defined in subsection + (l)(3)(B)) and that are otherwise included in the plan; and''; + and + (2) in subsection (l), by adding at the end the following + new paragraph: + + ``(3)(A) <<NOTE: Definitions.>> The term `freestanding birth center +services' means services furnished to an individual at a freestanding +birth center (as defined in subparagraph (B)) at such center. + + ``(B) The term `freestanding birth center' means a health facility-- + ``(i) that is not a hospital; + ``(ii) where childbirth is planned to occur away from the + pregnant woman's residence; + ``(iii) that is licensed or otherwise approved by the State + to provide prenatal labor and delivery or postpartum care and + other ambulatory services that are included in the plan; and + ``(iv) that complies with such other requirements relating + to the health and safety of individuals furnished services by + the facility as the State shall establish. + + ``(C) <<NOTE: Payments.>> A State shall provide separate payments +to providers administering prenatal labor and delivery or postpartum +care in a freestanding birth center (as defined in subparagraph (B)), +such as nurse midwives and other providers of services such as birth +attendants recognized under State law, as determined appropriate by the +Secretary. For purposes of the preceding sentence, the term `birth +attendant' means an individual who is recognized or registered by the +State involved to provide health care at childbirth and who provides +such care within the scope of practice under which the individual is +legally authorized to perform such care under State law (or the State +regulatory mechanism provided by State law), regardless of whether the +individual is under the supervision of, or associated with, a physician +or other health care provider. Nothing in this subparagraph shall be +construed as changing State law requirements applicable to a birth +attendant.''. + + (b) Conforming Amendment.--Section 1902(a)(10)(A) of the Social +Security Act (42 U.S.C. 1396a(a)(10)(A)), is amended in the + +[[Page 124 STAT. 293]] + +matter preceding clause (i) by striking ``and (21)'' and inserting ``, +(21), and (28)''. + (c) <<NOTE: 42 USC 1396a note.>> Effective Date.-- + (1) In general.-- <<NOTE: Applicability.>> Except as + provided in paragraph (2), the amendments made by this section + shall take effect on the date of the enactment of this Act and + shall apply to services furnished on or after such date. + (2) Exception if state legislation required.-- + <<NOTE: Determination.>> In the case of a State plan for medical + assistance under title XIX of the Social Security Act which the + Secretary of Health and Human Services determines requires State + legislation (other than legislation appropriating funds) in + order for the plan to meet the additional requirement imposed by + the amendments made by this section, the State plan shall not be + regarded as failing to comply with the requirements of such + title solely on the basis of its failure to meet this additional + requirement before the first day of the first calendar quarter + beginning after the close of the first regular session of the + State legislature that begins after the date of the enactment of + this Act. For purposes of the previous sentence, in the case of + a State that has a 2-year legislative session, each year of such + session shall be deemed to be a separate regular session of the + State legislature. + +SEC. 2302. CONCURRENT CARE FOR CHILDREN. + + (a) In General.--Section 1905(o)(1) of the Social Security Act (42 +U.S.C. 1396d(o)(1)) is amended-- + (1) in subparagraph (A), by striking ``subparagraph (B)'' + and inserting ``subparagraphs (B) and (C)''; and + (2) by adding at the end the following new subparagraph: + + ``(C) A voluntary election to have payment made for hospice care for +a child (as defined by the State) shall not constitute a waiver of any +rights of the child to be provided with, or to have payment made under +this title for, services that are related to the treatment of the +child's condition for which a diagnosis of terminal illness has been +made.''. + (b) Application to CHIP.--Section 2110(a)(23) of the Social Security +Act (42 U.S.C. 1397jj(a)(23)) is amended by inserting ``(concurrent, in +the case of an individual who is a child, with care related to the +treatment of the child's condition with respect to which a diagnosis of +terminal illness has been made'' after ``hospice care''. + +SEC. 2303. STATE ELIGIBILITY OPTION FOR FAMILY PLANNING SERVICES. + + (a) Coverage as Optional Categorically Needy Group.-- + (1) In general.--Section 1902(a)(10)(A)(ii) of the Social + Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by + section 2001(e), is amended-- + (A) in subclause (XIX), by striking ``or'' at the + end; + (B) in subclause (XX), by adding ``or'' at the end; + and + (C) by adding at the end the following new + subclause: + ``(XXI) who are described in + subsection (ii) (relating to individuals + who meet certain income standards);''. + (2) Group described.--Section 1902 of such Act (42 U.S.C. + 1396a), as amended by section 2001(d), is amended by adding at + the end the following new subsection: + +[[Page 124 STAT. 294]] + + ``(ii)(1) Individuals described in this subsection are individuals-- + ``(A) whose income does not exceed an income + eligibility level established by the State that does not + exceed the highest income eligibility level established + under the State plan under this title (or under its + State child health plan under title XXI) for pregnant + women; and + ``(B) who are not pregnant. + ``(2) At the option of a State, individuals described in + this subsection may include individuals who, had individuals + applied on or before January 1, 2007, would have been made + eligible pursuant to the standards and processes imposed by that + State for benefits described in clause (XV) of the matter + following subparagraph (G) of section subsection (a)(10) + pursuant to a waiver granted under section 1115. + ``(3) At the option of a State, for purposes of subsection + (a)(17)(B), in determining eligibility for services under this + subsection, the State may consider only the income of the + applicant or recipient.''. + (3) Limitation on benefits.--Section 1902(a)(10) of the + Social Security Act (42 U.S.C. 1396a(a)(10)), as amended by + section 2001(a)(5)(A), is amended in the matter following + subparagraph (G)-- + (A) by striking ``and (XV)'' and inserting ``(XV)''; + and + (B) by inserting ``, and (XVI) the medical + assistance made available to an individual described in + subsection (ii) shall be limited to family planning + services and supplies described in section 1905(a)(4)(C) + including medical diagnosis and treatment services that + are provided pursuant to a family planning service in a + family planning setting'' before the semicolon. + (4) Conforming amendments.-- + (A) Section 1905(a) of the Social Security Act (42 + U.S.C. 1396d(a)), as amended by section 2001(e)(2)(A), + is amended in the matter preceding paragraph (1)-- + (i) in clause (xiv), by striking ``or'' at the + end; + (ii) in clause (xv), by adding ``or'' at the + end; and + (iii) by inserting after clause (xv) the + following: + ``(xvi) individuals described in section + 1902(ii),''. + (B) Section 1903(f)(4) of such Act (42 U.S.C. + 1396b(f)(4)), as amended by section 2001(e)(2)(B), is + amended by inserting ``1902(a)(10)(A)(ii)(XXI),'' after + ``1902(a)(10)(A)(ii)(XX),''. + + (b) Presumptive Eligibility.-- + (1) In general.--Title XIX of the Social Security Act (42 + U.S.C. 1396 et seq.) is amended by inserting after section 1920B + the following: + + + ``presumptive eligibility for family planning services + + + ``Sec. 1920C. <<NOTE: 42 USC 1396r-1c.>> (a) State Option.--State +plan approved under section 1902 may provide for making medical +assistance available to an individual described in section 1902(ii) +(relating to individuals who meet certain income eligibility standard) +during a presumptive eligibility period. In the case of an individual +described in section 1902(ii), such medical assistance shall be limited +to family planning services and supplies described in 1905(a)(4)(C) and, +at the State's option, medical diagnosis and treatment services that are +provided + +[[Page 124 STAT. 295]] + +in conjunction with a family planning service in a family planning +setting. + + ``(b) Definitions.--For purposes of this section: + ``(1) Presumptive eligibility period.--The term `presumptive + eligibility period' means, with respect to an individual + described in subsection (a), the period that-- + ``(A) begins with the date on which a qualified + entity determines, on the basis of preliminary + information, that the individual is described in section + 1902(ii); and + ``(B) ends with (and includes) the earlier of-- + ``(i) the day on which a determination is made + with respect to the eligibility of such individual + for services under the State plan; or + ``(ii) in the case of such an individual who + does not file an application by the last day of + the month following the month during which the + entity makes the determination referred to in + subparagraph (A), such last day. + ``(2) Qualified entity.-- + ``(A) In general.--Subject to subparagraph (B), the + term `qualified entity' means any entity that-- + ``(i) is eligible for payments under a State + plan approved under this title; and + ``(ii) is determined by the State agency to be + capable of making determinations of the type + described in paragraph (1)(A). + ``(B) Rule of construction.--Nothing in this + paragraph shall be construed as preventing a State from + limiting the classes of entities that may become + qualified entities in order to prevent fraud and abuse. + + ``(c) Administration.-- + ``(1) In general.--The State agency shall provide qualified + entities with-- + ``(A) such forms as are necessary for an application + to be made by an individual described in subsection (a) + for medical assistance under the State plan; and + ``(B) information on how to assist such individuals + in completing and filing such forms. + ``(2) Notification requirements.--A qualified entity that + determines under subsection (b)(1)(A) that an individual + described in subsection (a) is presumptively eligible for + medical assistance under a State plan shall-- + ``(A) <<NOTE: Deadline.>> notify the State agency + of the determination within 5 working days after the + date on which determination is made; and + ``(B) inform such individual at the time the + determination is made that an application for medical + assistance is required to be made by not later than the + last day of the month following the month during which + the determination is made. + ``(3) Application for medical assistance.-- + <<NOTE: Deadline.>> In the case of an individual described in + subsection (a) who is determined by a qualified entity to be + presumptively eligible for medical assistance under a State + plan, the individual shall apply for medical assistance by not + later than the last day of the month following the month during + which the determination is made. + +[[Page 124 STAT. 296]] + + ``(d) Payment.--Notwithstanding any other provision of law, medical +assistance that-- + ``(1) is furnished to an individual described in subsection + (a)-- + ``(A) during a presumptive eligibility period; and + ``(B) by a entity that is eligible for payments + under the State plan; and + ``(2) is included in the care and services covered by the + State plan, + +shall be treated as medical assistance provided by such plan for +purposes of clause (4) of the first sentence of section 1905(b).''. + (2) Conforming amendments.-- + (A) Section 1902(a)(47) of the Social Security Act + (42 U.S.C. 1396a(a)(47)), as amended by section 2202(a), + is amended-- + (i) in subparagraph (A), by inserting before + the semicolon at the end the following: ``and + provide for making medical assistance available to + individuals described in subsection (a) of section + 1920C during a presumptive eligibility period in + accordance with such section''; and + (ii) in subparagraph (B), by striking ``or + 1920B'' and inserting ``1920B, or 1920C''. + (B) Section 1903(u)(1)(D)(v) of such Act (42 U.S.C. + 1396b(u)(1)(D)(v)), as amended by section 2202(b), is + amended by inserting ``or for medical assistance + provided to an individual described in subsection (a) of + section 1920C during a presumptive eligibility period + under such section,'' after ``1920B during a presumptive + eligibility period under such section,''. + + (c) Clarification of Coverage of Family Planning Services and +Supplies.--Section 1937(b) of the Social Security Act (42 U.S.C. 1396u- +7(b)), as amended by section 2001(c), is amended by adding at the end +the following: + ``(7) Coverage of family planning services and supplies.-- + Notwithstanding the previous provisions of this section, a State + may not provide for medical assistance through enrollment of an + individual with benchmark coverage or benchmark-equivalent + coverage under this section unless such coverage includes for + any individual described in section 1905(a)(4)(C), medical + assistance for family planning services and supplies in + accordance with such section.''. + + (d) Effective Date. <<NOTE: Applicability. 42 USC 1396a note.>> -- +The amendments made by this section take effect on the date of the +enactment of this Act and shall apply to items and services furnished on +or after such date. + +SEC. 2304. CLARIFICATION OF DEFINITION OF MEDICAL ASSISTANCE. + + Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) is +amended by inserting ``or the care and services themselves, or both'' +before ``(if provided in or after''. + +[[Page 124 STAT. 297]] + + Subtitle E--New Options for States to Provide Long-Term Services and + Supports + +SEC. 2401. COMMUNITY FIRST CHOICE OPTION. + + Section 1915 of the Social Security Act (42 U.S.C. 1396n) is amended +by adding at the end the following: + ``(k) State Plan Option To Provide Home and Community-based +Attendant Services and Supports.-- + ``(1) In general.-- <<NOTE: Effective date.>> Subject to the + succeeding provisions of this subsection, beginning October 1, + 2010, a State may provide through a State plan amendment for the + provision of medical assistance for home and community-based + attendant services and supports for individuals who are eligible + for medical assistance under the State plan whose income does + not exceed 150 percent of the poverty line (as defined in + section 2110(c)(5)) or, if greater, the income level applicable + for an individual who has been determined to require an + institutional level of care to be eligible for nursing facility + services under the State plan and with respect to whom there has + been a determination that, but for the provision of such + services, the individuals would require the level of care + provided in a hospital, a nursing facility, an intermediate care + facility for the mentally retarded, or an institution for mental + diseases, the cost of which could be reimbursed under the State + plan, but only if the individual chooses to receive such home + and community-based attendant services and supports, and only if + the State meets the following requirements: + ``(A) Availability.--The State shall make available + home and community-based attendant services and supports + to eligible individuals, as needed, to assist in + accomplishing activities of daily living, instrumental + activities of daily living, and health-related tasks + through hands-on assistance, supervision, or cueing-- + ``(i) <<NOTE: Contracts.>> under a person- + centered plan of services and supports that is + based on an assessment of functional need and that + is agreed to in writing by the individual or, as + appropriate, the individual's representative; + ``(ii) in a home or community setting, which + does not include a nursing facility, institution + for mental diseases, or an intermediate care + facility for the mentally retarded; + ``(iii) under an agency-provider model or + other model (as defined in paragraph (6)(C )); and + ``(iv) the furnishing of which-- + ``(I) is selected, managed, and + dismissed by the individual, or, as + appropriate, with assistance from the + individual's representative; + ``(II) is controlled, to the maximum + extent possible, by the individual or + where appropriate, the individual's + representative, regardless of who may + act as the employer of record; and + ``(III) provided by an individual + who is qualified to provide such + services, including family members (as + defined by the Secretary). + ``(B) Included services and supports.--In addition + to assistance in accomplishing activities of daily + living, + +[[Page 124 STAT. 298]] + + instrumental activities of daily living, and health + related tasks, the home and community-based attendant + services and supports made available include-- + ``(i) the acquisition, maintenance, and + enhancement of skills necessary for the individual + to accomplish activities of daily living, + instrumental activities of daily living, and + health related tasks; + ``(ii) back-up systems or mechanisms (such as + the use of beepers or other electronic devices) to + ensure continuity of services and supports; and + ``(iii) voluntary training on how to select, + manage, and dismiss attendants. + ``(C) Excluded services and supports.--Subject to + subparagraph (D), the home and community-based attendant + services and supports made available do not include-- + ``(i) room and board costs for the individual; + ``(ii) special education and related services + provided under the Individuals with Disabilities + Education Act and vocational rehabilitation + services provided under the Rehabilitation Act of + 1973; + ``(iii) assistive technology devices and + assistive technology services other than those + under (1)(B)(ii); + ``(iv) medical supplies and equipment; or + ``(v) home modifications. + ``(D) Permissible services and supports.--The home + and community-based attendant services and supports may + include-- + ``(i) expenditures for transition costs such + as rent and utility deposits, first month's rent + and utilities, bedding, basic kitchen supplies, + and other necessities required for an individual + to make the transition from a nursing facility, + institution for mental diseases, or intermediate + care facility for the mentally retarded to a + community-based home setting where the individual + resides; and + ``(ii) expenditures relating to a need + identified in an individual's person-centered plan + of services that increase independence or + substitute for human assistance, to the extent + that expenditures would otherwise be made for the + human assistance. + ``(2) Increased federal financial participation.--For + purposes of payments to a State under section 1903(a)(1), with + respect to amounts expended by the State to provide medical + assistance under the State plan for home and community-based + attendant services and supports to eligible individuals in + accordance with this subsection during a fiscal year quarter + occurring during the period described in paragraph (1), the + Federal medical assistance percentage applicable to the State + (as determined under section 1905(b)) shall be increased by 6 + percentage points. + ``(3) State requirements.--In order for a State plan + amendment to be approved under this subsection, the State + shall-- + ``(A) <<NOTE: Establishment.>> develop and + implement such amendment in collaboration with a + Development and Implementation Council established by + the State that includes a majority of members with + disabilities, elderly individuals, and their + +[[Page 124 STAT. 299]] + + representatives and consults and collaborates with such + individuals; + ``(B) provide consumer controlled home and + community-based attendant services and supports to + individuals on a statewide basis, in a manner that + provides such services and supports in the most + integrated setting appropriate to the individual's + needs, and without regard to the individual's age, type + or nature of disability, severity of disability, or the + form of home and community-based attendant services and + supports that the individual requires in order to lead + an independent life; + ``(C) with respect to expenditures during the first + full fiscal year in which the State plan amendment is + implemented, maintain or exceed the level of State + expenditures for medical assistance that is provided + under section 1905(a), section 1915, section 1115, or + otherwise to individuals with disabilities or elderly + individuals attributable to the preceding fiscal year; + ``(D) establish and maintain a comprehensive, + continuous quality assurance system with respect to + community- based attendant services and supports that-- + ``(i) includes standards for agency-based and + other delivery models with respect to training, + appeals for denials and reconsideration procedures + of an individual plan, and other factors as + determined by the Secretary; + ``(ii) incorporates feedback from consumers + and their representatives, disability + organizations, providers, families of disabled or + elderly individuals, members of the community, and + others and maximizes consumer independence and + consumer control; + ``(iii) monitors the health and well-being of + each individual who receives home and community- + based attendant services and supports, including a + process for the mandatory reporting, + investigation, and resolution of allegations of + neglect, abuse, or exploitation in connection with + the provision of such services and supports; and + ``(iv) provides information about the + provisions of the quality assurance required under + clauses (i) through (iii) to each individual + receiving such services; and + ``(E) <<NOTE: Reports. Determination.>> collect and + report information, as determined necessary by the + Secretary, for the purposes of approving the State plan + amendment, providing Federal oversight, and conducting + an evaluation under paragraph (5)(A), including data + regarding how the State provides home and community- + based attendant services and supports and other home and + community-based services, the cost of such services and + supports, and how the State provides individuals with + disabilities who otherwise qualify for institutional + care under the State plan or under a waiver the choice + to instead receive home and community-based services in + lieu of institutional care. + ``(4) Compliance with certain laws.--A State shall ensure + that, regardless of whether the State uses an agency-provider + model or other models to provide home and community-based + attendant services and supports under a State plan + +[[Page 124 STAT. 300]] + + amendment under this subsection, such services and supports are + provided in accordance with the requirements of the Fair Labor + Standards Act of 1938 and applicable Federal and State laws + regarding-- + ``(A) withholding and payment of Federal and State + income and payroll taxes; + ``(B) the provision of unemployment and workers + compensation insurance; + ``(C) maintenance of general liability insurance; + and + ``(D) occupational health and safety. + ``(5) Evaluation, data collection, and report to congress.-- + ``(A) Evaluation.--The Secretary shall conduct an + evaluation of the provision of home and community-based + attendant services and supports under this subsection in + order to determine the effectiveness of the provision of + such services and supports in allowing the individuals + receiving such services and supports to lead an + independent life to the maximum extent possible; the + impact on the physical and emotional health of the + individuals who receive such services; and an + comparative analysis of the costs of services provided + under the State plan amendment under this subsection and + those provided under institutional care in a nursing + facility, institution for mental diseases, or an + intermediate care facility for the mentally retarded. + ``(B) Data collection.--The State shall provide the + Secretary with the following information regarding the + provision of home and community-based attendant services + and supports under this subsection for each fiscal year + for which such services and supports are provided: + ``(i) The number of individuals who are + estimated to receive home and community-based + attendant services and supports under this + subsection during the fiscal year. + ``(ii) The number of individuals that received + such services and supports during the preceding + fiscal year. + ``(iii) The specific number of individuals + served by type of disability, age, gender, + education level, and employment status. + ``(iv) Whether the specific individuals have + been previously served under any other home and + community based services program under the State + plan or under a waiver. + ``(C) Reports.--Not later than-- + ``(i) December 31, 2013, the Secretary shall + submit to Congress and make available to the + public an interim report on the findings of the + evaluation under subparagraph (A); and + ``(ii) December 31, 2015, the Secretary shall + submit to Congress and make available to the + public a final report on the findings of the + evaluation under subparagraph (A). + ``(6) Definitions.--In this subsection: + ``(A) Activities of daily living.--The term + `activities of daily living' includes tasks such as + eating, toileting, grooming, dressing, bathing, and + transferring. + +[[Page 124 STAT. 301]] + + ``(B) Consumer controlled.--The term `consumer + controlled' means a method of selecting and providing + services and supports that allow the individual, or + where appropriate, the individual's representative, + maximum control of the home and community-based + attendant services and supports, regardless of who acts + as the employer of record. + ``(C) Delivery models.-- + ``(i) Agency-provider model.--The term + `agency-provider model' means, with respect to the + provision of home and community-based attendant + services and supports for an individual, subject + to paragraph (4), a method of providing consumer + controlled services and supports under which + entities contract for the provision of such + services and supports. + ``(ii) Other models.--The term `other models' + means, subject to paragraph (4), methods, other + than an agency-provider model, for the provision + of consumer controlled services and supports. Such + models may include the provision of vouchers, + direct cash payments, or use of a fiscal agent to + assist in obtaining services. + ``(D) Health-related tasks.--The term `health- + related tasks' means specific tasks related to the needs + of an individual, which can be delegated or assigned by + licensed health-care professionals under State law to be + performed by an attendant. + ``(E) Individual's representative.--The term + `individual's representative' means a parent, family + member, guardian, advocate, or other authorized + representative of an individual + ``(F) Instrumental activities of daily living.--The + term `instrumental activities of daily living' includes + (but is not limited to) meal planning and preparation, + managing finances, shopping for food, clothing, and + other essential items, performing essential household + chores, communicating by phone or other media, and + traveling around and participating in the community.''. + +SEC. 2402. REMOVAL OF BARRIERS TO PROVIDING HOME AND COMMUNITY-BASED + SERVICES. + + (a) <<NOTE: 42 USC 1396n note.>> Oversight and Assessment of the +Administration of Home and Community-based Services.-- +<<NOTE: Regulations.>> The Secretary of Health and Human Services shall +promulgate regulations to ensure that all States develop service systems +that are designed to-- + (1) allocate resources for services in a manner that is + responsive to the changing needs and choices of beneficiaries + receiving non-institutionally-based long-term services and + supports (including such services and supports that are provided + under programs other the State Medicaid program), and that + provides strategies for beneficiaries receiving such services to + maximize their independence, including through the use of + client-employed providers; + (2) provide the support and coordination needed for a + beneficiary in need of such services (and their family + caregivers or representative, if applicable) to design an + individualized, self-directed, community-supported life; and + +[[Page 124 STAT. 302]] + + (3) improve coordination among, and the regulation of, all + providers of such services under federally and State-funded + programs in order to-- + (A) achieve a more consistent administration of + policies and procedures across programs in relation to + the provision of such services; and + (B) oversee and monitor all service system functions + to assure-- + (i) coordination of, and effectiveness of, + eligibility determinations and individual + assessments; + (ii) development and service monitoring of a + complaint system, a management system, a system to + qualify and monitor providers, and systems for + role-setting and individual budget determinations; + and + (iii) an adequate number of qualified direct + care workers to provide self-directed personal + assistance services. + + (b) Additional State Options.--Section 1915(i) of the Social +Security Act (42 U.S.C. 1396n(i)) is amended by adding at the end the +following new paragraphs: + ``(6) State option to provide home and community-based + services to individuals eligible for services under a waiver.-- + ``(A) In general.--A State that provides home and + community-based services in accordance with this + subsection to individuals who satisfy the needs-based + criteria for the receipt of such services established + under paragraph (1)(A) may, in addition to continuing to + provide such services to such individuals, elect to + provide home and community-based services in accordance + with the requirements of this paragraph to individuals + who are eligible for home and community-based services + under a waiver approved for the State under subsection + (c), (d), or (e) or under section 1115 to provide such + services, but only for those individuals whose income + does not exceed 300 percent of the supplemental security + income benefit rate established by section 1611(b)(1). + ``(B) Application of same requirements for + individuals satisfying needs-based criteria.--Subject to + subparagraph (C), a State shall provide home and + community-based services to individuals under this + paragraph in the same manner and subject to the same + requirements as apply under the other paragraphs of this + subsection to the provision of home and community-based + services to individuals who satisfy the needs-based + criteria established under paragraph (1)(A). + ``(C) Authority to offer different type, amount, + duration, or scope of home and community-based + services.--A State may offer home and community-based + services to individuals under this paragraph that differ + in type, amount, duration, or scope from the home and + community-based services offered for individuals who + satisfy the needs-based criteria established under + paragraph (1)(A), so long as such services are within + the scope of services described in paragraph (4)(B) of + subsection (c) for which the Secretary has the authority + to approve a waiver and do not include room or board. + +[[Page 124 STAT. 303]] + + ``(7) State option to offer home and community-based + services to specific, targeted populations.-- + ``(A) In general.--A State may elect in a State plan + amendment under this subsection to target the provision + of home and community-based services under this + subsection to specific populations and to differ the + type, amount, duration, or scope of such services to + such specific populations. + ``(B) 5-year term.-- + ``(i) In general.--An election by a State + under this paragraph shall be for a period of 5 + years. + ``(ii) Phase-in of services and eligibility + permitted during initial 5-year period.--A State + making an election under this paragraph may, + during the first 5-year period for which the + election is made, phase-in the enrollment of + eligible individuals, or the provision of services + to such individuals, or both, so long as all + eligible individuals in the State for such + services are enrolled, and all such services are + provided, before the end of the initial 5-year + period. + ``(C) Renewal. <<NOTE: Time + period. Determination. Deadline.>> --An election by a + State under this paragraph may be renewed for additional + 5-year terms if the Secretary determines, prior to + beginning of each such renewal period, that the State + has-- + ``(i) adhered to the requirements of this + subsection and paragraph in providing services + under such an election; and + ``(ii) met the State's objectives with respect + to quality improvement and beneficiary + outcomes.''. + + (c) Removal of Limitation on Scope of Services.--Paragraph (1) of +section 1915(i) of the Social Security Act (42 U.S.C. 1396n(i)), as +amended by subsection (a), is amended by striking ``or such other +services requested by the State as the Secretary may approve''. + (d) Optional Eligibility Category To Provide Full Medicaid Benefits +to Individuals Receiving Home and Community-based Services Under a State +Plan Amendment.-- + (1) In general.--Section 1902(a)(10)(A)(ii) of the Social + Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by + section 2304(a)(1), is amended-- + (A) in subclause (XX), by striking ``or'' at the + end; + (B) in subclause (XXI), by adding ``or'' at the end; + and + (C) by inserting after subclause (XXI), the + following new subclause: + ``(XXII) who are eligible for home + and community-based services under + needs-based criteria established under + paragraph (1)(A) of section 1915(i), or + who are eligible for home and community- + based services under paragraph (6) of + such section, and who will receive home + and community-based services pursuant to + a State plan amendment under such + subsection;''. + (2) Conforming amendments.-- + (A) Section 1903(f)(4) of the Social Security Act + (42 U.S.C. 1396b(f)(4)), as amended by section + 2304(a)(4)(B), is amended in the matter preceding + subparagraph (A), + +[[Page 124 STAT. 304]] + + by inserting ``1902(a)(10)(A)(ii)(XXII),'' after + ``1902(a)(10)(A)(ii)(XXI),''. + (B) Section 1905(a) of the Social Security Act (42 + U.S.C. 1396d(a)), as so amended, is amended in the + matter preceding paragraph (1)-- + (i) in clause (xv), by striking ``or'' at the + end; + (ii) in clause (xvi), by adding ``or'' at the + end; and + (iii) by inserting after clause (xvi) the + following new clause: + ``(xvii) individuals who are eligible for home and + community-based services under needs-based criteria established + under paragraph (1)(A) of section 1915(i), or who are eligible + for home and community-based services under paragraph (6) of + such section, and who will receive home and community-based + services pursuant to a State plan amendment under such + subsection,''. + + (e) Elimination of Option To Limit Number of Eligible Individuals or +Length of Period for Grandfathered Individuals if Eligibility Criteria +Is Modified.--Paragraph (1) of section 1915(i) of such Act (42 U.S.C. +1396n(i)) is amended-- + (1) by striking subparagraph (C) and inserting the + following: + ``(C) Projection of number of individuals to be + provided home and community-based services.--The State + submits to the Secretary, in such form and manner, and + upon such frequency as the Secretary shall specify, the + projected number of individuals to be provided home and + community-based services.''; and + (2) in subclause (II) of subparagraph (D)(ii), by striking + ``to be eligible for such services for a period of at least 12 + months beginning on the date the individual first received + medical assistance for such services'' and inserting ``to + continue to be eligible for such services after the effective + date of the modification and until such time as the individual + no longer meets the standard for receipt of such services under + such pre-modified criteria''. + + (f) Elimination of Option To Waive Statewideness; Addition of Option +To Waive Comparability.--Paragraph (3) of section 1915(i) of such Act +(42 U.S.C. 1396n(3)) is amended by striking ``1902(a)(1) (relating to +statewideness)'' and inserting ``1902(a)(10)(B) (relating to +comparability)''. + (g) <<NOTE: 42 USC 1396a note.>> Effective Date.--The amendments +made by subsections (b) through (f) take effect on the first day of the +first fiscal year quarter that begins after the date of enactment of +this Act. + +SEC. 2403. MONEY FOLLOWS THE PERSON REBALANCING DEMONSTRATION. + + (a) Extension of Demonstration.-- + (1) In general.--Section 6071(h) of the Deficit Reduction + Act of 2005 (42 U.S.C. 1396a note) is amended-- + (A) in paragraph (1)(E), by striking ``fiscal year + 2011'' and inserting ``each of fiscal years 2011 through + 2016''; and + (B) in paragraph (2), by striking ``2011'' and + inserting ``2016''. + +[[Page 124 STAT. 305]] + + (2) Evaluation.--Paragraphs (2) and (3) of section 6071(g) + of such Act is amended are each amended by striking ``2011'' and + inserting ``2016''. + + (b) Reduction of Institutional Residency Period.-- + (1) In general.--Section 6071(b)(2) of the Deficit Reduction + Act of 2005 (42 U.S.C. 1396a note) is amended-- + (A) in subparagraph (A)(i), by striking ``, for a + period of not less than 6 months or for such longer + minimum period, not to exceed 2 years, as may be + specified by the State'' and inserting ``for a period of + not less than 90 consecutive days''; and + (B) by adding at the end the following: + ``Any days that an individual resides in an institution on the + basis of having been admitted solely for purposes of receiving + short-term rehabilitative services for a period for which + payment for such services is limited under title XVIII shall not + be taken into account for purposes of determining the 90-day + period required under subparagraph (A)(i).''. + (2) <<NOTE: 42 USC 1396a note.>> Effective date.--The + amendments made by this subsection take effect 30 days after the + date of enactment of this Act. + +SEC. 2404. <<NOTE: 42 USC 1396r-5 note.>> PROTECTION FOR RECIPIENTS OF + HOME AND COMMUNITY-BASED SERVICES AGAINST SPOUSAL + IMPOVERISHMENT. + + <<NOTE: Time period. Applicability.>> During the 5-year period that +begins on January 1, 2014, section 1924(h)(1)(A) of the Social Security +Act (42 U.S.C. 1396r-5(h)(1)(A)) shall be applied as though ``is +eligible for medical assistance for home and community-based services +provided under subsection (c), (d), or (i) of section 1915, under a +waiver approved under section 1115, or who is eligible for such medical +assistance by reason of being determined eligible under section +1902(a)(10)(C) or by reason of section 1902(f) or otherwise on the basis +of a reduction of income based on costs incurred for medical or other +remedial care, or who is eligible for medical assistance for home and +community-based attendant services and supports under section 1915(k)'' +were substituted in such section for ``(at the option of the State) is +described in section 1902(a)(10)(A)(ii)(VI)''. + +SEC. 2405. FUNDING TO EXPAND STATE AGING AND DISABILITY RESOURCE + CENTERS. + + Out of any funds in the Treasury not otherwise appropriated, there +is appropriated to the Secretary of Health and Human Services, acting +through the Assistant Secretary for Aging, $10,000,000 for each of +fiscal years 2010 through 2014, to carry out subsections (a)(20)(B)(iii) +and (b)(8) of section 202 of the Older Americans Act of 1965 (42 U.S.C. +3012). + +SEC. 2406. SENSE OF THE SENATE REGARDING LONG-TERM CARE. + + (a) Findings.--The Senate makes the following findings: + (1) Nearly 2 decades have passed since Congress seriously + considered long-term care reform. The United States Bipartisan + Commission on Comprehensive Health Care, also know as the + ``Pepper Commission'', released its ``Call for Action'' + blueprint for health reform in September 1990. In the 20 years + since those recommendations were made, Congress has never acted + on the report. + (2) In 1999, under the United States Supreme Court's + decision in Olmstead v. L.C., 527 U.S. 581 (1999), individuals + +[[Page 124 STAT. 306]] + + with disabilities have the right to choose to receive their + long-term services and supports in the community, rather than in + an institutional setting. + (3) Despite the Pepper Commission and Olmstead decision, the + long-term care provided to our Nation's elderly and disabled has + not improved. In fact, for many, it has gotten far worse. + (4) In 2007, 69 percent of Medicaid long-term care spending + for elderly individuals and adults with physical disabilities + paid for institutional services. Only 6 states spent 50 percent + or more of their Medicaid long-term care dollars on home and + community-based services for elderly individuals and adults with + physical disabilities while \1/2\ of the States spent less than + 25 percent. This disparity continues even though, on average, it + is estimated that Medicaid dollars can support nearly 3 elderly + individuals and adults with physical disabilities in home and + community-based services for every individual in a nursing home. + Although every State has chosen to provide certain services + under home and community-based waivers, these services are + unevenly available within and across States, and reach a small + percentage of eligible individuals. + + (b) Sense of the Senate.--It is the sense of the Senate that-- + (1) during the 111th session of Congress, Congress should + address long-term services and supports in a comprehensive way + that guarantees elderly and disabled individuals the care they + need; and + (2) long term services and supports should be made available + in the community in addition to in institutions. + + Subtitle F--Medicaid Prescription Drug Coverage + +SEC. 2501. PRESCRIPTION DRUG REBATES. + + (a) Increase in Minimum Rebate Percentage for Single Source Drugs +and Innovator Multiple Source Drugs.-- + (1) In general.--Section 1927(c)(1)(B) of the Social + Security Act (42 U.S.C. 1396r-8(c)(1)(B)) is amended-- + (A) in clause (i)-- + (i) in subclause (IV), by striking ``and'' at + the end; + (ii) in subclause (V)-- + (I) by inserting ``and before + January 1, 2010'' after ``December 31, + 1995,''; and + (II) by striking the period at the + end and inserting ``; and''; and + (iii) by adding at the end the following new + subclause: + ``(VI) except as provided in clause + (iii), after December 31, 2009, 23.1 + percent.''; and + (B) by adding at the end the following new clause: + ``(iii) Minimum rebate percentage for certain + drugs.-- + ``(I) In general.--In the case of a + single source drug or an innovator + multiple source drug described in + subclause (II), the minimum rebate + percentage for rebate periods specified + in clause (i)(VI) is 17.1 percent. + +[[Page 124 STAT. 307]] + + ``(II) Drug described.--For purposes + of subclause (I), a single source drug + or an innovator multiple source drug + described in this subclause is any of + the following drugs: + ``(aa) A clotting factor for + which a separate furnishing + payment is made under section + 1842(o)(5) and which is included + on a list of such factors + specified and updated regularly + by the Secretary. + ``(bb) A drug approved by + the Food and Drug Administration + exclusively for pediatric + indications.''. + (2) Recapture of total savings due to increase.--Section + 1927(b)(1) of such Act (42 U.S.C. 1396r-8(b)(1)) is amended by + adding at the end the following new subparagraph: + ``(C) Special rule for increased minimum rebate + percentage.-- + ``(i) In general. <<NOTE: Time period.>> --In + addition to the amounts applied as a reduction + under subparagraph (B), for rebate periods + beginning on or after January 1, 2010, during a + fiscal year, the Secretary shall reduce payments + to a State under section 1903(a) in the manner + specified in clause (ii), in an amount equal to + the product of-- + ``(I) 100 percent minus the Federal + medical assistance percentage applicable + to the rebate period for the State; and + ``(II) the amounts received by the + State under such subparagraph that are + attributable (as estimated by the + Secretary based on utilization and other + data) to the increase in the minimum + rebate percentage effected by the + amendments made by subsections (a)(1), + (b), and (d) of section 2501 of the + Patient Protection and Affordable Care + Act, taking into account the additional + drugs included under the amendments made + by subsection (c) of section 2501 of + such Act. + <<NOTE: Determination.>> The Secretary shall + adjust such payment reduction for a calendar + quarter to the extent the Secretary determines, + based upon subsequent utilization and other data, + that the reduction for such quarter was greater or + less than the amount of payment reduction that + should have been made. + ``(ii) Manner of payment reduction.--The + amount of the payment reduction under clause (i) + for a State for a quarter shall be deemed an + overpayment to the State under this title to be + disallowed against the State's regular quarterly + draw for all Medicaid spending under section + 1903(d)(2). Such a disallowance is not subject to + a reconsideration under section 1116(d).''. + + (b) Increase in Rebate for Other Drugs.--Section 1927(c)(3)(B) of +such Act (42 U.S.C. 1396r-8(c)(3)(B)) is amended-- + (1) in clause (i), by striking ``and'' at the end; + (2) in clause (ii)-- + (A) by inserting ``and before January 1, 2010,'' + after ``December 31, 1993,''; and + +[[Page 124 STAT. 308]] + + (B) by striking the period and inserting ``; and''; + and + (3) by adding at the end the following new clause: + ``(iii) after December 31, 2009, is 13 + percent.''. + + (c) Extension of Prescription Drug Discounts to Enrollees of +Medicaid Managed Care Organizations.-- + (1) In general.--Section 1903(m)(2)(A) of such Act (42 + U.S.C. 1396b(m)(2)(A)) is amended-- + (A) in clause (xi), by striking ``and'' at the end; + (B) in clause (xii), by striking the period at the + end and inserting ``; and''; and + (C) by adding at the end the following: + + ``(xiii) <<NOTE: Contracts. Reports. Determination. + >> such contract provides that (I) covered + outpatient drugs dispensed to individuals eligible + for medical assistance who are enrolled with the + entity shall be subject to the same rebate + required by the agreement entered into under + section 1927 as the State is subject to and that + the State shall collect such rebates from + manufacturers, (II) capitation rates paid to the + entity shall be based on actual cost experience + related to rebates and subject to the Federal + regulations requiring actuarially sound rates, and + (III) the entity shall report to the State, on + such timely and periodic basis as specified by the + Secretary in order to include in the information + submitted by the State to a manufacturer and the + Secretary under section 1927(b)(2)(A), information + on the total number of units of each dosage form + and strength and package size by National Drug + Code of each covered outpatient drug dispensed to + individuals eligible for medical assistance who + are enrolled with the entity and for which the + entity is responsible for coverage of such drug + under this subsection (other than covered + outpatient drugs that under subsection (j)(1) of + section 1927 are not subject to the requirements + of that section) and such other data as the + Secretary determines necessary to carry out this + subsection.''. + (2) Conforming amendments.--Section 1927 (42 U.S.C. 1396r-8) + is amended-- + (A) in subsection (b)-- + (i) in paragraph (1)(A), in the first + sentence, by inserting ``, including such drugs + dispensed to individuals enrolled with a medicaid + managed care organization if the organization is + responsible for coverage of such drugs'' before + the period; and + (ii) in paragraph (2)(A), by inserting + ``including such information reported by each + medicaid managed care organization,'' after ``for + which payment was made under the plan during the + period,''; and + (B) in subsection (j), by striking paragraph (1) and + inserting the following: + ``(1) Covered outpatient drugs are not subject to the + requirements of this section if such drugs are-- + ``(A) dispensed by health maintenance organizations, + including Medicaid managed care organizations that + contract under section 1903(m); and + ``(B) subject to discounts under section 340B of the + Public Health Service Act.''. + +[[Page 124 STAT. 309]] + + (d) Additional Rebate for New Formulations of Existing Drugs.-- + (1) In general.--Section 1927(c)(2) of the Social Security + Act (42 U.S.C. 1396r-8(c)(2)) is amended by adding at the end + the following new subparagraph: + ``(C) Treatment of new formulations.-- + ``(i) In general.--Except as provided in + clause (ii), in the case of a drug that is a new + formulation, such as an extended-release + formulation, of a single source drug or an + innovator multiple source drug, the rebate + obligation with respect to the drug under this + section shall be the amount computed under this + section for the new formulation of the drug or, if + greater, the product of-- + ``(I) the average manufacturer price + for each dosage form and strength of the + new formulation of the single source + drug or innovator multiple source drug; + ``(II) the highest additional rebate + (calculated as a percentage of average + manufacturer price) under this section + for any strength of the original single + source drug or innovator multiple source + drug; and + ``(III) the total number of units of + each dosage form and strength of the new + formulation paid for under the State + plan in the rebate period (as reported + by the State). + ``(ii) No application to new formulations of + orphan drugs.--Clause (i) shall not apply to a new + formulation of a covered outpatient drug that is + or has been designated under section 526 of the + Federal Food, Drug, and Cosmetic Act (21 U.S.C. + 360bb) for a rare disease or condition, without + regard to whether the period of market exclusivity + for the drug under section 527 of such Act has + expired or the specific indication for use of the + drug.''. + (2) <<NOTE: 42 USC 1396r-8 note.>> Effective date.--The + amendment made by paragraph (1) shall apply to drugs that are + paid for by a State after December 31, 2009. + + (e) Maximum Rebate Amount.--Section 1927(c)(2) of such Act (42 +U.S.C. 1396r-8(c)(2)), as amended by subsection (d), is amended by +adding at the end the following new subparagraph: + ``(D) Maximum rebate amount.--In no case shall the + sum of the amounts applied under paragraph (1)(A)(ii) + and this paragraph with respect to each dosage form and + strength of a single source drug or an innovator + multiple source drug for a rebate period beginning after + December 31, 2009, exceed 100 percent of the average + manufacturer price of the drug.''. + + (f) Conforming Amendments.-- + (1) In general.--Section 340B of the Public Health Service + Act (42 U.S.C. 256b) is amended-- + (A) in subsection (a)(2)(B)(i), by striking + ``1927(c)(4)'' and inserting ``1927(c)(3)''; and + (B) by striking subsection (c); and + (C) redesignating subsection (d) as subsection (c). + +[[Page 124 STAT. 310]] + + (2) <<NOTE: 42 USC 256b note.>> Effective date.--The + amendments made by this subsection take effect on January 1, + 2010. + +SEC. 2502. ELIMINATION OF EXCLUSION OF COVERAGE OF CERTAIN DRUGS. + + (a) In General.--Section 1927(d) of the Social Security Act (42 +U.S.C. 1397r-8(d)) is amended-- + (1) in paragraph (2)-- + (A) by striking subparagraphs (E), (I), and (J), + respectively; and + (B) by redesignating subparagraphs (F), (G), (H), + and (K) as subparagraphs (E), (F), (G), and (H), + respectively; and + (2) by adding at the end the following new paragraph: + ``(7) Non-excludable drugs.--The following drugs or classes + of drugs, or their medical uses, shall not be excluded from + coverage: + ``(A) Agents when used to promote smoking cessation, + including agents approved by the Food and Drug + Administration under the over-the-counter monograph + process for purposes of promoting, and when used to + promote, tobacco cessation. + ``(B) Barbiturates. + ``(C) Benzodiazepines.''. + + (b) <<NOTE: 42 USC 1396r-8 note.>> Effective Date.--The amendments +made by this section shall apply to services furnished on or after +January 1, 2014. + +SEC. 2503. PROVIDING ADEQUATE PHARMACY REIMBURSEMENT. + + (a) Pharmacy Reimbursement Limits.-- + (1) In general.--Section 1927(e) of the Social Security Act + (42 U.S.C. 1396r-8(e)) is amended-- + (A) in paragraph (4), by striking ``(or, effective + January 1, 2007, two or more)''; and + (B) by striking paragraph (5) and inserting the + following: + ``(5) Use of amp in upper payment limits.--The Secretary + shall calculate the Federal upper reimbursement limit + established under paragraph (4) as no less than 175 percent of + the weighted average (determined on the basis of utilization) of + the most recently reported monthly average manufacturer prices + for pharmaceutically and therapeutically equivalent multiple + source drug products that are available for purchase by retail + community pharmacies on a nationwide basis. The Secretary shall + implement a smoothing process for average manufacturer prices. + Such process shall be similar to the smoothing process used in + determining the average sales price of a drug or biological + under section 1847A.''. + (2) Definition of amp.--Section 1927(k)(1) of such Act (42 + U.S.C. 1396r-8(k)(1)) is amended-- + (A) in subparagraph (A), by striking ``by'' and all + that follows through the period and inserting ``by-- + ``(i) wholesalers for drugs distributed to + retail community pharmacies; and + ``(ii) retail community pharmacies that + purchase drugs directly from the manufacturer.''; + and + (B) by striking subparagraph (B) and inserting the + following: + +[[Page 124 STAT. 311]] + + ``(B) Exclusion of customary prompt pay discounts + and other payments.-- + ``(i) In general.--The average manufacturer + price for a covered outpatient drug shall + exclude-- + ``(I) customary prompt pay discounts + extended to wholesalers; + ``(II) bona fide service fees paid + by manufacturers to wholesalers or + retail community pharmacies, including + (but not limited to) distribution + service fees, inventory management fees, + product stocking allowances, and fees + associated with administrative services + agreements and patient care programs + (such as medication compliance programs + and patient education programs); + ``(III) reimbursement by + manufacturers for recalled, damaged, + expired, or otherwise unsalable returned + goods, including (but not limited to) + reimbursement for the cost of the goods + and any reimbursement of costs + associated with return goods handling + and processing, reverse logistics, and + drug destruction; and + ``(IV) payments received from, and + rebates or discounts provided to, + pharmacy benefit managers, managed care + organizations, health maintenance + organizations, insurers, hospitals, + clinics, mail order pharmacies, long + term care providers, manufacturers, or + any other entity that does not conduct + business as a wholesaler or a retail + community pharmacy. + ``(ii) Inclusion of other discounts and + payments.--Notwithstanding clause (i), any other + discounts, rebates, payments, or other financial + transactions that are received by, paid by, or + passed through to, retail community pharmacies + shall be included in the average manufacturer + price for a covered outpatient drug.''; and + (C) in subparagraph (C), by striking ``the retail + pharmacy class of trade'' and inserting ``retail + community pharmacies''. + (3) Definition of multiple source drug.--Section 1927(k)(7) + of such Act (42 U.S.C. 1396r-8(k)(7)) is amended-- + (A) in subparagraph (A)(i)(III), by striking ``the + State'' and inserting ``the United States''; and + (B) in subparagraph (C)-- + (i) in clause (i), by inserting ``and'' after + the semicolon; + (ii) in clause (ii), by striking ``; and'' and + inserting a period; and + (iii) by striking clause (iii). + (4) Definitions of retail community pharmacy; wholesaler.-- + Section 1927(k) of such Act (42 U.S.C. 1396r-8(k)) is amended by + adding at the end the following new paragraphs: + ``(10) Retail community pharmacy.--The term `retail + community pharmacy' means an independent pharmacy, a chain + pharmacy, a supermarket pharmacy, or a mass merchandiser + pharmacy that is licensed as a pharmacy by the State and that + dispenses medications to the general public at retail + +[[Page 124 STAT. 312]] + + prices. Such term does not include a pharmacy that dispenses + prescription medications to patients primarily through the mail, + nursing home pharmacies, long-term care facility pharmacies, + hospital pharmacies, clinics, charitable or not-for-profit + pharmacies, government pharmacies, or pharmacy benefit managers. + ``(11) Wholesaler.--The term `wholesaler' means a drug + wholesaler that is engaged in wholesale distribution of + prescription drugs to retail community pharmacies, including + (but not limited to) manufacturers, repackers, distributors, + own-label distributors, private-label distributors, jobbers, + brokers, warehouses (including manufacturer's and distributor's + warehouses, chain drug warehouses, and wholesale drug + warehouses) independent wholesale drug traders, and retail + community pharmacies that conduct wholesale distributions.''. + + (b) Disclosure of Price Information to the Public.--Section +1927(b)(3) of such Act (42 U.S.C. 1396r-8(b)(3)) is amended-- + (1) in subparagraph (A)-- + (A) in the first sentence, by inserting after clause + (iii) the following: + ``(iv) not later than 30 days after the last + day of each month of a rebate period under the + agreement, on the manufacturer's total number of + units that are used to calculate the monthly + average manufacturer price for each covered + outpatient drug;''; and + (B) in the second sentence, by inserting ``(relating + to the weighted average of the most recently reported + monthly average manufacturer prices)'' after ``(D)(v)''; + and + (2) in subparagraph (D)(v), by striking ``average + manufacturer prices'' and inserting ``the weighted average of + the most recently reported monthly average manufacturer prices + and the average retail survey price determined for each multiple + source drug in accordance with subsection (f)''. + + (c) Clarification of Application of Survey of Retail Prices.-- +Section 1927(f)(1) of such Act (42 U.S.C. 1396r-8(b)(1)) is amended-- + (1) in subparagraph (A)(i), by inserting ``with respect to a + retail community pharmacy,'' before ``the determination''; and + (2) in subparagraph (C)(ii), by striking ``retail + pharmacies'' and inserting ``retail community pharmacies''. + + (d) <<NOTE: 42 USC 1396r-8 note.>> Effective Date.--The amendments +made by this section shall take effect on the first day of the first +calendar year quarter that begins at least 180 days after the date of +enactment of this Act, without regard to whether or not final +regulations to carry out such amendments have been promulgated by such +date. + + Subtitle G--Medicaid Disproportionate Share Hospital (DSH) Payments + +SEC. 2551. DISPROPORTIONATE SHARE HOSPITAL PAYMENTS. + + (a) In General.--Section 1923(f) of the Social Security Act (42 +U.S.C. 1396r-4(f)) is amended-- + (1) in paragraph (1), by striking ``and (3)'' and inserting + ``, (3), and (7)''; + (2) in paragraph (3)(A), by striking ``paragraph (6)'' and + inserting ``paragraphs (6) and (7)''; + +[[Page 124 STAT. 313]] + + (3) by redesignating paragraph (7) as paragraph (8); and + (4) by inserting after paragraph (6) the following new + paragraph: + ``(7) Reduction of state dsh allotments once reduction in + uninsured threshold reached.-- + ``(A) In general.--Subject to subparagraph (E), the + DSH allotment for a State for fiscal years beginning + with the fiscal year described in subparagraph (C) (with + respect to the State), is equal to-- + ``(i) in the case of the first fiscal year + described in subparagraph (C) with respect to a + State, the DSH allotment that would be determined + under this subsection for the State for the fiscal + year without application of this paragraph (but + after the application of subparagraph (D)), + reduced by the applicable percentage determined + for the State for the fiscal year under + subparagraph (B)(i); and + ``(ii) in the case of any subsequent fiscal + year with respect to the State, the DSH allotment + determined under this paragraph for the State for + the preceding fiscal year, reduced by the + applicable percentage determined for the State for + the fiscal year under subparagraph (B)(ii). + ``(B) Applicable percentage.--For purposes of + subparagraph (A), the applicable percentage for a State + for a fiscal year is the following: + ``(i) Uninsured reduction threshold fiscal + year.--In the case of the first fiscal year + described in subparagraph (C) with respect to the + State-- + ``(I) if the State is a low DSH + State described in paragraph (5)(B), the + applicable percentage is equal to 25 + percent; and + ``(II) if the State is any other + State, the applicable percentage is 50 + percent. + ``(ii) Subsequent fiscal years in which the + percentage of uninsured + decreases <<NOTE: Determination.>> .--In the case + of any fiscal year after the first fiscal year + described in subparagraph (C) with respect to a + State, if the Secretary determines on the basis of + the most recent American Community Survey of the + Bureau of the Census, that the percentage of + uncovered individuals residing in the State is + less than the percentage of such individuals + determined for the State for the preceding fiscal + year-- + ``(I) if the State is a low DSH + State described in paragraph (5)(B), the + applicable percentage is equal to the + product of the percentage reduction in + uncovered individuals for the fiscal + year from the preceding fiscal year and + 25 percent; and + ``(II) if the State is any other + State, the applicable percentage is + equal to the product of the percentage + reduction in uncovered individuals for + the fiscal year from the preceding + fiscal year and 50 percent. + ``(C) Fiscal year + described. <<NOTE: Determination.>> --For purposes of + subparagraph (A), the fiscal year described in this + subparagraph with respect to a State is the first fiscal + year that + +[[Page 124 STAT. 314]] + + occurs after fiscal year 2012 for which the Secretary + determines, on the basis of the most recent American + Community Survey of the Bureau of the Census, that the + percentage of uncovered individuals residing in the + State is at least 45 percent less than the percentage of + such individuals determined for the State for fiscal + year 2009. + ``(D) Exclusion of portions diverted for coverage + expansions.--For purposes of applying the applicable + percentage reduction under subparagraph (A) to the DSH + allotment for a State for a fiscal year, the DSH + allotment for a State that would be determined under + this subsection for the State for the fiscal year + without the application of this paragraph (and prior to + any such reduction) shall not include any portion of the + allotment for which the Secretary has approved the + State's diversion to the costs of providing medical + assistance or other health benefits coverage under a + waiver that is in effect on July 2009. + ``(E) Minimum allotment.--In no event shall the DSH + allotment determined for a State in accordance with this + paragraph for fiscal year 2013 or any succeeding fiscal + year be less than the amount equal to 35 percent of the + DSH allotment determined for the State for fiscal year + 2012 under this subsection (and after the application of + this paragraph, if applicable), increased by the + percentage change in the consumer price index for all + urban consumers (all items, U.S. city average) for each + previous fiscal year occurring before the fiscal year. + ``(F) Uncovered + individuals. <<NOTE: Definition.>> --In this paragraph, + the term `uncovered individuals' means individuals with + no health insurance coverage at any time during a year + (as determined by the Secretary based on the most recent + data available).''. + + (b) <<NOTE: 42 USC 1396r-4 note.>> Effective Date.--The amendments +made by subsection (a) take effect on October 1, 2011. + + Subtitle H--Improved Coordination for Dual Eligible Beneficiaries + +SEC. 2601. 5-YEAR PERIOD FOR DEMONSTRATION PROJECTS. + + (a) In General.--Section 1915(h) of the Social Security Act (42 +U.S.C. 1396n(h)) is amended-- + (1) by inserting ``(1)'' after ``(h)''; + (2) by inserting ``, or a waiver described in paragraph + (2)'' after ``(e)''; and + (3) by adding at the end the following new paragraph: + + ``(2)(A) <<NOTE: Determination.>> Notwithstanding subsections +(c)(3) and (d) (3), any waiver under subsection (b), (c), or (d), or a +waiver under section 1115, that provides medical assistance for dual +eligible individuals (including any such waivers under which non dual +eligible individuals may be enrolled in addition to dual eligible +individuals) may be conducted for a period of 5 years and, upon the +request of the State, may be extended for additional 5-year periods +unless the Secretary determines that for the previous waiver period the +conditions for the waiver have not been met or it would no longer be +cost-effective and efficient, or consistent with the purposes of this +title, to extend the waiver. + +[[Page 124 STAT. 315]] + + ``(B) <<NOTE: Definition.>> In this paragraph, the term `dual +eligible individual' means an individual who is entitled to, or enrolled +for, benefits under part A of title XVIII, or enrolled for benefits +under part B of title XVIII, and is eligible for medical assistance +under the State plan under this title or under a waiver of such plan.''. + + (b) Conforming Amendments.-- + (1) Section 1915 of such Act (42 U.S.C. 1396n) is amended-- + (A) in subsection (b), by adding at the end the + following new sentence: ``Subsection (h)(2) shall apply + to a waiver under this subsection.''; + (B) in subsection (c)(3), in the second sentence, by + inserting ``(other than a waiver described in subsection + (h)(2))'' after ``A waiver under this subsection''; + (C) in subsection (d)(3), in the second sentence, by + inserting ``(other than a waiver described in subsection + (h)(2))'' after ``A waiver under this subsection''. + (2) Section 1115 of such Act (42 U.S.C. 1315) is amended-- + (A) in subsection (e)(2), by inserting ``(5 years, + in the case of a waiver described in section + 1915(h)(2))'' after ``3 years''; and + (B) in subsection (f)(6), by inserting ``(5 years, + in the case of a waiver described in section + 1915(h)(2))'' after ``3 years''. + +SEC. 2602. <<NOTE: 42 USC 1315b.>> PROVIDING FEDERAL COVERAGE AND + PAYMENT COORDINATION FOR DUAL ELIGIBLE BENEFICIARIES. + + (a) Establishment of Federal Coordinated Health Care Office.-- + (1) In general.-- <<NOTE: Deadline.>> Not later than March + 1, 2010, the Secretary of Health and Human Services (in this + section referred to as the ``Secretary'') shall establish a + Federal Coordinated Health Care Office. + (2) Establishment and reporting to cms administrator.--The + Federal Coordinated Health Care Office-- + (A) shall be established within the Centers for + Medicare & Medicaid Services; and + (B) <<NOTE: Appointment.>> have as the Office a + Director who shall be appointed by, and be in direct + line of authority to, the Administrator of the Centers + for Medicare & Medicaid Services. + + (b) Purpose.--The purpose of the Federal Coordinated Health Care +Office is to bring together officers and employees of the Medicare and +Medicaid programs at the Centers for Medicare & Medicaid Services in +order to-- + (1) more effectively integrate benefits under the Medicare + program under title XVIII of the Social Security Act and the + Medicaid program under title XIX of such Act; and + (2) improve the coordination between the Federal Government + and States for individuals eligible for benefits under both such + programs in order to ensure that such individuals get full + access to the items and services to which they are entitled + under titles XVIII and XIX of the Social Security Act. + + (c) Goals.--The goals of the Federal Coordinated Health Care Office +are as follows: + (1) Providing dual eligible individuals full access to the + benefits to which such individuals are entitled under the + Medicare and Medicaid programs. + +[[Page 124 STAT. 316]] + + (2) Simplifying the processes for dual eligible individuals + to access the items and services they are entitled to under the + Medicare and Medicaid programs. + (3) Improving the quality of health care and long-term + services for dual eligible individuals. + (4) Increasing dual eligible individuals' understanding of + and satisfaction with coverage under the Medicare and Medicaid + programs. + (5) Eliminating regulatory conflicts between rules under the + Medicare and Medicaid programs. + (6) Improving care continuity and ensuring safe and + effective care transitions for dual eligible individuals. + (7) Eliminating cost-shifting between the Medicare and + Medicaid program and among related health care providers. + (8) Improving the quality of performance of providers of + services and suppliers under the Medicare and Medicaid programs. + + (d) Specific Responsibilities.--The specific responsibilities of the +Federal Coordinated Health Care Office are as follows: + (1) Providing States, specialized MA plans for special needs + individuals (as defined in section 1859(b)(6) of the Social + Security Act (42 U.S.C. 1395w-28(b)(6))), physicians and other + relevant entities or individuals with the education and tools + necessary for developing programs that align benefits under the + Medicare and Medicaid programs for dual eligible individuals. + (2) Supporting State efforts to coordinate and align acute + care and long-term care services for dual eligible individuals + with other items and services furnished under the Medicare + program. + (3) Providing support for coordination of contracting and + oversight by States and the Centers for Medicare & Medicaid + Services with respect to the integration of the Medicare and + Medicaid programs in a manner that is supportive of the goals + described in paragraph (3). + (4) To consult and coordinate with the Medicare Payment + Advisory Commission established under section 1805 of the Social + Security Act (42 U.S.C. 1395b-6) and the Medicaid and CHIP + Payment and Access Commission established under section 1900 of + such Act (42 U.S.C. 1396) with respect to policies relating to + the enrollment in, and provision of, benefits to dual eligible + individuals under the Medicare program under title XVIII of the + Social Security Act and the Medicaid program under title XIX of + such Act. + (5) To study the provision of drug coverage for new full- + benefit dual eligible individuals (as defined in section + 1935(c)(6) of the Social Security Act (42 U.S.C. 1396u-5(c)(6)), + as well as to monitor and report annual total expenditures, + health outcomes, and access to benefits for all dual eligible + individuals. + + (e) Report.--The Secretary shall, as part of the budget transmitted +under section 1105(a) of title 31, United States Code, submit to +Congress an annual report containing recommendations for legislation +that would improve care coordination and benefits for dual eligible +individuals. + (f) Dual Eligible Defined.--In this section, the term ``dual +eligible individual'' means an individual who is entitled to, or +enrolled for, benefits under part A of title XVIII of the Social +Security Act, or enrolled for benefits under part B of title XVIII + +[[Page 124 STAT. 317]] + +of such Act, and is eligible for medical assistance under a State plan +under title XIX of such Act or under a waiver of such plan. + +Subtitle I--Improving the Quality of Medicaid for Patients and Providers + +SEC. 2701. ADULT HEALTH QUALITY MEASURES. + + Title XI of the Social Security Act (42 U.S.C. 1301 et seq.), as +amended by section 401 of the Children's Health Insurance Program +Reauthorization Act of 2009 (Public Law 111-3), is amended by inserting +after section 1139A the following new section: + +``SEC. 1139B. <<NOTE: 42 USC 1320b-9b.>> ADULT HEALTH QUALITY MEASURES. + + ``(a) Development of Core Set of Health Care Quality Measures for +Adults Eligible for Benefits Under Medicaid.-- +The <<NOTE: Publication.>> Secretary shall identify and publish a +recommended core set of adult health quality measures for Medicaid +eligible adults in the same manner as the Secretary identifies and +publishes a core set of child health quality measures under section +1139A, including with respect to identifying and publishing existing +adult health quality measures that are in use under public and privately +sponsored health care coverage arrangements, or that are part of +reporting systems that measure both the presence and duration of health +insurance coverage over time, that may be applicable to Medicaid +eligible adults. + + ``(b) Deadlines.-- + ``(1) Recommended measures.-- <<NOTE: Publication.>> Not + later than January 1, 2011, the Secretary shall identify and + publish for comment a recommended core set of adult health + quality measures for Medicaid eligible adults. + ``(2) Dissemination.-- <<NOTE: Publication.>> Not later than + January 1, 2012, the Secretary shall publish an initial core set + of adult health quality measures that are applicable to Medicaid + eligible adults. + ``(3) Standardized reporting.--Not later than January 1, + 2013, the Secretary, in consultation with States, shall develop + a standardized format for reporting information based on the + initial core set of adult health quality measures and create + procedures to encourage States to use such measures to + voluntarily report information regarding the quality of health + care for Medicaid eligible adults. + ``(4) Reports to congress.--Not later than January 1, 2014, + and every 3 years thereafter, the Secretary shall include in the + report to Congress required under section 1139A(a)(6) + information similar to the information required under that + section with respect to the measures established under this + section. + ``(5) Establishment of medicaid quality measurement + program.-- + ``(A) In general.--Not later than 12 months after + the release of the recommended core set of adult health + quality measures under paragraph (1)), the Secretary + shall establish a Medicaid Quality Measurement Program + in the same manner as the Secretary establishes the + pediatric quality measures program under section + 1139A(b). The aggregate amount awarded by the Secretary + for grants and contracts for the development, testing, + and validation of emerging + +[[Page 124 STAT. 318]] + + and innovative evidence-based measures under such + program shall equal the aggregate amount awarded by the + Secretary for grants under section 1139A(b)(4)(A) + ``(B) Revising, strengthening, and improving initial + core measures. <<NOTE: Publication.>> --Beginning not + later than 24 months after the establishment of the + Medicaid Quality Measurement Program, and annually + thereafter, the Secretary shall publish recommended + changes to the initial core set of adult health quality + measures that shall reflect the results of the testing, + validation, and consensus process for the development of + adult health quality measures. + + ``(c) Construction.--Nothing in this section shall be construed as +supporting the restriction of coverage, under title XIX or XXI or +otherwise, to only those services that are evidence-based, or in anyway +limiting available services. + ``(d) Annual State Reports Regarding State-Specific Quality of Care +Measures Applied Under Medicaid.-- + ``(1) Annual state reports.--Each State with a State plan or + waiver approved under title XIX shall annually report + (separately or as part of the annual report required under + section 1139A(c)), to the Secretary on the-- + ``(A) State-specific adult health quality measures + applied by the State under the such plan, including + measures described in subsection (a)(5); and + ``(B) State-specific information on the quality of + health care furnished to Medicaid eligible adults under + such plan, including information collected through + external quality reviews of managed care organizations + under section 1932 and benchmark plans under section + 1937. + ``(2) Publication.-- <<NOTE: Deadlines. Public + information.>> Not later than September 30, 2014, and annually + thereafter, the Secretary shall collect, analyze, and make + publicly available the information reported by States under + paragraph (1). + + ``(e) Appropriation.--Out of any funds in the Treasury not otherwise +appropriated, there is appropriated for each of fiscal years 2010 +through 2014, $60,000,000 for the purpose of carrying out this section. +Funds appropriated under this subsection shall remain available until +expended.''. + +SEC. 2702. <<NOTE: 42 USC 1396b-1.>> PAYMENT ADJUSTMENT FOR HEALTH + CARE-ACQUIRED CONDITIONS. + + (a) In General. <<NOTE: Determination. Regulations. Effective +date.>> --The Secretary of Health and Human Services (in this subsection +referred to as the ``Secretary'') shall identify current State practices +that prohibit payment for health care-acquired conditions and shall +incorporate the practices identified, or elements of such practices, +which the Secretary determines appropriate for application to the +Medicaid program in regulations. Such regulations shall be effective as +of July 1, 2011, and shall prohibit payments to States under section +1903 of the Social Security Act for any amounts expended for providing +medical assistance for health care-acquired conditions specified in the +regulations. The regulations shall ensure that the prohibition on +payment for health care-acquired conditions shall not result in a loss +of access to care or services for Medicaid beneficiaries. + +Effective +date. + + (b) Health Care-Acquired Condition. <<NOTE: Definition.>> --In this +section. the term ``health care-acquired condition'' means a medical +condition for which an individual was diagnosed that could be identified + +[[Page 124 STAT. 319]] + +by a secondary diagnostic code described in section 1886(d)(4)(D)(iv) of +the Social Security Act (42 U.S.C. 1395ww(d)(4)(D)(iv)). + + (c) <<NOTE: Applicability.>> Medicare Provisions.--In carrying out +this section, the Secretary shall apply to State plans (or waivers) +under title XIX of the Social Security Act the regulations promulgated +pursuant to section 1886(d)(4)(D) of such Act (42 U.S.C. +1395ww(d)(4)(D)) relating to the prohibition of payments based on the +presence of a secondary diagnosis code specified by the Secretary in +such regulations, as appropriate for the Medicaid program. The Secretary +may exclude certain conditions identified under title XVIII of the +Social Security Act for non-payment under title XIX of such Act when the +Secretary finds the inclusion of such conditions to be inapplicable to +beneficiaries under title XIX. + +SEC. 2703. STATE OPTION TO PROVIDE HEALTH HOMES FOR ENROLLEES WITH + CHRONIC CONDITIONS. + + (a) State Plan Amendment.--Title XIX of the Social Security Act (42 +U.S.C. 1396a et seq.), as amended by sections 2201 and 2305, is amended +by adding at the end the following new section: + ``Sec. 1945. <<NOTE: 42 USC 1396w-4.>> State Option To Provide +Coordinated Care Through a Health Home for Individuals With Chronic +Conditions.-- + + ``(a) <<NOTE: Determination. Effective date.>> In General.-- +Notwithstanding section 1902(a)(1) (relating to statewideness), section +1902(a)(10)(B) (relating to comparability), and any other provision of +this title for which the Secretary determines it is necessary to waive +in order to implement this section, beginning January 1, 2011, a State, +at its option as a State plan amendment, may provide for medical +assistance under this title to eligible individuals with chronic +conditions who select a designated provider (as described under +subsection (h)(5)), a team of health care professionals (as described +under subsection (h)(6)) operating with such a provider, or a health +team (as described under subsection (h)(7)) as the individual's health +home for purposes of providing the individual with health home services. + + ``(b) Health Home Qualification Standards.--The Secretary shall +establish standards for qualification as a designated provider for the +purpose of being eligible to be a health home for purposes of this +section. + ``(c) Payments.-- + ``(1) In general.--A State shall provide a designated + provider, a team of health care professionals operating with + such a provider, or a health team with payments for the + provision of health home services to each eligible individual + with chronic conditions that selects such provider, team of + health care professionals, or health team as the individual's + health home. Payments made to a designated provider, a team of + health care professionals operating with such a provider, or a + health team for such services shall be treated as medical + assistance for purposes of section 1903(a), except that, during + the first 8 fiscal year quarters that the State plan amendment + is in effect, the Federal medical assistance percentage + applicable to such payments shall be equal to 90 percent. + ``(2) Methodology.-- + ``(A) In general.--The State shall specify in the + State plan amendment the methodology the State will use + for determining payment for the provision of health home + services. Such methodology for determining payment-- + +[[Page 124 STAT. 320]] + + ``(i) may be tiered to reflect, with respect + to each eligible individual with chronic + conditions provided such services by a designated + provider, a team of health care professionals + operating with such a provider, or a health team, + as well as the severity or number of each such + individual's chronic conditions or the specific + capabilities of the provider, team of health care + professionals, or health team; and + ``(ii) shall be established consistent with + section 1902(a)(30)(A). + ``(B) Alternate models of payment.--The methodology + for determining payment for provision of health home + services under this section shall not be limited to a + per-member per-month basis and may provide (as proposed + by the State and subject to approval by the Secretary) + for alternate models of payment. + ``(3) Planning grants.-- + ``(A) <<NOTE: Effective date.>> In general.-- + Beginning January 1, 2011, the Secretary may award + planning grants to States for purposes of developing a + State plan amendment under this section. A planning + grant awarded to a State under this paragraph shall + remain available until expended. + ``(B) State contribution.--A State awarded a + planning grant shall contribute an amount equal to the + State percentage determined under section 1905(b) + (without regard to section 5001 of Public Law 111-5) for + each fiscal year for which the grant is awarded. + ``(C) Limitation.--The total amount of payments made + to States under this paragraph shall not exceed + $25,000,000. + + ``(d) Hospital Referrals.--A State shall include in the State plan +amendment a requirement for hospitals that are participating providers +under the State plan or a waiver of such plan to establish procedures +for referring any eligible individuals with chronic conditions who seek +or need treatment in a hospital emergency department to designated +providers. + ``(e) Coordination.--A State shall consult and coordinate, as +appropriate, with the Substance Abuse and Mental Health Services +Administration in addressing issues regarding the prevention and +treatment of mental illness and substance abuse among eligible +individuals with chronic conditions. + ``(f) Monitoring.--A State shall include in the State plan +amendment-- + ``(1) a methodology for tracking avoidable hospital + readmissions and calculating savings that result from improved + chronic care coordination and management under this section; and + ``(2) a proposal for use of health information technology in + providing health home services under this section and improving + service delivery and coordination across the care continuum + (including the use of wireless patient technology to improve + coordination and management of care and patient adherence to + recommendations made by their provider). + + ``(g) Report on Quality Measures.--As a condition for receiving +payment for health home services provided to an eligible individual with +chronic conditions, a designated provider shall report to the State, in +accordance with such requirements as the Secretary shall specify, on all +applicable measures for determining + +[[Page 124 STAT. 321]] + +the quality of such services. When appropriate and feasible, a +designated provider shall use health information technology in providing +the State with such information. + ``(h) Definitions.--In this section: + ``(1) Eligible individual with chronic conditions.-- + ``(A) In general.--Subject to subparagraph (B), the + term `eligible individual with chronic conditions' means + an individual who-- + ``(i) is eligible for medical assistance under + the State plan or under a waiver of such plan; and + ``(ii) has at least-- + ``(I) 2 chronic conditions; + ``(II) 1 chronic condition and is at + risk of having a second chronic + condition; or + ``(III) 1 serious and persistent + mental health condition. + ``(B) Rule of construction.--Nothing in this + paragraph shall prevent the Secretary from establishing + higher levels as to the number or severity of chronic or + mental health conditions for purposes of determining + eligibility for receipt of health home services under + this section. + ``(2) Chronic condition.--The term `chronic condition' has + the meaning given that term by the Secretary and shall include, + but is not limited to, the following: + ``(A) A mental health condition. + ``(B) Substance use disorder. + ``(C) Asthma. + ``(D) Diabetes. + ``(E) Heart disease. + ``(F) Being overweight, as evidenced by having a + Body Mass Index (BMI) over 25. + ``(3) Health home.--The term `health home' means a + designated provider (including a provider that operates in + coordination with a team of health care professionals) or a + health team selected by an eligible individual with chronic + conditions to provide health home services. + ``(4) Health home services.-- + ``(A) In general.--The term `health home services' + means comprehensive and timely high-quality services + described in subparagraph (B) that are provided by a + designated provider, a team of health care professionals + operating with such a provider, or a health team. + ``(B) Services described.--The services described in + this subparagraph are-- + ``(i) comprehensive care management; + ``(ii) care coordination and health promotion; + ``(iii) comprehensive transitional care, + including appropriate follow-up, from inpatient to + other settings; + ``(iv) patient and family support (including + authorized representatives); + ``(v) referral to community and social support + services, if relevant; and + ``(vi) use of health information technology to + link services, as feasible and appropriate. + ``(5) Designated provider.--The term `designated provider' + means a physician, clinical practice or clinical group practice, + rural clinic, community health center, community mental health + +[[Page 124 STAT. 322]] + + center, home health agency, or any other entity or provider + (including pediatricians, gynecologists, and obstetricians) that + is determined by the State and approved by the Secretary to be + qualified to be a health home for eligible individuals with + chronic conditions on the basis of documentation evidencing that + the physician, practice, or clinic-- + ``(A) has the systems and infrastructure in place to + provide health home services; and + ``(B) satisfies the qualification standards + established by the Secretary under subsection (b). + ``(6) Team of health care professionals.--The term `team of + health care professionals' means a team of health professionals + (as described in the State plan amendment) that may-- + ``(A) include physicians and other professionals, + such as a nurse care coordinator, nutritionist, social + worker, behavioral health professional, or any + professionals deemed appropriate by the State; and + ``(B) be free standing, virtual, or based at a + hospital, community health center, community mental + health center, rural clinic, clinical practice or + clinical group practice, academic health center, or any + entity deemed appropriate by the State and approved by + the Secretary. + ``(7) Health team.--The term `health team' has the meaning + given such term for purposes of section 3502 of the Patient + Protection and Affordable Care Act.''. + + (b) Evaluation.-- + (1) Independent evaluation.-- + (A) In general.-- <<NOTE: Contracts.>> The Secretary + shall enter into a contract with an independent entity + or organization to conduct an evaluation and assessment + of the States that have elected the option to provide + coordinated care through a health home for Medicaid + beneficiaries with chronic conditions under section 1945 + of the Social Security Act (as added by subsection (a)) + for the purpose of determining the effect of such option + on reducing hospital admissions, emergency room visits, + and admissions to skilled nursing facilities. + (B) Evaluation report.--Not later than January 1, + 2017, the Secretary shall report to Congress on the + evaluation and assessment conducted under subparagraph + (A). + (2) <<NOTE: 42 USC 1396w-4 note.>> Survey and interim + report.-- + (A) In general.--Not later than January 1, 2014, the + Secretary of Health and Human Services shall survey + States that have elected the option under section 1945 + of the Social Security Act (as added by subsection (a)) + and report to Congress on the nature, extent, and use of + such option, particularly as it pertains to-- + (i) hospital admission rates; + (ii) chronic disease management; + (iii) coordination of care for individuals + with chronic conditions; + (iv) assessment of program implementation; + (v) processes and lessons learned (as + described in subparagraph (B)); + (vi) assessment of quality improvements and + clinical outcomes under such option; and + +[[Page 124 STAT. 323]] + + (vii) estimates of cost savings. + (B) Implementation reporting.--A State that has + elected the option under section 1945 of the Social + Security Act (as added by subsection (a)) shall report + to the Secretary, as necessary, on processes that have + been developed and lessons learned regarding provision + of coordinated care through a health home for Medicaid + beneficiaries with chronic conditions under such option. + +SEC. 2704. <<NOTE: 42 USC 1396a note.>> DEMONSTRATION PROJECT TO + EVALUATE INTEGRATED CARE AROUND A HOSPITALIZATION. + + (a) Authority To Conduct Project.-- + (1) In general.--The Secretary of Health and Human Services + (in this section referred to as the ``Secretary'') shall + establish a demonstration project under title XIX of the Social + Security Act to evaluate the use of bundled payments for the + provision of integrated care for a Medicaid beneficiary-- + (A) with respect to an episode of care that includes + a hospitalization; and + (B) for concurrent physicians services provided + during a hospitalization. + (2) Duration.--The demonstration project shall begin on + January 1, 2012, and shall end on December 31, 2016. + + (b) Requirements.--The demonstration project shall be conducted in +accordance with the following: + (1) <<NOTE: Determination.>> The demonstration project + shall be conducted in up to 8 States, determined by the + Secretary based on consideration of the potential to lower costs + under the Medicaid program while improving care for Medicaid + beneficiaries. A State selected to participate in the + demonstration project may target the demonstration project to + particular categories of beneficiaries, beneficiaries with + particular diagnoses, or particular geographic regions of the + State, but the Secretary shall insure that, as a whole, the + demonstration project is, to the greatest extent possible, + representative of the demographic and geographic composition of + Medicaid beneficiaries nationally. + (2) The demonstration project shall focus on conditions + where there is evidence of an opportunity for providers of + services and suppliers to improve the quality of care furnished + to Medicaid beneficiaries while reducing total expenditures + under the State Medicaid programs selected to participate, as + determined by the Secretary. + (3) A State selected to participate in the demonstration + project shall specify the 1 or more episodes of care the State + proposes to address in the project, the services to be included + in the bundled payments, and the rationale for the selection of + such episodes of care and services. The Secretary may modify the + episodes of care as well as the services to be included in the + bundled payments prior to or after approving the project. The + Secretary may also vary such factors among the different States + participating in the demonstration project. + (4) The Secretary shall ensure that payments made under the + demonstration project are adjusted for severity of illness and + other characteristics of Medicaid beneficiaries within a + category or having a diagnosis targeted as part of the + demonstration project. States shall ensure that Medicaid + beneficiaries are not liable for any additional cost sharing + than + +[[Page 124 STAT. 324]] + + if their care had not been subject to payment under the + demonstration project. + (5) Hospitals participating in the demonstration project + shall have or establish robust discharge planning programs to + ensure that Medicaid beneficiaries requiring post-acute care are + appropriately placed in, or have ready access to, post-acute + care settings. + (6) The Secretary and each State selected to participate in + the demonstration project shall ensure that the demonstration + project does not result in the Medicaid beneficiaries whose care + is subject to payment under the demonstration project being + provided with less items and services for which medical + assistance is provided under the State Medicaid program than the + items and services for which medical assistance would have been + provided to such beneficiaries under the State Medicaid program + in the absence of the demonstration project. + + (c) Waiver of Provisions.--Notwithstanding section 1115(a) of the +Social Security Act (42 U.S.C. 1315(a)), the Secretary may waive such +provisions of titles XIX, XVIII, and XI of that Act as may be necessary +to accomplish the goals of the demonstration, ensure beneficiary access +to acute and post-acute care, and maintain quality of care. + (d) Evaluation and Report.-- + (1) Data.--Each State selected to participate in the + demonstration project under this section shall provide to the + Secretary, in such form and manner as the Secretary shall + specify, relevant data necessary to monitor outcomes, costs, and + quality, and evaluate the rationales for selection of the + episodes of care and services specified by States under + subsection (b)(3). + (2) Report.--Not later than 1 year after the conclusion of + the demonstration project, the Secretary shall submit a report + to Congress on the results of the demonstration project. + +SEC. 2705. <<NOTE: 42 USC 1315a note.>> MEDICAID GLOBAL PAYMENT SYSTEM + DEMONSTRATION PROJECT. + + (a) In General.--The Secretary of Health and Human Services +(referred to in this section as the ``Secretary'') shall, in +coordination with the Center for Medicare and Medicaid Innovation (as +established under section 1115A of the Social Security Act, as added by +section 3021 of this Act), establish the Medicaid Global Payment System +Demonstration Project under which a participating State shall adjust the +payments made to an eligible safety net hospital system or network from +a fee-for-service payment structure to a global capitated payment model. + (b) Duration and Scope.--The demonstration project conducted under +this section shall operate during a period of fiscal years 2010 through +2012. <<NOTE: Selection.>> The Secretary shall select not more than 5 +States to participate in the demonstration project. + + (c) Eligible Safety Net Hospital System or +Network. <<NOTE: Definition.>> --For purposes of this section, the term +``eligible safety net hospital system or network'' means a large, safety +net hospital system or network (as defined by the Secretary) that +operates within a State selected by the Secretary under subsection (b). + + (d) Evaluation.-- + (1) Testing.--The Innovation Center shall test and evaluate + the demonstration project conducted under this section + +[[Page 124 STAT. 325]] + + to examine any changes in health care quality outcomes and + spending by the eligible safety net hospital systems or + networks. + (2) Budget neutrality.--During the testing period under + paragraph (1), any budget neutrality requirements under section + 1115A(b)(3) of the Social Security Act (as so added) shall not + be applicable. + (3) Modification.--During the testing period under paragraph + (1), the Secretary may, in the Secretary's discretion, modify or + terminate the demonstration project conducted under this + section. + + (e) Report.--Not later than 12 months after the date of completion +of the demonstration project under this section, the Secretary shall +submit to Congress a report containing the results of the evaluation and +testing conducted under subsection (d), together with recommendations +for such legislation and administrative action as the Secretary +determines appropriate. + (f) Authorization of Appropriations.--There are authorized to be +appropriated such sums as are necessary to carry out this section. + +SEC. 2706. <<NOTE: 42 USC 1396a note.>> PEDIATRIC ACCOUNTABLE CARE + ORGANIZATION DEMONSTRATION PROJECT. + + (a) Authority To Conduct Demonstration.-- + (1) In general.--The Secretary of Health and Human Services + (referred to in this section as the ``Secretary'') shall + establish the Pediatric Accountable Care Organization + Demonstration Project to authorize a participating State to + allow pediatric medical providers that meet specified + requirements to be recognized as an accountable care + organization for purposes of receiving incentive payments (as + described under subsection (d)), in the same manner as an + accountable care organization is recognized and provided with + incentive payments under section 1899 of the Social Security Act + (as added by section 3022). + (2) Duration.--The demonstration project shall begin on + January 1, 2012, and shall end on December 31, 2016. + + (b) Application.--A State that desires to participate in the +demonstration project under this section shall submit to the Secretary +an application at such time, in such manner, and containing such +information as the Secretary may require. + (c) Requirements.-- + (1) Performance guidelines.--The Secretary, in consultation + with the States and pediatric providers, shall establish + guidelines to ensure that the quality of care delivered to + individuals by a provider recognized as an accountable care + organization under this section is not less than the quality of + care that would have otherwise been provided to such + individuals. + (2) Savings requirement.--A participating State, in + consultation with the Secretary, shall establish an annual + minimal level of savings in expenditures for items and services + covered under the Medicaid program under title XIX of the Social + Security Act and the CHIP program under title XXI of such Act + that must be reached by an accountable care organization in + order for such organization to receive an incentive payment + under subsection (d). + (3) <<NOTE: Contracts.>> Minimum participation period.--A + provider desiring to be recognized as an accountable care + organization under + +[[Page 124 STAT. 326]] + + the demonstration project shall enter into an agreement with the + State to participate in the project for not less than a 3-year + period. + + (d) Incentive Payment.--An accountable care organization that meets +the performance guidelines established by the Secretary under subsection +(c)(1) and achieves savings greater than the annual minimal savings +level established by the State under subsection (c)(2) shall receive an +incentive payment for such year equal to a portion (as determined +appropriate by the Secretary) of the amount of such excess savings. The +Secretary may establish an annual cap on incentive payments for an +accountable care organization. + (e) Authorization of Appropriations.--There are authorized to be +appropriated such sums as are necessary to carry out this section. + +SEC. 2707. <<NOTE: 42 USC 1396a note.>> MEDICAID EMERGENCY PSYCHIATRIC + DEMONSTRATION PROJECT. + + (a) Authority To Conduct Demonstration Project.--The Secretary of +Health and Human Services (in this section referred to as the +``Secretary'') shall establish a demonstration project under which an +eligible State (as described in subsection (c)) shall provide payment +under the State Medicaid plan under title XIX of the Social Security Act +to an institution for mental diseases that is not publicly owned or +operated and that is subject to the requirements of section 1867 of the +Social Security Act (42 U.S.C. 1395dd) for the provision of medical +assistance available under such plan to individuals who-- + (1) have attained age 21, but have not attained age 65; + (2) are eligible for medical assistance under such plan; and + (3) require such medical assistance to stabilize an + emergency medical condition. + + (b) Stabilization Review.--A State shall specify in its application +described in subsection (c)(1) establish a mechanism for how it will +ensure that institutions participating in the demonstration will +determine whether or not such individuals have been stabilized (as +defined in subsection (h)(5)). <<NOTE: Commencement date.>> This +mechanism shall commence before the third day of the inpatient stay. +States participating in the demonstration project may manage the +provision of services for the stabilization of medical emergency +conditions through utilization review, authorization, or management +practices, or the application of medical necessity and appropriateness +criteria applicable to behavioral health. + + (c) Eligible State Defined.-- + (1) In general.--An eligible State is a State that has made + an application and has been selected pursuant to paragraphs (2) + and (3). + (2) Application.--A State seeking to participate in the + demonstration project under this section shall submit to the + Secretary, at such time and in such format as the Secretary + requires, an application that includes such information, + provisions, and assurances, as the Secretary may require. + (3) Selection.--A State shall be determined eligible for the + demonstration by the Secretary on a competitive basis among + States with applications meeting the requirements of + +[[Page 124 STAT. 327]] + + paragraph (1). In selecting State applications for the + demonstration project, the Secretary shall seek to achieve an + appropriate national balance in the geographic distribution of + such projects. + + (d) Length of Demonstration Project.--The demonstration project +established under this section shall be conducted for a period of 3 +consecutive years. + (e) Limitations on Federal Funding.-- + (1) Appropriation.-- + (A) In general.--Out of any funds in the Treasury + not otherwise appropriated, there is appropriated to + carry out this section, $75,000,000 for fiscal year + 2011. + (B) Budget authority.--Subparagraph (A) constitutes + budget authority in advance of appropriations Act and + represents the obligation of the Federal Government to + provide for the payment of the amounts appropriated + under that subparagraph. + (2) 5-year availability.--Funds appropriated under paragraph + (1) shall remain available for obligation through December 31, + 2015. + (3) Limitation on payments.--In no case may-- + (A) the aggregate amount of payments made by the + Secretary to eligible States under this section exceed + $75,000,000; or + (B) payments be provided by the Secretary under this + section after December 31, 2015. + (4) Funds allocated to states.--Funds shall be allocated to + eligible States on the basis of criteria, including a State's + application and the availability of funds, as determined by the + Secretary. + (5) Payments to states.--The Secretary shall pay to each + eligible State, from its allocation under paragraph (4), an + amount each quarter equal to the Federal medical assistance + percentage of expenditures in the quarter for medical assistance + described in subsection (a). As a condition of receiving + payment, a State shall collect and report information, as + determined necessary by the Secretary, for the purposes of + providing Federal oversight and conducting an evaluation under + subsection (f)(1). + + (f) Evaluation and Report to Congress.-- + (1) Evaluation.--The Secretary shall conduct an evaluation + of the demonstration project in order to determine the impact on + the functioning of the health and mental health service system + and on individuals enrolled in the Medicaid program and shall + include the following: + (A) An assessment of access to inpatient mental + health services under the Medicaid program; average + lengths of inpatient stays; and emergency room visits. + (B) An assessment of discharge planning by + participating hospitals. + (C) An assessment of the impact of the demonstration + project on the costs of the full range of mental health + services (including inpatient, emergency and ambulatory + care). + (D) An analysis of the percentage of consumers with + Medicaid coverage who are admitted to inpatient + facilities as a result of the demonstration project as + compared to + +[[Page 124 STAT. 328]] + + those admitted to these same facilities through other + means. + (E) A recommendation regarding whether the + demonstration project should be continued after December + 31, 2013, and expanded on a national basis. + (2) Report.--Not later than December 31, 2013, the Secretary + shall submit to Congress and make available to the public a + report on the findings of the evaluation under paragraph (1). + + (g) Waiver Authority.-- + (1) In general.--The Secretary shall waive the limitation of + subdivision (B) following paragraph (28) of section 1905(a) of + the Social Security Act (42 U.S.C. 1396d(a)) (relating to + limitations on payments for care or services for individuals + under 65 years of age who are patients in an institution for + mental diseases) for purposes of carrying out the demonstration + project under this section. + (2) Limited other waiver authority.--The Secretary may waive + other requirements of titles XI and XIX of the Social Security + Act (including the requirements of sections 1902(a)(1) (relating + to statewideness) and 1902(1)(10)(B) (relating to + comparability)) only to extent necessary to carry out the + demonstration project under this section. + + (h) Definitions.--In this section: + (1) Emergency medical condition.--The term ``emergency + medical condition'' means, with respect to an individual, an + individual who expresses suicidal or homicidal thoughts or + gestures, if determined dangerous to self or others. + (2) Federal medical assistance percentage.--The term + ``Federal medical assistance percentage'' has the meaning given + that term with respect to a State under section 1905(b) of the + Social Security Act (42 U.S.C. 1396d(b)). + (3) Institution for mental diseases.--The term ``institution + for mental diseases'' has the meaning given to that term in + section 1905(i) of the Social Security Act (42 U.S.C. 1396d(i)). + (4) Medical assistance.--The term ``medical assistance'' has + the meaning given that term in section 1905(a) of the Social + Security Act (42 U.S.C. 1396d(a)). + (5) Stabilized.--The term ``stabilized'' means, with respect + to an individual, that the emergency medical condition no longer + exists with respect to the individual and the individual is no + longer dangerous to self or others. + (6) State.--The term ``State'' has the meaning given that + term for purposes of title XIX of the Social Security Act (42 + U.S.C. 1396 et seq.). + + Subtitle J--Improvements to the Medicaid and CHIP Payment and Access + Commission (MACPAC) + +SEC. 2801. MACPAC ASSESSMENT OF POLICIES AFFECTING ALL MEDICAID + BENEFICIARIES. + + (a) In General.--Section 1900 of the Social Security Act (42 U.S.C. +1396) is amended-- + (1) in subsection (b)-- + +[[Page 124 STAT. 329]] + + (A) in paragraph (1)-- + (i) in the paragraph heading, by inserting + ``for all states'' before ``and annual''; and + (ii) in subparagraph (A), by striking + ``children's''; + (iii) in subparagraph (B), by inserting ``, + the Secretary, and States'' after ``Congress''; + (iv) in subparagraph (C), by striking ``March + 1'' and inserting ``March 15''; and + (v) in subparagraph (D), by striking ``June + 1'' and inserting ``June 15''; + (B) in paragraph (2)-- + (i) in subparagraph (A)-- + (I) in clause (i)-- + (aa) by inserting ``the + efficient provision of'' after + ``expenditures for''; and + (bb) by striking ``hospital, + skilled nursing facility, + physician, Federally-qualified + health center, rural health + center, and other fees'' and + inserting ``payments to medical, + dental, and health + professionals, hospitals, + residential and long-term care + providers, providers of home and + community based services, + Federally-qualified health + centers and rural health + clinics, managed care entities, + and providers of other covered + items and services''; and + (II) in clause (iii), by inserting + ``(including how such factors and + methodologies enable such beneficiaries + to obtain the services for which they + are eligible, affect provider supply, + and affect providers that serve a + disproportionate share of low-income and + other vulnerable populations)'' after + ``beneficiaries''; + (ii) by redesignating subparagraphs (B) and + (C) as subparagraphs (F) and (H), respectively; + (iii) by inserting after subparagraph (A), the + following: + ``(B) Eligibility policies.--Medicaid and CHIP + eligibility policies, including a determination of the + degree to which Federal and State policies provide + health care coverage to needy populations. + ``(C) Enrollment and retention processes.--Medicaid + and CHIP enrollment and retention processes, including a + determination of the degree to which Federal and State + policies encourage the enrollment of individuals who are + eligible for such programs and screen out individuals + who are ineligible, while minimizing the share of + program expenses devoted to such processes. + ``(D) Coverage policies.--Medicaid and CHIP benefit + and coverage policies, including a determination of the + degree to which Federal and State policies provide + access to the services enrollees require to improve and + maintain their health and functional status. + ``(E) Quality of care.--Medicaid and CHIP policies + as they relate to the quality of care provided under + those programs, including a determination of the degree + to which Federal and State policies achieve their stated + goals and + +[[Page 124 STAT. 330]] + + interact with similar goals established by other + purchasers of health care services.''; + (iv) by inserting after subparagraph (F) (as + redesignated by clause (ii) of this subparagraph), + the following: + ``(G) Interactions with medicare and medicaid.-- + Consistent with paragraph (11), the interaction of + policies under Medicaid and the Medicare program under + title XVIII, including with respect to how such + interactions affect access to services, payments, and + dual eligible individuals.'' and + (v) in subparagraph (H) (as so redesignated), + by inserting ``and preventive, acute, and long- + term services and supports'' after ``barriers''; + (C) by redesignating paragraphs (3) through (9) as + paragraphs (4) through (10), respectively; + (D) by inserting after paragraph (2), the following + new paragraph: + ``(3) Recommendations and reports of state-specific data.-- + MACPAC shall-- + ``(A) review national and State-specific Medicaid + and CHIP data; and + ``(B) submit reports and recommendations to + Congress, the Secretary, and States based on such + reviews.''; + (E) in paragraph (4), as redesignated by + subparagraph (C), by striking ``or any other problems'' + and all that follows through the period and inserting + ``, as well as other factors that adversely affect, or + have the potential to adversely affect, access to care + by, or the health care status of, Medicaid and CHIP + beneficiaries. MACPAC shall include in the annual report + required under paragraph (1)(D) a description of all + such areas or problems identified with respect to the + period addressed in the report.''; + (F) in paragraph (5), as so redesignated,-- + (i) in the paragraph heading, by inserting + ``and regulations'' after ``reports''; and + (ii) by striking ``If'' and inserting the + following: + ``(A) Certain secretarial reports.--If''; and + (iii) in the second sentence, by inserting + ``and the Secretary'' after ``appropriate + committees of Congress''; and + (iv) by adding at the end the following: + ``(B) Regulations.--MACPAC shall review Medicaid and + CHIP regulations and may comment through submission of a + report to the appropriate committees of Congress and the + Secretary, on any such regulations that affect access, + quality, or efficiency of health care.''; + (G) in paragraph (10), as so redesignated, by + inserting `` <<NOTE: Reports.>> , and shall submit with + any recommendations, a report on the Federal and State- + specific budget consequences of the recommendations'' + before the period; and + (H) by adding at the end the following: + ``(11) Consultation and coordination with medpac.-- + ``(A) In general.--MACPAC shall consult with the + Medicare Payment Advisory Commission (in this paragraph + referred to as `MedPAC') established under section 1805 + in carrying out its duties under this section, as + appropriate and particularly with respect to the issues + specified in + +[[Page 124 STAT. 331]] + + paragraph (2) as they relate to those Medicaid + beneficiaries who are dually eligible for Medicaid and + the Medicare program under title XVIII, adult Medicaid + beneficiaries (who are not dually eligible for + Medicare), and beneficiaries under Medicare. + Responsibility for analysis of and recommendations to + change Medicare policy regarding Medicare beneficiaries, + including Medicare beneficiaries who are dually eligible + for Medicare and Medicaid, shall rest with MedPAC. + ``(B) Information sharing.--MACPAC and MedPAC shall + have access to deliberations and records of the other + such entity, respectively, upon the request of the other + such entity. + ``(12) Consultation with states.--MACPAC shall regularly + consult with States in carrying out its duties under this + section, including with respect to developing processes for + carrying out such duties, and shall ensure that input from + States is taken into account and represented in MACPAC's + recommendations and reports. + ``(13) Coordinate and consult with the federal coordinated + health care office.--MACPAC shall coordinate and consult with + the Federal Coordinated Health Care Office established under + section 2081 of the Patient Protection and Affordable Care Act + before making any recommendations regarding dual eligible + individuals. + ``(14) Programmatic oversight vested in the secretary.-- + MACPAC's authority to make recommendations in accordance with + this section shall not affect, or be considered to duplicate, + the Secretary's authority to carry out Federal responsibilities + with respect to Medicaid and CHIP.''; + (2) in subsection (c)(2)-- + (A) by striking subparagraphs (A) and (B) and + inserting the following: + ``(A) In general.--The membership of MACPAC shall + include individuals who have had direct experience as + enrollees or parents or caregivers of enrollees in + Medicaid or CHIP and individuals with national + recognition for their expertise in Federal safety net + health programs, health finance and economics, actuarial + science, health plans and integrated delivery systems, + reimbursement for health care, health information + technology, and other providers of health services, + public health, and other related fields, who provide a + mix of different professions, broad geographic + representation, and a balance between urban and rural + representation. + ``(B) Inclusion.--The membership of MACPAC shall + include (but not be limited to) physicians, dentists, + and other health professionals, employers, third-party + payers, and individuals with expertise in the delivery + of health services. Such membership shall also include + representatives of children, pregnant women, the + elderly, individuals with disabilities, caregivers, and + dual eligible individuals, current or former + representatives of State agencies responsible for + administering Medicaid, and current or former + representatives of State agencies responsible for + administering CHIP.''. + +[[Page 124 STAT. 332]] + + (3) in subsection (d)(2), by inserting ``and State'' after + ``Federal''; + (4) in subsection (e)(1), in the first sentence, by + inserting ``and, as a condition for receiving payments under + sections 1903(a) and 2105(a), from any State agency responsible + for administering Medicaid or CHIP,'' after ``United States''; + and + (5) in subsection (f)-- + (A) in the subsection heading, by striking + ``Authorization of Appropriations'' and inserting + ``Funding''; + (B) in paragraph (1), by inserting ``(other than for + fiscal year 2010)'' before ``in the same manner''; and + (C) by adding at the end the following: + ``(3) Funding for fiscal year 2010.-- + ``(A) In general.--Out of any funds in the Treasury + not otherwise appropriated, there is appropriated to + MACPAC to carry out the provisions of this section for + fiscal year 2010, $9,000,000. + ``(B) Transfer of funds.--Notwithstanding section + 2104(a)(13), from the amounts appropriated in such + section for fiscal year 2010, $2,000,000 is hereby + transferred and made available in such fiscal year to + MACPAC to carry out the provisions of this section. + ``(4) Availability.--Amounts made available under paragraphs + (2) and (3) to MACPAC to carry out the provisions of this + section shall remain available until expended.''. + + (b) Conforming MedPAC Amendments.--Section 1805(b) of the Social +Security Act (42 U.S.C. 1395b-6(b)), is amended-- + (1) in paragraph (1)(C), by striking ``March 1 of each year + (beginning with 1998)'' and inserting ``March 15''; + (2) in paragraph (1)(D), by inserting ``, and (beginning + with 2012) containing an examination of the topics described in + paragraph (9), to the extent feasible'' before the period; and + (3) by adding at the end the following: + ``(9) Review and annual report on medicaid and commercial + trends.--The Commission shall review and report on aggregate + trends in spending, utilization, and financial performance under + the Medicaid program under title XIX and the private market for + health care services with respect to providers for which, on an + aggregate national basis, a significant portion of revenue or + services is associated with the Medicaid program. Where + appropriate, the Commission shall conduct such review in + consultation with the Medicaid and CHIP Payment and Access + Commission established under section 1900 (in this section + referred to as `MACPAC'). + ``(10) Coordinate and consult with the federal coordinated + health care office.--The Commission shall coordinate and consult + with the Federal Coordinated Health Care Office established + under section 2081 of the Patient Protection and Affordable Care + Act before making any recommendations regarding dual eligible + individuals. + ``(11) Interaction of medicaid and medicare.--The Commission + shall consult with MACPAC in carrying out its duties under this + section, as appropriate. Responsibility for analysis of and + recommendations to change Medicare policy regarding Medicare + beneficiaries, including Medicare beneficiaries who are dually + eligible for Medicare and Medicaid, + +[[Page 124 STAT. 333]] + + shall rest with the Commission. Responsibility for analysis of + and recommendations to change Medicaid policy regarding Medicaid + beneficiaries, including Medicaid beneficiaries who are dually + eligible for Medicare and Medicaid, shall rest with MACPAC.''. + + Subtitle K--Protections for American Indians and Alaska Natives + +SEC. 2901. SPECIAL RULES RELATING TO INDIANS. + + (a) <<NOTE: 25 USC 1623.>> No Cost-sharing for Indians With Income +at or Below 300 Percent of Poverty Enrolled in Coverage Through a State +Exchange.--For provisions prohibiting cost sharing for Indians enrolled +in any qualified health plan in the individual market through an +Exchange, see section 1402(d) of the Patient Protection and Affordable +Care Act. + + (b) <<NOTE: 25 USC 1623.>> Payer of Last Resort.--Health programs +operated by the Indian Health Service, Indian tribes, tribal +organizations, and Urban Indian organizations (as those terms are +defined in section 4 of the Indian Health Care Improvement Act (25 +U.S.C. 1603)) shall be the payer of last resort for services provided by +such Service, tribes, or organizations to individuals eligible for +services through such programs, notwithstanding any Federal, State, or +local law to the contrary. + + (c) Facilitating Enrollment of Indians Under the Express Lane +Option.--Section 1902(e)(13)(F)(ii) of the Social Security Act (42 +U.S.C. 1396a(e)(13)(F)(ii)) is amended-- + (1) in the clause heading, by inserting ``and indian tribes + and tribal organizations'' after ``agencies''; and + (2) by adding at the end the following: + ``(IV) The Indian Health Service, an + Indian Tribe, Tribal Organization, or + Urban Indian Organization (as defined in + section 1139(c)).''. + + (d) Technical Corrections.--Section 1139(c) of the Social Security +Act (42 U.S.C. 1320b-9(c)) is amended by striking ``In this section'' +and inserting ``For purposes of this section, title XIX, and title +XXI''. + +SEC. 2902. ELIMINATION OF SUNSET FOR REIMBURSEMENT FOR ALL MEDICARE PART + B SERVICES FURNISHED BY CERTAIN INDIAN HOSPITALS AND + CLINICS. + + (a) Reimbursement for All Medicare Part B Services Furnished by +Certain Indian Hospitals and Clinics.--Section 1880(e)(1)(A) of the +Social Security Act (42 U.S.C. 1395qq(e)(1)(A)) is amended by striking +``during the 5-year period beginning on'' and inserting ``on or after''. + (b) Effective Date.-- <<NOTE: Applicability. 42 USC 1395qq +note.>> The amendments made by this section shall apply to items or +services furnished on or after January 1, 2010. + +[[Page 124 STAT. 334]] + + Subtitle L--Maternal and Child Health Services + +SEC. 2951. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME VISITING PROGRAMS. + + Title V of the Social Security Act (42 U.S.C. 701 et seq.) is +amended by adding at the end the following new section: + +``SEC. 511. <<NOTE: 42 USC 711.>> MATERNAL, INFANT, AND EARLY CHILDHOOD + HOME VISITING PROGRAMS. + + ``(a) Purposes.--The purposes of this section are-- + ``(1) to strengthen and improve the programs and activities + carried out under this title; + ``(2) to improve coordination of services for at risk + communities; and + ``(3) to identify and provide comprehensive services to + improve outcomes for families who reside in at risk communities. + + ``(b) Requirement for All States To Assess Statewide Needs and +Identify at Risk Communities.-- + ``(1) In general.-- <<NOTE: Deadline.>> Not later than 6 + months after the date of enactment of this section, each State + shall, as a condition of receiving payments from an allotment + for the State under section 502 for fiscal year 2011, conduct a + statewide needs assessment (which shall be separate from the + statewide needs assessment required under section 505(a)) that + identifies-- + ``(A) communities with concentrations of-- + ``(i) premature birth, low-birth weight + infants, and infant mortality, including infant + death due to neglect, or other indicators of at- + risk prenatal, maternal, newborn, or child health; + ``(ii) poverty; + ``(iii) crime; + ``(iv) domestic violence; + ``(v) high rates of high-school drop-outs; + ``(vi) substance abuse; + ``(vii) unemployment; or + ``(viii) child maltreatment; + ``(B) the quality and capacity of existing programs + or initiatives for early childhood home visitation in + the State including-- + ``(i) the number and types of individuals and + families who are receiving services under such + programs or initiatives; + ``(ii) the gaps in early childhood home + visitation in the State; and + ``(iii) the extent to which such programs or + initiatives are meeting the needs of eligible + families described in subsection (k)(2); and + ``(C) the State's capacity for providing substance + abuse treatment and counseling services to individuals + and families in need of such treatment or services. + ``(2) Coordination with other assessments.--In conducting + the statewide needs assessment required under paragraph (1), the + State shall coordinate with, and take into account, other + appropriate needs assessments conducted by + +[[Page 124 STAT. 335]] + + the State, as determined by the Secretary, including the needs + assessment required under section 505(a) (both the most recently + completed assessment and any such assessment in progress), the + communitywide strategic planning and needs assessments conducted + in accordance with section 640(g)(1)(C) of the Head Start Act, + and the inventory of current unmet needs and current community- + based and prevention-focused programs and activities to prevent + child abuse and neglect, and other family resource services + operating in the State required under section 205(3) of the + Child Abuse Prevention and Treatment Act. + ``(3) Submission to the secretary.--Each State shall submit + to the Secretary, in such form and manner as the Secretary shall + require-- + ``(A) the results of the statewide needs assessment + required under paragraph (1); and + ``(B) a description of how the State intends to + address needs identified by the assessment, particularly + with respect to communities identified under paragraph + (1)(A), which may include applying for a grant to + conduct an early childhood home visitation program in + accordance with the requirements of this section. + + ``(c) Grants for Early Childhood Home Visitation Programs.-- + ``(1) Authority to make grants.--In addition to any other + payments made under this title to a State, the Secretary shall + make grants to eligible entities to enable the entities to + deliver services under early childhood home visitation programs + that satisfy the requirements of subsection (d) to eligible + families in order to promote improvements in maternal and + prenatal health, infant health, child health and development, + parenting related to child development outcomes, school + readiness, and the socioeconomic status of such families, and + reductions in child abuse, neglect, and injuries. + ``(2) Authority to use initial grant funds for planning or + implementation.--An eligible entity that receives a grant under + paragraph (1) may use a portion of the funds made available to + the entity during the first 6 months of the period for which the + grant is made for planning or implementation activities to + assist with the establishment of early childhood home visitation + programs that satisfy the requirements of subsection (d). + ``(3) <<NOTE: Determination.>> Grant duration.--The + Secretary shall determine the period of years for which a grant + is made to an eligible entity under paragraph (1). + ``(4) Technical assistance.--The Secretary shall provide an + eligible entity that receives a grant under paragraph (1) with + technical assistance in administering programs or activities + conducted in whole or in part with grant funds. + + ``(d) Requirements.--The requirements of this subsection for an +early childhood home visitation program conducted with a grant made +under this section are as follows: + ``(1) Quantifiable, measurable improvement in benchmark + areas.-- + ``(A) In general.--The eligible entity establishes, + subject to the approval of the Secretary, quantifiable, + measurable 3- and 5-year benchmarks for demonstrating + that the + +[[Page 124 STAT. 336]] + + program results in improvements for the eligible + families participating in the program in each of the + following areas: + ``(i) Improved maternal and newborn health. + ``(ii) Prevention of child injuries, child + abuse, neglect, or maltreatment, and reduction of + emergency department visits. + ``(iii) Improvement in school readiness and + achievement. + ``(iv) Reduction in crime or domestic + violence. + ``(v) Improvements in family economic self- + sufficiency. + ``(vi) Improvements in the coordination and + referrals for other community resources and + supports. + ``(B) Demonstration of improvements after 3 years.-- + ``(i) Report to the secretary.--Not later than + 30 days after the end of the 3rd year in which the + eligible entity conducts the program, the entity + submits to the Secretary a report demonstrating + improvement in at least 4 of the areas specified + in subparagraph (A). + ``(ii) Corrective action plan.--If the report + submitted by the eligible entity under clause (i) + fails to demonstrate improvement in at least 4 of + the areas specified in subparagraph (A), the + entity shall develop and implement a plan to + improve outcomes in each of the areas specified in + subparagraph (A), subject to approval by the + Secretary. The plan shall include provisions for + the Secretary to monitor implementation of the + plan and conduct continued oversight of the + program, including through submission by the + entity of regular reports to the Secretary. + ``(iii) Technical assistance.-- + ``(I) In general.--The Secretary + shall provide an eligible entity + required to develop and implement an + improvement plan under clause (ii) with + technical assistance to develop and + implement the plan. The Secretary may + provide the technical assistance + directly or through grants, contracts, + or cooperative agreements. + ``(II) Advisory + panel. <<NOTE: Establishment.>> --The + Secretary shall establish an advisory + panel for purposes of obtaining + recommendations regarding the technical + assistance provided to entities in + accordance with subclause (I). + ``(iv) No improvement or failure to submit + report. <<NOTE: Determination. Termination.>> --If + the Secretary determines after a period of time + specified by the Secretary that an eligible entity + implementing an improvement plan under clause (ii) + has failed to demonstrate any improvement in the + areas specified in subparagraph (A), or if the + Secretary determines that an eligible entity has + failed to submit the report required under clause + (i), the Secretary shall terminate the entity's + grant and may include any unexpended grant funds + in grants made to nonprofit organizations under + subsection (h)(2)(B). + +[[Page 124 STAT. 337]] + + ``(C) Final report.--Not later than December 31, + 2015, the eligible entity shall submit a report to the + Secretary demonstrating improvements (if any) in each of + the areas specified in subparagraph (A). + ``(2) Improvements in outcomes for individual families.-- + ``(A) In general.--The program is designed, with + respect to an eligible family participating in the + program, to result in the participant outcomes described + in subparagraph (B) that the eligible entity identifies + on the basis of an individualized assessment of the + family, are relevant for that family. + ``(B) Participant outcomes.--The participant + outcomes described in this subparagraph are the + following: + ``(i) Improvements in prenatal, maternal, and + newborn health, including improved pregnancy + outcomes + ``(ii) Improvements in child health and + development, including the prevention of child + injuries and maltreatment and improvements in + cognitive, language, social-emotional, and + physical developmental indicators. + ``(iii) Improvements in parenting skills. + ``(iv) Improvements in school readiness and + child academic achievement. + ``(v) Reductions in crime or domestic + violence. + ``(vi) Improvements in family economic self- + sufficiency. + ``(vii) Improvements in the coordination of + referrals for, and the provision of, other + community resources and supports for eligible + families, consistent with State child welfare + agency training. + ``(3) Core components.--The program includes the following + core components: + ``(A) Service delivery model or models.-- + ``(i) In general.--Subject to clause (ii), the + program is conducted using 1 or more of the + service delivery models described in item (aa) or + (bb) of subclause (I) or in subclause (II) + selected by the eligible entity: + ``(I) The model conforms to a clear + consistent home visitation model that + has been in existence for at least 3 + years and is research-based, grounded in + relevant empirically-based knowledge, + linked to program determined outcomes, + associated with a national organization + or institution of higher education that + has comprehensive home visitation + program standards that ensure high + quality service delivery and continuous + program quality improvement, and has + demonstrated significant, (and in the + case of the service delivery model + described in item (aa), sustained) + positive outcomes, as described in the + benchmark areas specified in paragraph + (1)(A) and the participant outcomes + described in paragraph (2)(B), when + evaluated using well-designed and + rigorous-- + +[[Page 124 STAT. 338]] + + ``(aa) randomized controlled + research designs, and the + evaluation results have been + published in a peer-reviewed + journal; or + ``(bb) quasi-experimental + research designs. + ``(II) The model conforms to a + promising and new approach to achieving + the benchmark areas specified in + paragraph (1)(A) and the participant + outcomes described in paragraph (2)(B), + has been developed or identified by a + national organization or institution of + higher education, and will be evaluated + through well-designed and rigorous + process. + ``(ii) Majority of grant funds used for + evidence-based models.--An eligible entity shall + use not more than 25 percent of the amount of the + grant paid to the entity for a fiscal year for + purposes of conducting a program using the service + delivery model described in clause (i)(II). + ``(iii) Criteria for evidence of effectiveness + of models.--The Secretary shall establish criteria + for evidence of effectiveness of the service + delivery models and shall ensure that the process + for establishing the criteria is transparent and + provides the opportunity for public comment. + ``(B) Additional requirements.-- + ``(i) The program adheres to a clear, + consistent model that satisfies the requirements + of being grounded in empirically-based knowledge + related to home visiting and linked to the + benchmark areas specified in paragraph (1)(A) and + the participant outcomes described in paragraph + (2)(B) related to the purposes of the program. + ``(ii) The program employs well-trained and + competent staff, as demonstrated by education or + training, such as nurses, social workers, + educators, child development specialists, or other + well-trained and competent staff, and provides + ongoing and specific training on the model being + delivered. + ``(iii) The program maintains high quality + supervision to establish home visitor + competencies. + ``(iv) The program demonstrates strong + organizational capacity to implement the + activities involved. + ``(v) The program establishes appropriate + linkages and referral networks to other community + resources and supports for eligible families. + ``(vi) The program monitors the fidelity of + program implementation to ensure that services are + delivered pursuant to the specified model. + ``(4) Priority for serving high-risk populations.--The + eligible entity gives priority to providing services under the + program to the following: + ``(A) Eligible families who reside in communities in + need of such services, as identified in the statewide + needs assessment required under subsection (b)(1)(A). + ``(B) Low-income eligible families. + ``(C) Eligible families who are pregnant women who + have not attained age 21. + +[[Page 124 STAT. 339]] + + ``(D) Eligible families that have a history of child + abuse or neglect or have had interactions with child + welfare services. + ``(E) Eligible families that have a history of + substance abuse or need substance abuse treatment. + ``(F) Eligible families that have users of tobacco + products in the home. + ``(G) Eligible families that are or have children + with low student achievement. + ``(H) Eligible families with children with + developmental delays or disabilities. + ``(I) Eligible families who, or that include + individuals who, are serving or formerly served in the + Armed Forces, including such families that have members + of the Armed Forces who have had multiple deployments + outside of the United States. + + ``(e) Application Requirements.--An eligible entity desiring a grant +under this section shall submit an application to the Secretary for +approval, in such manner as the Secretary may require, that includes the +following: + ``(1) A description of the populations to be served by the + entity, including specific information regarding how the entity + will serve high risk populations described in subsection (d)(4). + ``(2) An assurance that the entity will give priority to + serving low-income eligible families and eligible families who + reside in at risk communities identified in the statewide needs + assessment required under subsection (b)(1)(A). + ``(3) The service delivery model or models described in + subsection (d)(3)(A) that the entity will use under the program + and the basis for the selection of the model or models. + ``(4) A statement identifying how the selection of the + populations to be served and the service delivery model or + models that the entity will use under the program for such + populations is consistent with the results of the statewide + needs assessment conducted under subsection (b). + ``(5) The quantifiable, measurable benchmarks established by + the State to demonstrate that the program contributes to + improvements in the areas specified in subsection (d)(1)(A). + ``(6) An assurance that the entity will obtain and submit + documentation or other appropriate evidence from the + organization or entity that developed the service delivery model + or models used under the program to verify that the program is + implemented and services are delivered according to the model + specifications. + ``(7) Assurances that the entity will establish procedures + to ensure that-- + ``(A) the participation of each eligible family in + the program is voluntary; and + ``(B) services are provided to an eligible family in + accordance with the individual assessment for that + family. + ``(8) Assurances that the entity will-- + ``(A) submit annual reports to the Secretary + regarding the program and activities carried out under + the program that include such information and data as + the Secretary shall require; and + ``(B) participate in, and cooperate with, data and + information collection necessary for the evaluation + required + +[[Page 124 STAT. 340]] + + under subsection (g)(2) and other research and + evaluation activities carried out under subsection + (h)(3). + ``(9) A description of other State programs that include + home visitation services, including, if applicable to the State, + other programs carried out under this title with funds made + available from allotments under section 502(c), programs funded + under title IV, title II of the Child Abuse Prevention and + Treatment Act (relating to community-based grants for the + prevention of child abuse and neglect), and section 645A of the + Head Start Act (relating to Early Head Start programs). + ``(10) Other information as required by the Secretary. + + ``(f) Maintenance of Effort.--Funds provided to an eligible entity +receiving a grant under this section shall supplement, and not supplant, +funds from other sources for early childhood home visitation programs or +initiatives. + ``(g) Evaluation.-- + ``(1) Independent, expert advisory + panel. <<NOTE: Establishment.>> --The Secretary, in accordance + with subsection (h)(1)(A), shall appoint an independent advisory + panel consisting of experts in program evaluation and research, + education, and early childhood development-- + ``(A) to review, and make recommendations on, the + design and plan for the evaluation required under + paragraph (2) within 1 year after the date of enactment + of this section; + ``(B) to maintain and advise the Secretary regarding + the progress of the evaluation; and + ``(C) to comment, if the panel so desires, on the + report submitted under paragraph (3). + ``(2) <<NOTE: Grants. Contracts.>> Authority to conduct + evaluation.--On the basis of the recommendations of the advisory + panel under paragraph (1), the Secretary shall, by grant, + contract, or interagency agreement, conduct an evaluation of the + statewide needs assessments submitted under subsection (b) and + the grants made under subsections (c) and (h)(3)(B). The + evaluation shall include-- + ``(A) an analysis, on a State-by-State basis, of the + results of such assessments, including indicators of + maternal and prenatal health and infant health and + mortality, and State actions in response to the + assessments; and + ``(B) an assessment of <<NOTE: Assessment.>> -- + ``(i) the effect of early childhood home + visitation programs on child and parent outcomes, + including with respect to each of the benchmark + areas specified in subsection (d)(1)(A) and the + participant outcomes described in subsection + (d)(2)(B); + ``(ii) the effectiveness of such programs on + different populations, including the extent to + which the ability of programs to improve + participant outcomes varies across programs and + populations; and + ``(iii) the potential for the activities + conducted under such programs, if scaled broadly, + to improve health care practices, eliminate health + disparities, and improve health care system + quality, efficiencies, and reduce costs. + +[[Page 124 STAT. 341]] + + ``(3) Report.--Not later than March 31, 2015, the Secretary + shall submit a report to Congress on the results of the + evaluation conducted under paragraph (2) and shall make the + report publicly available. + + ``(h) Other Provisions.-- + ``(1) Intra-agency collaboration.--The Secretary shall + ensure that the Maternal and Child Health Bureau and the + Administration for Children and Families collaborate with + respect to carrying out this section, including with respect + to-- + ``(A) reviewing and analyzing the statewide needs + assessments required under subsection (b), the awarding + and oversight of grants awarded under this section, the + establishment of the advisory panels required under + subsections (d)(1)(B)(iii)(II) and (g)(1), and the + evaluation and report required under subsection (g); and + ``(B) consulting with other Federal agencies with + responsibility for administering or evaluating programs + that serve eligible families to coordinate and + collaborate with respect to research related to such + programs and families, including the Office of the + Assistant Secretary for Planning and Evaluation of the + Department of Health and Human Services, the Centers for + Disease Control and Prevention, the National Institute + of Child Health and Human Development of the National + Institutes of Health, the Office of Juvenile Justice and + Delinquency Prevention of the Department of Justice, and + the Institute of Education Sciences of the Department of + Education. + ``(2) <<NOTE: Requirements.>> Grants to eligible entities + that are not states.-- + ``(A) Indian tribes, tribal organizations, or urban + indian organizations.--The Secretary shall specify + requirements for eligible entities that are Indian + Tribes (or a consortium of Indian Tribes), Tribal + Organizations, or Urban Indian Organizations to apply + for and conduct an early childhood home visitation + program with a grant under this section. Such + requirements shall, to the greatest extent practicable, + be consistent with the requirements applicable to + eligible entities that are States and shall require an + Indian Tribe (or consortium), Tribal Organization, or + Urban Indian Organization to-- + ``(i) conduct a needs assessment similar to + the assessment required for all States under + subsection (b); and + ``(ii) establish quantifiable, measurable 3- + and 5-year benchmarks consistent with subsection + (d)(1)(A). + ``(B) Nonprofit organizations.--If, as of the + beginning of fiscal year 2012, a State has not applied + or been approved for a grant under this section, the + Secretary may use amounts appropriated under paragraph + (1) of subsection (j) that are available for expenditure + under paragraph (3) of that subsection to make a grant + to an eligible entity that is a nonprofit organization + described in subsection (k)(1)(B) to conduct an early + childhood home visitation program in the State. The + Secretary shall specify the requirements for such an + organization to apply for and conduct the program which + shall, to the greatest extent practicable, be consistent + with the requirements applicable + +[[Page 124 STAT. 342]] + + to eligible entities that are States and shall require + the organization to-- + ``(i) carry out the program based on the needs + assessment conducted by the State under subsection + (b); and + ``(ii) establish quantifiable, measurable 3- + and 5-year benchmarks consistent with subsection + (d)(1)(A). + ``(3) Research and other evaluation activities.-- + ``(A) In general.--The Secretary shall carry out a + continuous program of research and evaluation activities + in order to increase knowledge about the implementation + and effectiveness of home visiting programs, using + random assignment designs to the maximum extent + feasible. The Secretary may carry out such activities + directly, or through grants, cooperative agreements, or + contracts. + ``(B) Requirements.--The Secretary shall ensure + that-- + ``(i) evaluation of a specific program or + project is conducted by persons or individuals not + directly involved in the operation of such program + or project; and + ``(ii) the conduct of research and evaluation + activities includes consultation with independent + researchers, State officials, and developers and + providers of home visiting programs on topics + including research design and administrative data + matching. + ``(4) Report and recommendation.--Not later than December + 31, 2015, the Secretary shall submit a report to Congress + regarding the programs conducted with grants under this section. + The report required under this paragraph shall include-- + ``(A) information regarding the extent to which + eligible entities receiving grants under this section + demonstrated improvements in each of the areas specified + in subsection (d)(1)(A); + ``(B) information regarding any technical assistance + provided under subsection (d)(1)(B)(iii)(I), including + the type of any such assistance provided; and + ``(C) recommendations for such legislative or + administrative action as the Secretary determines + appropriate. + + ``(i) Application of Other Provisions of Title.-- + ``(1) In general.--Except as provided in paragraph (2), the + other provisions of this title shall not apply to a grant made + under this section. + ``(2) Exceptions.--The following provisions of this title + shall apply to a grant made under this section to the same + extent and in the same manner as such provisions apply to + allotments made under section 502(c): + ``(A) Section 504(b)(6) (relating to prohibition on + payments to excluded individuals and entities). + ``(B) Section 504(c) (relating to the use of funds + for the purchase of technical assistance). + ``(C) Section 504(d) (relating to a limitation on + administrative expenditures). + ``(D) Section 506 (relating to reports and audits), + but only to the extent determined by the Secretary to be + appropriate for grants made under this section. + +[[Page 124 STAT. 343]] + + ``(E) Section 507 (relating to penalties for false + statements). + ``(F) Section 508 (relating to nondiscrimination). + ``(G) Section 509(a) (relating to the administration + of the grant program). + + ``(j) Appropriations.-- + ``(1) In general.--Out of any funds in the Treasury not + otherwise appropriated, there are appropriated to the Secretary + to carry out this section-- + ``(A) $100,000,000 for fiscal year 2010; + ``(B) $250,000,000 for fiscal year 2011; + ``(C) $350,000,000 for fiscal year 2012; + ``(D) $400,000,000 for fiscal year 2013; and + ``(E) $400,000,000 for fiscal year 2014. + ``(2) Reservations.--Of the amount appropriated under this + subsection for a fiscal year, the Secretary shall reserve-- + ``(A) 3 percent of such amount for purposes of + making grants to eligible entities that are Indian + Tribes (or a consortium of Indian Tribes), Tribal + Organizations, or Urban Indian Organizations; and + ``(B) 3 percent of such amount for purposes of + carrying out subsections (d)(1)(B)(iii), (g), and + (h)(3). + ``(3) Availability.--Funds made available to an eligible + entity under this section for a fiscal year shall remain + available for expenditure by the eligible entity through the end + of the second succeeding fiscal year after award. Any funds that + are not expended by the eligible entity during the period in + which the funds are available under the preceding sentence may + be used for grants to nonprofit organizations under subsection + (h)(2)(B). + + ``(k) Definitions.--In this section: + ``(1) Eligible entity.-- + ``(A) In general.--The term `eligible entity' means + a State, an Indian Tribe, Tribal Organization, or Urban + Indian Organization, Puerto Rico, Guam, the Virgin + Islands, the Northern Mariana Islands, and American + Samoa. + ``(B) Nonprofit organizations.--Only for purposes of + awarding grants under subsection (h)(2)(B), such term + shall include a nonprofit organization with an + established record of providing early childhood home + visitation programs or initiatives in a State or several + States. + ``(2) Eligible family.--The term `eligible family' means-- + ``(A) a woman who is pregnant, and the father of the + child if the father is available; or + ``(B) a parent or primary caregiver of a child, + including grandparents or other relatives of the child, + and foster parents, who are serving as the child's + primary caregiver from birth to kindergarten entry, and + including a noncustodial parent who has an ongoing + relationship with, and at times provides physical care + for, the child. + ``(3) Indian tribe; tribal organization.--The terms `Indian + Tribe' and `Tribal Organization', and `Urban Indian + Organization' have the meanings given such terms in section 4 of + the Indian Health Care Improvement Act.''. + +[[Page 124 STAT. 344]] + +SEC. 2952. <<NOTE: 42 USC 712 note.>> SUPPORT, EDUCATION, AND RESEARCH + FOR POSTPARTUM DEPRESSION. + + (a) Research on Postpartum Conditions.-- + (1) Expansion and intensification of activities.--The + Secretary of Health and Human Services (in this subsection and + subsection (c) referred to as the ``Secretary'') is encouraged + to continue activities on postpartum depression or postpartum + psychosis (in this subsection and subsection (c) referred to as + ``postpartum conditions''), including research to expand the + understanding of the causes of, and treatments for, postpartum + conditions. Activities under this paragraph shall include + conducting and supporting the following: + (A) Basic research concerning the etiology and + causes of the conditions. + (B) Epidemiological studies to address the frequency + and natural history of the conditions and the + differences among racial and ethnic groups with respect + to the conditions. + (C) The development of improved screening and + diagnostic techniques. + (D) Clinical research for the development and + evaluation of new treatments. + (E) Information and education programs for health + care professionals and the public, which may include a + coordinated national campaign to increase the awareness + and knowledge of postpartum conditions. Activities under + such a national campaign may-- + (i) include public service announcements + through television, radio, and other means; and + (ii) focus on-- + (I) raising awareness about + screening; + (II) educating new mothers and their + families about postpartum conditions to + promote earlier diagnosis and treatment; + and + (III) ensuring that such education + includes complete information concerning + postpartum conditions, including its + symptoms, methods of coping with the + illness, and treatment resources. + (2) Sense of congress regarding longitudinal study of + relative mental health consequences for women of resolving a + pregnancy.-- + (A) Sense of congress.--It is the sense of Congress + that the Director of the National Institute of Mental + Health may conduct a nationally representative + longitudinal study (during the period of fiscal years + 2010 through 2019) of the relative mental health + consequences for women of resolving a pregnancy + (intended and unintended) in various ways, including + carrying the pregnancy to term and parenting the child, + carrying the pregnancy to term and placing the child for + adoption, miscarriage, and having an abortion. This + study may assess the incidence, timing, magnitude, and + duration of the immediate and long-term mental health + consequences (positive or negative) of these pregnancy + outcomes. + (B) Report.--Subject to the completion of the study + under subsection (a), beginning not later than 5 years + after the date of the enactment of this Act, and + periodically + +[[Page 124 STAT. 345]] + + thereafter for the duration of the study, such Director + may prepare and submit to the Congress reports on the + findings of the study. + + (b) Grants To Provide Services to Individuals With a Postpartum +Condition and Their Families.--Title V of the Social Security Act (42 +U.S.C. 701 et seq.), as amended by section 2951, is amended by adding at +the end the following new section: + +``SEC. 512. <<NOTE: 42 USC 712.>> SERVICES TO INDIVIDUALS WITH A + POSTPARTUM CONDITION AND THEIR FAMILIES. + + ``(a) In General.--In addition to any other payments made under this +title to a State, the Secretary may make grants to eligible entities for +projects for the establishment, operation, and coordination of effective +and cost-efficient systems for the delivery of essential services to +individuals with or at risk for postpartum conditions and their +families. + ``(b) Certain Activities.--To the extent practicable and +appropriate, the Secretary shall ensure that projects funded under +subsection (a) provide education and services with respect to the +diagnosis and management of postpartum conditions for individuals with +or at risk for postpartum conditions and their families. The Secretary +may allow such projects to include the following: + ``(1) Delivering or enhancing outpatient and home-based + health and support services, including case management and + comprehensive treatment services. + ``(2) Delivering or enhancing inpatient care management + services that ensure the well-being of the mother and family and + the future development of the infant. + ``(3) Improving the quality, availability, and organization + of health care and support services (including transportation + services, attendant care, homemaker services, day or respite + care, and providing counseling on financial assistance and + insurance). + ``(4) Providing education about postpartum conditions to + promote earlier diagnosis and treatment. Such education may + include-- + ``(A) providing complete information on postpartum + conditions, symptoms, methods of coping with the + illness, and treatment resources; and + ``(B) in the case of a grantee that is a State, + hospital, or birthing facility-- + ``(i) providing education to new mothers and + fathers, and other family members as appropriate, + concerning postpartum conditions before new + mothers leave the health facility; and + ``(ii) ensuring that training programs + regarding such education are carried out at the + health facility. + + ``(c) Integration With Other Programs.--To the extent practicable +and appropriate, the Secretary may integrate the grant program under +this section with other grant programs carried out by the Secretary, +including the program under section 330 of the Public Health Service +Act. + ``(d) Requirements.--The Secretary shall establish requirements for +grants made under this section that include a limit on the amount of +grants funds that may be used for administration, accounting, reporting, +or program oversight functions and a requirement for each eligible +entity that receives a grant to submit, for + +[[Page 124 STAT. 346]] + +each grant period, a report to the Secretary that describes how grant +funds were used during such period. + ``(e) Technical Assistance.--The Secretary may provide technical +assistance to entities seeking a grant under this section in order to +assist such entities in complying with the requirements of this section. + ``(f) Application of Other Provisions of Title.-- + ``(1) In general.--Except as provided in paragraph (2), the + other provisions of this title shall not apply to a grant made + under this section. + ``(2) Exceptions.--The following provisions of this title + shall apply to a grant made under this section to the same + extent and in the same manner as such provisions apply to + allotments made under section 502(c): + ``(A) Section 504(b)(6) (relating to prohibition on + payments to excluded individuals and entities). + ``(B) Section 504(c) (relating to the use of funds + for the purchase of technical assistance). + ``(C) Section 504(d) (relating to a limitation on + administrative expenditures). + ``(D) Section 506 (relating to reports and audits), + but only to the extent determined by the Secretary to be + appropriate for grants made under this section. + ``(E) Section 507 (relating to penalties for false + statements). + ``(F) Section 508 (relating to nondiscrimination). + ``(G) Section 509(a) (relating to the administration + of the grant program). + + ``(g) Definitions.--In this section: + ``(1) The term `eligible entity'-- + ``(A) means a public or nonprofit private entity; + and + ``(B) includes a State or local government, public- + private partnership, recipient of a grant under section + 330H of the Public Health Service Act (relating to the + Healthy Start Initiative), public or nonprofit private + hospital, community-based organization, hospice, + ambulatory care facility, community health center, + migrant health center, public housing primary care + center, or homeless health center. + ``(2) The term `postpartum condition' means postpartum + depression or postpartum psychosis.''. + + (c) General Provisions.-- + (1) Authorization of appropriations.--To carry out this + section and the amendment made by subsection (b), there are + authorized to be appropriated, in addition to such other sums as + may be available for such purpose-- + (A) $3,000,000 for fiscal year 2010; and + (B) such sums as may be necessary for fiscal years + 2011 and 2012. + (2) Report by the secretary.-- + (A) Study.--The Secretary shall conduct a study on + the benefits of screening for postpartum conditions. + (B) Report.--Not later than 2 years after the date + of the enactment of this Act, the Secretary shall + complete the study required by subparagraph (A) and + submit a report to the Congress on the results of such + study. + +[[Page 124 STAT. 347]] + +SEC. 2953. PERSONAL RESPONSIBILITY EDUCATION. + + Title V of the Social Security Act (42 U.S.C. 701 et seq.), as +amended by sections 2951 and 2952(c), is amended by adding at the end +the following: + +``SEC. 513. <<NOTE: 42 USC 713.>> PERSONAL RESPONSIBILITY EDUCATION. + + ``(a) Allotments to States.-- + ``(1) Amount.-- + ``(A) In general.--For the purpose described in + subsection (b), subject to the succeeding provisions of + this section, for each of fiscal years 2010 through + 2014, the Secretary shall allot to each State an amount + equal to the product of-- + ``(i) the amount appropriated under subsection + (f) for the fiscal year and available for + allotments to States after the application of + subsection (c); and + ``(ii) the State youth population percentage + determined under paragraph (2). + ``(B) Minimum allotment.-- + ``(i) In general.--Each State allotment under + this paragraph for a fiscal year shall be at least + $250,000. + ``(ii) Pro rata adjustments.--The Secretary + shall adjust on a pro rata basis the amount of the + State allotments determined under this paragraph + for a fiscal year to the extent necessary to + comply with clause (i). + ``(C) Application required to access allotments.-- + ``(i) In general.--A State shall not be paid + from its allotment for a fiscal year unless the + State submits an application to the Secretary for + the fiscal year and the Secretary approves the + application (or requires changes to the + application that the State satisfies) and meets + such additional requirements as the Secretary may + specify. + ``(ii) Requirements.--The State application + shall contain an assurance that the State has + complied with the requirements of this section in + preparing and submitting the application and shall + include the following as well as such additional + information as the Secretary may require: + ``(I) Based on data from the Centers + for Disease Control and Prevention + National Center for Health Statistics, + the most recent pregnancy rates for the + State for youth ages 10 to 14 and youth + ages 15 to 19 for which data are + available, the most recent birth rates + for such youth populations in the State + for which data are available, and trends + in those rates for the most recently + preceding 5-year period for which such + data are available. + ``(II) State-established goals for + reducing the pregnancy rates and birth + rates for such youth populations. + ``(III) A description of the State's + plan for using the State allotments + provided under this section to achieve + such goals, especially among youth + +[[Page 124 STAT. 348]] + + populations that are the most high-risk + or vulnerable for pregnancies or + otherwise have special circumstances, + including youth in foster care, homeless + youth, youth with HIV/AIDS, pregnant + youth who are under 21 years of age, + mothers who are under 21 years of age, + and youth residing in areas with high + birth rates for youth. + ``(2) State youth population percentage.-- + ``(A) In general.--For purposes of paragraph + (1)(A)(ii), the State youth population percentage is, + with respect to a State, the proportion (expressed as a + percentage) of-- + ``(i) the number of individuals who have + attained age 10 but not attained age 20 in the + State; to + ``(ii) the number of such individuals in all + States. + ``(B) Determination of number of youth.--The number + of individuals described in clauses (i) and (ii) of + subparagraph (A) in a State shall be determined on the + basis of the most recent Bureau of the Census data. + ``(3) Availability of state allotments.--Subject to + paragraph (4)(A), amounts allotted to a State pursuant to this + subsection for a fiscal year shall remain available for + expenditure by the State through the end of the second + succeeding fiscal year. + ``(4) Authority to award grants from state allotments to + local organizations and entities in nonparticipating states.-- + ``(A) Grants from unexpended allotments.--If a State + does not submit an application under this section for + fiscal year 2010 or 2011, the State shall no longer be + eligible to submit an application to receive funds from + the amounts allotted for the State for each of fiscal + years 2010 through 2014 and such amounts shall be used + by the Secretary to award grants under this paragraph + for each of fiscal years 2012 through 2014. The + Secretary also shall use any amounts from the allotments + of States that submit applications under this section + for a fiscal year that remain unexpended as of the end + of the period in which the allotments are available for + expenditure under paragraph (3) for awarding grants + under this paragraph. + ``(B) 3-year grants.-- + ``(i) In general.--The Secretary shall solicit + applications to award 3-year grants in each of + fiscal years 2012, 2013, and 2014 to local + organizations and entities to conduct, consistent + with subsection (b), programs and activities in + States that do not submit an application for an + allotment under this section for fiscal year 2010 + or 2011. + ``(ii) Faith-based organizations or + consortia.--The Secretary may solicit and award + grants under this paragraph to faith-based + organizations or consortia. + ``(C) Evaluation.--An organization or entity awarded + a grant under this paragraph shall agree to participate + in a rigorous Federal evaluation. + ``(5) Maintenance of effort.--No payment shall be made to a + State from the allotment determined for the State under this + subsection or to a local organization or entity awarded + +[[Page 124 STAT. 349]] + + a grant under paragraph (4), if the expenditure of non-federal + funds by the State, organization, or entity for activities, + programs, or initiatives for which amounts from allotments and + grants under this subsection may be expended is less than the + amount expended by the State, organization, or entity for such + programs or initiatives for fiscal year 2009. + ``(6) Data collection and reporting.--A State or local + organization or entity receiving funds under this section shall + cooperate with such requirements relating to the collection of + data and information and reporting on outcomes regarding the + programs and activities carried out with such funds, as the + Secretary shall specify. + + ``(b) Purpose.-- + ``(1) In general.--The purpose of an allotment under + subsection (a)(1) to a State is to enable the State (or, in the + case of grants made under subsection (a)(4)(B), to enable a + local organization or entity) to carry out personal + responsibility education programs consistent with this + subsection. + ``(2) Personal responsibility education programs.-- + ``(A) <<NOTE: Definition.>> In general.--In this + section, the term `personal responsibility education + program' means a program that is designed to educate + adolescents on-- + ``(i) both abstinence and contraception for + the prevention of pregnancy and sexually + transmitted infections, including HIV/AIDS, + consistent with the requirements of subparagraph + (B); and + ``(ii) at least 3 of the adulthood preparation + subjects described in subparagraph (C). + ``(B) Requirements.--The requirements of this + subparagraph are the following: + ``(i) The program replicates evidence-based + effective programs or substantially incorporates + elements of effective programs that have been + proven on the basis of rigorous scientific + research to change behavior, which means delaying + sexual activity, increasing condom or + contraceptive use for sexually active youth, or + reducing pregnancy among youth. + ``(ii) The program is medically-accurate and + complete. + ``(iii) The program includes activities to + educate youth who are sexually active regarding + responsible sexual behavior with respect to both + abstinence and the use of contraception. + ``(iv) The program places substantial emphasis + on both abstinence and contraception for the + prevention of pregnancy among youth and sexually + transmitted infections. + ``(v) The program provides age-appropriate + information and activities. + ``(vi) The information and activities carried + out under the program are provided in the cultural + context that is most appropriate for individuals + in the particular population group to which they + are directed. + ``(C) Adulthood preparation subjects.--The adulthood + preparation subjects described in this subparagraph are + the following: + +[[Page 124 STAT. 350]] + + ``(i) Healthy relationships, such as positive + self-esteem and relationship dynamics, + friendships, dating, romantic involvement, + marriage, and family interactions. + ``(ii) Adolescent development, such as the + development of healthy attitudes and values about + adolescent growth and development, body image, + racial and ethnic diversity, and other related + subjects. + ``(iii) Financial literacy. + ``(iv) Parent-child communication. + ``(v) Educational and career success, such as + developing skills for employment preparation, job + seeking, independent living, financial self- + sufficiency, and workplace productivity. + ``(vi) Healthy life skills, such as goal- + setting, decision making, negotiation, + communication and interpersonal skills, and stress + management. + + ``(c) Reservations of Funds.-- + ``(1) Grants to implement innovative strategies.--From the + amount appropriated under subsection (f) for the fiscal year, + the Secretary shall reserve $10,000,000 of such amount for + purposes of awarding grants to entities to implement innovative + youth pregnancy prevention strategies and target services to + high-risk, vulnerable, and culturally under-represented youth + populations, including youth in foster care, homeless youth, + youth with HIV/AIDS, pregnant women who are under 21 years of + age and their partners, mothers who are under 21 years of age + and their partners, and youth residing in areas with high birth + rates for youth. An entity awarded a grant under this paragraph + shall agree to participate in a rigorous Federal evaluation of + the activities carried out with grant funds. + ``(2) Other reservations.--From the amount appropriated + under subsection (f) for the fiscal year that remains after the + application of paragraph (1), the Secretary shall reserve the + following amounts: + ``(A) Grants for indian tribes or tribal + organizations.--The Secretary shall reserve 5 percent of + such remainder for purposes of awarding grants to Indian + tribes and tribal organizations in such manner, and + subject to such requirements, as the Secretary, in + consultation with Indian tribes and tribal + organizations, determines appropriate. + ``(B) Secretarial responsibilities.-- + ``(i) Reservation of funds.--The Secretary + shall reserve 10 percent of such remainder for + expenditures by the Secretary for the activities + described in clauses (ii) and (iii). + ``(ii) Program support.--The Secretary shall + provide, directly or through a competitive grant + process, research, training and technical + assistance, including dissemination of research + and information regarding effective and promising + practices, providing consultation and resources on + a broad array of teen pregnancy prevention + strategies, including abstinence and + contraception, and developing resources and + materials to support the activities of recipients + of grants and other State, tribal, and community + organizations working + +[[Page 124 STAT. 351]] + + to reduce teen pregnancy. In carrying out such + functions, the Secretary shall collaborate with a + variety of entities that have expertise in the + prevention of teen pregnancy, HIV and sexually + transmitted infections, healthy relationships, + financial literacy, and other topics addressed + through the personal responsibility education + programs. + ``(iii) Evaluation.--The Secretary shall + evaluate the programs and activities carried out + with funds made available through allotments or + grants under this section. + + ``(d) Administration.-- + ``(1) In general.--The Secretary shall administer this + section through the Assistant Secretary for the Administration + for Children and Families within the Department of Health and + Human Services. + ``(2) Application of other provisions of title.-- + ``(A) In general.--Except as provided in + subparagraph (B), the other provisions of this title + shall not apply to allotments or grants made under this + section. + ``(B) Exceptions.--The following provisions of this + title shall apply to allotments and grants made under + this section to the same extent and in the same manner + as such provisions apply to allotments made under + section 502(c): + ``(i) Section 504(b)(6) (relating to + prohibition on payments to excluded individuals + and entities). + ``(ii) Section 504(c) (relating to the use of + funds for the purchase of technical assistance). + ``(iii) Section 504(d) (relating to a + limitation on administrative expenditures). + ``(iv) Section 506 (relating to reports and + audits), but only to the extent determined by the + Secretary to be appropriate for grants made under + this section. + ``(v) Section 507 (relating to penalties for + false statements). + ``(vi) Section 508 (relating to + nondiscrimination). + + ``(e) Definitions.--In this section: + ``(1) Age-appropriate.--The term `age-appropriate', with + respect to the information in pregnancy prevention, means + topics, messages, and teaching methods suitable to particular + ages or age groups of children and adolescents, based on + developing cognitive, emotional, and behavioral capacity typical + for the age or age group. + ``(2) Medically accurate and complete.--The term `medically + accurate and complete' means verified or supported by the weight + of research conducted in compliance with accepted scientific + methods and-- + ``(A) published in peer-reviewed journals, where + applicable; or + ``(B) comprising information that leading + professional organizations and agencies with relevant + expertise in the field recognize as accurate, objective, + and complete. + ``(3) Indian tribes; tribal organizations.--The terms + `Indian tribe' and `Tribal organization' have the meanings given + such terms in section 4 of the Indian Health Care Improvement + Act (25 U.S.C. 1603)). + +[[Page 124 STAT. 352]] + + ``(4) Youth.--The term `youth' means an individual who has + attained age 10 but has not attained age 20. + + ``(f) Appropriation.--For the purpose of carrying out this section, +there is appropriated, out of any money in the Treasury not otherwise +appropriated, $75,000,000 for each of fiscal years 2010 through 2014. +Amounts appropriated under this subsection shall remain available until +expended.''. + +SEC. 2954. RESTORATION OF FUNDING FOR ABSTINENCE EDUCATION. + + Section 510 of the Social Security Act (42 U.S.C. 710) is amended-- + (1) in subsection (a), by striking ``fiscal year 1998 and + each subsequent fiscal year'' and inserting ``each of fiscal + years 2010 through 2014''; and + (2) in subsection (d)-- + (A) in the first sentence, by striking ``1998 + through 2003'' and inserting ``2010 through 2014''; and + (B) in the second sentence, by inserting ``(except + that such appropriation shall be made on the date of + enactment of the Patient Protection and Affordable Care + Act in the case of fiscal year 2010)'' before the + period. + +SEC. 2955. INCLUSION OF INFORMATION ABOUT THE IMPORTANCE OF HAVING A + HEALTH CARE POWER OF ATTORNEY IN TRANSITION PLANNING FOR + CHILDREN AGING OUT OF FOSTER CARE AND INDEPENDENT LIVING + PROGRAMS. + + (a) Transition Planning.--Section 475(5)(H) of the Social Security +Act (42 U.S.C. 675(5)(H)) is amended by inserting ``includes information +about the importance of designating another individual to make health +care treatment decisions on behalf of the child if the child becomes +unable to participate in such decisions and the child does not have, or +does not want, a relative who would otherwise be authorized under State +law to make such decisions, and provides the child with the option to +execute a health care power of attorney, health care proxy, or other +similar document recognized under State law,'' after ``employment +services,''. + (b) Independent Living Education.--Section 477(b)(3) of such Act (42 +U.S.C. 677(b)(3)) is amended by adding at the end the following: + ``(K) <<NOTE: Certification.>> A certification by + the chief executive officer of the State that the State + will ensure that an adolescent participating in the + program under this section are provided with education + about the importance of designating another individual + to make health care treatment decisions on behalf of the + adolescent if the adolescent becomes unable to + participate in such decisions and the adolescent does + not have, or does not want, a relative who would + otherwise be authorized under State law to make such + decisions, whether a health care power of attorney, + health care proxy, or other similar document is + recognized under State law, and how to execute such a + document if the adolescent wants to do so.''. + + (c) Health Oversight and Coordination Plan.--Section 422(b)(15)(A) +of such Act (42 U.S.C. 622(b)(15)(A)) is amended-- + (1) in clause (v), by striking ``and'' at the end; and + (2) by adding at the end the following: + ``(vii) steps to ensure that the components of + the transition plan development process required + under + +[[Page 124 STAT. 353]] + + section 475(5)(H) that relate to the health care + needs of children aging out of foster care, + including the requirements to include options for + health insurance, information about a health care + power of attorney, health care proxy, or other + similar document recognized under State law, and + to provide the child with the option to execute + such a document, are met; and''. + + (d) <<NOTE: 42 USC 622 note.>> Effective Date.--The amendments made +by this section take effect on October 1, 2010. + + TITLE III--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE + + Subtitle A--Transforming the Health Care Delivery System + + PART I--LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE MEDICARE PROGRAM + +SEC. 3001. HOSPITAL VALUE-BASED PURCHASING PROGRAM. + + (a) Program.-- + (1) In general.--Section 1886 of the Social Security Act (42 + U.S.C. 1395ww), as amended by section 4102(a) of the HITECH Act + (Public Law 111-5), is amended by adding at the end the + following new subsection: + + ``(o) Hospital Value-Based Purchasing Program.-- + ``(1) Establishment.-- + ``(A) In general.--Subject to the succeeding + provisions of this subsection, the Secretary shall + establish a hospital value-based purchasing program (in + this subsection referred to as the `Program') under + which value-based incentive payments are made in a + fiscal year to hospitals that meet the performance + standards under paragraph (3) for the performance period + for such fiscal year (as established under paragraph + (4)). + ``(B) Program to begin in fiscal year 2013.--The + Program shall apply to payments for discharges occurring + on or after October 1, 2012. + ``(C) Applicability of program to hospitals.-- + ``(i) In general.--For purposes of this + subsection, subject to clause (ii), the term + `hospital' means a subsection (d) hospital (as + defined in subsection (d)(1)(B)). + ``(ii) Exclusions.--The term `hospital' shall + not include, with respect to a fiscal year, a + hospital-- + ``(I) that is subject to the payment + reduction under subsection + (b)(3)(B)(viii)(I) for such fiscal year; + ``(II) for which, during the + performance period for such fiscal year, + the Secretary has cited deficiencies + that pose immediate jeopardy to the + health or safety of patients; + +[[Page 124 STAT. 354]] + + ``(III) for which there are not a + minimum number (as determined by the + Secretary) of measures that apply to the + hospital for the performance period for + such fiscal year; or + ``(IV) for which there are not a + minimum number (as determined by the + Secretary) of cases for the measures + that apply to the hospital for the + performance period for such fiscal year. + ``(iii) Independent analysis.--For purposes of + determining the minimum numbers under subclauses + (III) and (IV) of clause (ii), the Secretary shall + have conducted an independent analysis of what + numbers are appropriate. + ``(iv) Exemption.--In the case of a hospital + that is paid under section 1814(b)(3), the + Secretary may exempt such hospital from the + application of this subsection if the State which + is paid under such section submits an annual + report to the Secretary describing how a similar + program in the State for a participating hospital + or hospitals achieves or surpasses the measured + results in terms of patient health outcomes and + cost savings established under this subsection. + ``(2) Measures.-- + ``(A) In general.--The Secretary shall select + measures for purposes of the Program. Such measures + shall be selected from the measures specified under + subsection (b)(3)(B)(viii). + ``(B) Requirements.-- + ``(i) For fiscal year 2013.--For value-based + incentive payments made with respect to discharges + occurring during fiscal year 2013, the Secretary + shall ensure the following: + ``(I) Conditions or procedures.-- + Measures are selected under subparagraph + (A) that cover at least the following 5 + specific conditions or procedures: + ``(aa) Acute myocardial + infarction (AMI). + ``(bb) Heart failure. + ``(cc) Pneumonia. + ``(dd) Surgeries, as + measured by the Surgical Care + Improvement Project (formerly + referred to as `Surgical + Infection Prevention' for + discharges occurring before July + 2006). + ``(ee) Healthcare-associated + infections, as measured by the + prevention metrics and targets + established in the HHS Action + Plan to Prevent Healthcare- + Associated Infections (or any + successor plan) of the + Department of Health and Human + Services. + ``(II) HCAHPS.--Measures selected + under subparagraph (A) shall be related + to the Hospital Consumer Assessment of + Healthcare Providers and Systems survey + (HCAHPS). + ``(ii) Inclusion of efficiency measures.--For + value-based incentive payments made with respect + to + +[[Page 124 STAT. 355]] + + discharges occurring during fiscal year 2014 or a + subsequent fiscal year, the Secretary shall ensure + that measures selected under subparagraph (A) + include efficiency measures, including measures of + `Medicare spending per beneficiary'. Such measures + shall be adjusted for factors such as age, sex, + race, severity of illness, and other factors that + the Secretary determines appropriate. + ``(C) Limitations.-- + ``(i) Time requirement for prior reporting and + notice.--The Secretary may not select a measure + under subparagraph (A) for use under the Program + with respect to a performance period for a fiscal + year (as established under paragraph (4)) unless + such measure has been specified under subsection + (b)(3)(B)(viii) and included on the Hospital + Compare Internet website for at least 1 year prior + to the beginning of such performance period. + ``(ii) Measure not applicable unless hospital + furnishes services appropriate to the measure.--A + measure selected under subparagraph (A) shall not + apply to a hospital if such hospital does not + furnish services appropriate to such measure. + ``(D) Replacing measures.--Subclause (VI) of + subsection (b)(3)(B)(viii) shall apply to measures + selected under subparagraph (A) in the same manner as + such subclause applies to measures selected under such + subsection. + ``(3) Performance standards.-- + ``(A) Establishment.--The Secretary shall establish + performance standards with respect to measures selected + under paragraph (2) for a performance period for a + fiscal year (as established under paragraph (4)). + ``(B) Achievement and improvement.--The performance + standards established under subparagraph (A) shall + include levels of achievement and improvement. + ``(C) Timing.--The Secretary shall establish and + announce the performance standards under subparagraph + (A) not later than 60 days prior to the beginning of the + performance period for the fiscal year involved. + ``(D) Considerations in establishing standards.--In + establishing performance standards with respect to + measures under this paragraph, the Secretary shall take + into account appropriate factors, such as-- + ``(i) practical experience with the measures + involved, including whether a significant + proportion of hospitals failed to meet the + performance standard during previous performance + periods; + ``(ii) historical performance standards; + ``(iii) improvement rates; and + ``(iv) the opportunity for continued + improvement. + ``(4) Performance period.--For purposes of the Program, the + Secretary shall establish the performance period for a fiscal + year. Such performance period shall begin and end prior to the + beginning of such fiscal year. + ``(5) Hospital performance score.-- + ``(A) In general.--Subject to subparagraph (B), the + Secretary shall develop a methodology for assessing the + +[[Page 124 STAT. 356]] + + total performance of each hospital based on performance + standards with respect to the measures selected under + paragraph (2) for a performance period (as established + under paragraph (4)). Using such methodology, the + Secretary shall provide for an assessment (in this + subsection referred to as the `hospital performance + score') for each hospital for each performance period. + ``(B) Application.-- + ``(i) Appropriate distribution.--The Secretary + shall ensure that the application of the + methodology developed under subparagraph (A) + results in an appropriate distribution of value- + based incentive payments under paragraph (6) among + hospitals achieving different levels of hospital + performance scores, with hospitals achieving the + highest hospital performance scores receiving the + largest value-based incentive payments. + ``(ii) Higher of achievement or improvement.-- + The methodology developed under subparagraph (A) + shall provide that the hospital performance score + is determined using the higher of its achievement + or improvement score for each measure. + ``(iii) Weights.--The methodology developed + under subparagraph (A) shall provide for the + assignment of weights for categories of measures + as the Secretary determines appropriate. + ``(iv) No minimum performance standard.--The + Secretary shall not set a minimum performance + standard in determining the hospital performance + score for any hospital. + ``(v) Reflection of measures applicable to the + hospital.--The hospital performance score for a + hospital shall reflect the measures that apply to + the hospital. + ``(6) Calculation of value-based incentive payments.-- + ``(A) <<NOTE: Determination.>> In general.--In the + case of a hospital that the Secretary determines meets + (or exceeds) the performance standards under paragraph + (3) for the performance period for a fiscal year (as + established under paragraph (4)), the Secretary shall + increase the base operating DRG payment amount (as + defined in paragraph (7)(D)), as determined after + application of paragraph (7)(B)(i), for a hospital for + each discharge occurring in such fiscal year by the + value-based incentive payment amount. + ``(B) Value-based incentive payment amount.--The + value-based incentive payment amount for each discharge + of a hospital in a fiscal year shall be equal to the + product of-- + ``(i) the base operating DRG payment amount + (as defined in paragraph (7)(D)) for the discharge + for the hospital for such fiscal year; and + ``(ii) the value-based incentive payment + percentage specified under subparagraph (C) for + the hospital for such fiscal year. + ``(C) Value-based incentive payment percentage.-- + +[[Page 124 STAT. 357]] + + ``(i) In general.--The Secretary shall specify + a value-based incentive payment percentage for a + hospital for a fiscal year. + ``(ii) Requirements.--In specifying the value- + based incentive payment percentage for each + hospital for a fiscal year under clause (i), the + Secretary shall ensure that-- + ``(I) such percentage is based on + the hospital performance score of the + hospital under paragraph (5); and + ``(II) the total amount of value- + based incentive payments under this + paragraph to all hospitals in such + fiscal year is equal to the total amount + available for value-based incentive + payments for such fiscal year under + paragraph (7)(A), as estimated by the + Secretary. + ``(7) Funding for value-based incentive payments.-- + ``(A) Amount.--The total amount available for value- + based incentive payments under paragraph (6) for all + hospitals for a fiscal year shall be equal to the total + amount of reduced payments for all hospitals under + subparagraph (B) for such fiscal year, as estimated by + the Secretary. + ``(B) Adjustment to payments.-- + ``(i) In general.--The Secretary shall reduce + the base operating DRG payment amount (as defined + in subparagraph (D)) for a hospital for each + discharge in a fiscal year (beginning with fiscal + year 2013) by an amount equal to the applicable + percent (as defined in subparagraph (C)) of the + base operating DRG payment amount for the + discharge for the hospital for such fiscal year. + The Secretary shall make such reductions for all + hospitals in the fiscal year involved, regardless + of whether or not the hospital has been determined + by the Secretary to have earned a value-based + incentive payment under paragraph (6) for such + fiscal year. + ``(ii) No effect on other payments.--Payments + described in items (aa) and (bb) of subparagraph + (D)(i)(II) for a hospital shall be determined as + if this subsection had not been enacted. + ``(C) Applicable percent defined.--For purposes of + subparagraph (B), the term `applicable percent' means-- + ``(i) with respect to fiscal year 2013, 1.0 + percent; + ``(ii) with respect to fiscal year 2014, 1.25 + percent; + ``(iii) with respect to fiscal year 2015, 1.5 + percent; + ``(iv) with respect to fiscal year 2016, 1.75 + percent; and + ``(v) with respect to fiscal year 2017 and + succeeding fiscal years, 2 percent. + ``(D) Base operating drg payment amount defined.-- + ``(i) In general.--Except as provided in + clause (ii), in this subsection, the term `base + operating DRG payment amount' means, with respect + to a hospital for a fiscal year-- + ``(I) the payment amount that would + otherwise be made under subsection (d) + (determined without + +[[Page 124 STAT. 358]] + + regard to subsection (q)) for a + discharge if this subsection did not + apply; reduced by + ``(II) any portion of such payment + amount that is attributable to-- + ``(aa) payments under + paragraphs (5)(A), (5)(B), + (5)(F), and (12) of subsection + (d); and + ``(bb) such other payments + under subsection (d) determined + appropriate by the Secretary. + ``(ii) Special rules for certain hospitals.-- + ``(I) Sole community hospitals and + medicare-dependent, small rural + hospitals.--In the case of a medicare- + dependent, small rural hospital (with + respect to discharges occurring during + fiscal year 2012 and 2013) or a sole + community hospital, in applying + subparagraph (A)(i), the payment amount + that would otherwise be made under + subsection (d) shall be determined + without regard to subparagraphs (I) and + (L) of subsection (b)(3) and + subparagraphs (D) and (G) of subsection + (d)(5). + ``(II) Hospitals paid under section + 1814.--In the case of a hospital that is + paid under section 1814(b)(3), the term + `base operating DRG payment amount' + means the payment amount under such + section. + ``(8) Announcement of net result of + adjustments. <<NOTE: Deadline.>> --Under the Program, the + Secretary shall, not later than 60 days prior to the fiscal year + involved, inform each hospital of the adjustments to payments to + the hospital for discharges occurring in such fiscal year under + paragraphs (6) and (7)(B)(i). + ``(9) No effect in subsequent fiscal years.--The value-based + incentive payment under paragraph (6) and the payment reduction + under paragraph (7)(B)(i) shall each apply only with respect to + the fiscal year involved, and the Secretary shall not take into + account such value-based incentive payment or payment reduction + in making payments to a hospital under this section in a + subsequent fiscal year. + ``(10) Public reporting.-- + ``(A) Hospital specific information.-- + ``(i) In general.--The Secretary shall make + information available to the public regarding the + performance of individual hospitals under the + Program, including-- + ``(I) the performance of the + hospital with respect to each measure + that applies to the hospital; + ``(II) the performance of the + hospital with respect to each condition + or procedure; and + ``(III) the hospital performance + score assessing the total performance of + the hospital. + ``(ii) Opportunity to review and submit + corrections.--The Secretary shall ensure that a + hospital has the opportunity to review, and submit + corrections for, the information to be made public + with respect to the hospital under clause (i) + prior to such information being made public. + +[[Page 124 STAT. 359]] + + ``(iii) Website.--Such information shall be + posted on the Hospital Compare Internet website in + an easily understandable format. + ``(B) Aggregate information.-- <<NOTE: Web + posting.>> The Secretary shall periodically post on the + Hospital Compare Internet website aggregate information + on the Program, including-- + ``(i) the number of hospitals receiving value- + based incentive payments under paragraph (6) and + the range and total amount of such value-based + incentive payments; and + ``(ii) the number of hospitals receiving less + than the maximum value-based incentive payment + available to the hospital for the fiscal year + involved and the range and amount of such + payments. + ``(11) Implementation.-- + ``(A) Appeals.--The Secretary shall establish a + process by which hospitals may appeal the calculation of + a hospital's performance assessment with respect to the + performance standards established under paragraph (3)(A) + and the hospital performance score under paragraph (5). + The Secretary shall ensure that such process provides + for resolution of such appeals in a timely manner. + ``(B) Limitation on review.--Except as provided in + subparagraph (A), there shall be no administrative or + judicial review under section 1869, section 1878, or + otherwise of the following: + ``(i) The methodology used to determine the + amount of the value-based incentive payment under + paragraph (6) and the determination of such + amount. + ``(ii) The determination of the amount of + funding available for such value-based incentive + payments under paragraph (7)(A) and the payment + reduction under paragraph (7)(B)(i). + ``(iii) The establishment of the performance + standards under paragraph (3) and the performance + period under paragraph (4). + ``(iv) The measures specified under subsection + (b)(3)(B)(viii) and the measures selected under + paragraph (2). + ``(v) The methodology developed under + paragraph (5) that is used to calculate hospital + performance scores and the calculation of such + scores. + ``(vi) The validation methodology specified in + subsection (b)(3)(B)(viii)(XI). + ``(C) Consultation with small hospitals.--The + Secretary shall consult with small rural and urban + hospitals on the application of the Program to such + hospitals. + ``(12) Promulgation of regulations.--The Secretary shall + promulgate regulations to carry out the Program, including the + selection of measures under paragraph (2), the methodology + developed under paragraph (5) that is used to calculate hospital + performance scores, and the methodology used to determine the + amount of value-based incentive payments under paragraph (6).''. + (2) Amendments for reporting of hospital quality + information.--Section 1886(b)(3)(B)(viii) of the Social Security + Act (42 U.S.C. 1395ww(b)(3)(B)(viii)) is amended-- + +[[Page 124 STAT. 360]] + + (A) in subclause (II), by adding at the end the + following sentence: ``The Secretary may require + hospitals to submit data on measures that are not used + for the determination of value-based incentive payments + under subsection (o).''; + (B) in subclause (V), by striking ``beginning with + fiscal year 2008'' and inserting ``for fiscal years 2008 + through 2012''; + (C) in subclause (VII), in the first sentence, by + striking ``data submitted'' and inserting ``information + regarding measures submitted''; and + (D) by adding at the end the following new + subclauses: + + ``(VIII) <<NOTE: Effective date.>> Effective for payments beginning +with fiscal year 2013, with respect to quality measures for outcomes of +care, the Secretary shall provide for such risk adjustment as the +Secretary determines to be appropriate to maintain incentives for +hospitals to treat patients with severe illnesses or conditions. + + ``(IX)(aa) Subject to item (bb), effective for payments beginning +with fiscal year 2013, each measure specified by the Secretary under +this clause shall be endorsed by the entity with a contract under +section 1890(a). + ``(bb) In the case of a specified area or medical topic determined +appropriate by the Secretary for which a feasible and practical measure +has not been endorsed by the entity with a contract under section +1890(a), the Secretary may specify a measure that is not so endorsed as +long as due consideration is given to measures that have been endorsed +or adopted by a consensus organization identified by the Secretary. + ``(X) To the extent practicable, the Secretary shall, with input +from consensus organizations and other stakeholders, take steps to +ensure that the measures specified by the Secretary under this clause +are coordinated and aligned with quality measures applicable to-- + ``(aa) physicians under section 1848(k); and + ``(bb) other providers of services and suppliers under this + title. + + ``(XI) <<NOTE: Validation process.>> The Secretary shall establish a +process to validate measures specified under this clause as appropriate. +Such process shall include the auditing of a number of randomly selected +hospitals sufficient to ensure validity of the reporting program under +this clause as a whole and shall provide a hospital with an opportunity +to appeal the validation of measures reported by such hospital.''. + (3) Website improvements.--Section 1886(b)(3)(B) of the + Social Security Act (42 U.S.C. 1395ww(b)(3)(B)), as amended by + section 4102(b) of the HITECH Act (Public Law 111-5), is amended + by adding at the end the following new clause: + + ``(x)(I) <<NOTE: Web posting. Reports.>> The Secretary shall develop +standard Internet website reports tailored to meet the needs of various +stakeholders such as hospitals, patients, researchers, and policymakers. +The Secretary shall seek input from such stakeholders in determining the +type of information that is useful and the formats that best facilitate +the use of the information. + + ``(II) The Secretary shall modify the Hospital Compare Internet +website to make the use and navigation of that website readily available +to individuals accessing it.''. + (4) GAO study and report.-- + (A) Study.--The Comptroller General of the United + States shall conduct a study on the performance of the + +[[Page 124 STAT. 361]] + + hospital value-based purchasing program established + under section 1886(o) of the Social Security Act, as + added by paragraph (1). Such study shall include an + analysis of the impact of such program on-- + (i) the quality of care furnished to Medicare + beneficiaries, including diverse Medicare + beneficiary populations (such as diverse in terms + of race, ethnicity, and socioeconomic status); + (ii) expenditures under the Medicare program, + including any reduced expenditures under Part A of + title XVIII of such Act that are attributable to + the improvement in the delivery of inpatient + hospital services by reason of such hospital + value-based purchasing program; + (iii) the quality performance among safety net + hospitals and any barriers such hospitals face in + meeting the performance standards applicable under + such hospital value-based purchasing program; and + (iv) the quality performance among small rural + and small urban hospitals and any barriers such + hospitals face in meeting the performance + standards applicable under such hospital value- + based purchasing program. + (B) Reports.-- + (i) Interim report.--Not later than October 1, + 2015, the Comptroller General of the United States + shall submit to Congress an interim report + containing the results of the study conducted + under subparagraph (A), together with + recommendations for such legislation and + administrative action as the Comptroller General + determines appropriate. + (ii) Final report.--Not later than July 1, + 2017, the Comptroller General of the United States + shall submit to Congress a report containing the + results of the study conducted under subparagraph + (A), together with recommendations for such + legislation and administrative action as the + Comptroller General determines appropriate. + (5) HHS study and report.-- + (A) Study.--The Secretary of Health and Human + Services shall conduct a study on the performance of the + hospital value-based purchasing program established + under section 1886(o) of the Social Security Act, as + added by paragraph (1). Such study shall include an + analysis-- + (i) of ways to improve the hospital value- + based purchasing program and ways to address any + unintended consequences that may occur as a result + of such program; + (ii) of whether the hospital value-based + purchasing program resulted in lower spending + under the Medicare program under title XVIII of + such Act or other financial savings to hospitals; + (iii) the appropriateness of the Medicare + program sharing in any savings generated through + the hospital value-based purchasing program; and + (iv) any other area determined appropriate by + the Secretary. + +[[Page 124 STAT. 362]] + + (B) Report.--Not later than January 1, 2016, the + Secretary of Health and Human Services shall submit to + Congress a report containing the results of the study + conducted under subparagraph (A), together with + recommendations for such legislation and administrative + action as the Secretary determines appropriate. + + (b) <<NOTE: 42 USC 1395ww note.>> Value-Based Purchasing +Demonstration Programs.-- + (1) Value-based purchasing demonstration program for + inpatient critical access hospitals.-- + (A) Establishment.-- + (i) In general.-- <<NOTE: Deadline.>> Not + later than 2 years after the date of enactment of + this Act, the Secretary of Health and Human + Services (in this subsection referred to as the + ``Secretary'') shall establish a demonstration + program under which the Secretary establishes a + value-based purchasing program under the Medicare + program under title XVIII of the Social Security + Act for critical access hospitals (as defined in + paragraph (1) of section 1861(mm) of such Act (42 + U.S.C. 1395x(mm))) with respect to inpatient + critical access hospital services (as defined in + paragraph (2) of such section) in order to test + innovative methods of measuring and rewarding + quality and efficient health care furnished by + such hospitals. + (ii) Duration.--The demonstration program + under this paragraph shall be conducted for a 3- + year period. + (iii) Sites.--The Secretary shall conduct the + demonstration program under this paragraph at an + appropriate number (as determined by the + Secretary) of critical access hospitals. The + Secretary shall ensure that such hospitals are + representative of the spectrum of such hospitals + that participate in the Medicare program. + (B) Waiver authority.--The Secretary may waive such + requirements of titles XI and XVIII of the Social + Security Act as may be necessary to carry out the + demonstration program under this paragraph. + (C) Budget neutrality requirement.--In conducting + the demonstration program under this section, the + Secretary shall ensure that the aggregate payments made + by the Secretary do not exceed the amount which the + Secretary would have paid if the demonstration program + under this section was not implemented. + (D) Report.--Not later than 18 months after the + completion of the demonstration program under this + paragraph, the Secretary shall submit to Congress a + report on the demonstration program together with-- + (i) recommendations on the establishment of a + permanent value-based purchasing program under the + Medicare program for critical access hospitals + with respect to inpatient critical access hospital + services; and + (ii) recommendations for such other + legislation and administrative action as the + Secretary determines appropriate. + +[[Page 124 STAT. 363]] + + (2) Value-based purchasing demonstration program for + hospitals excluded from hospital value-based purchasing program + as a result of insufficient numbers of measures and cases.-- + (A) Establishment.-- + (i) In general.-- <<NOTE: Deadline.>> Not + later than 2 years after the date of enactment of + this Act, the Secretary shall establish a + demonstration program under which the Secretary + establishes a value-based purchasing program under + the Medicare program under title XVIII of the + Social Security Act for applicable hospitals (as + defined in clause (ii)) with respect to inpatient + hospital services (as defined in section 1861(b) + of the Social Security Act (42 U.S.C. 1395x(b))) + in order to test innovative methods of measuring + and rewarding quality and efficient health care + furnished by such hospitals. + (ii) Applicable hospital defined.--For + purposes of this paragraph, the term ``applicable + hospital'' means a hospital described in subclause + (III) or (IV) of section 1886(o)(1)(C)(ii) of the + Social Security Act, as added by subsection + (a)(1). + (iii) Duration.--The demonstration program + under this paragraph shall be conducted for a 3- + year period. + (iv) Sites.--The Secretary shall conduct the + demonstration program under this paragraph at an + appropriate number (as determined by the + Secretary) of applicable hospitals. The Secretary + shall ensure that such hospitals are + representative of the spectrum of such hospitals + that participate in the Medicare program. + (B) Waiver authority.--The Secretary may waive such + requirements of titles XI and XVIII of the Social + Security Act as may be necessary to carry out the + demonstration program under this paragraph. + (C) Budget neutrality requirement.--In conducting + the demonstration program under this section, the + Secretary shall ensure that the aggregate payments made + by the Secretary do not exceed the amount which the + Secretary would have paid if the demonstration program + under this section was not implemented. + (D) Report.--Not later than 18 months after the + completion of the demonstration program under this + paragraph, the Secretary shall submit to Congress a + report on the demonstration program together with-- + (i) recommendations on the establishment of a + permanent value-based purchasing program under the + Medicare program for applicable hospitals with + respect to inpatient hospital services; and + (ii) recommendations for such other + legislation and administrative action as the + Secretary determines appropriate. + +SEC. 3002. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING SYSTEM. + + (a) Extension.--Section 1848(m) of the Social Security Act (42 +U.S.C. 1395w-4(m)) is amended-- + +[[Page 124 STAT. 364]] + + (1) in paragraph (1)-- + (A) in subparagraph (A), in the matter preceding + clause (i), by striking ``2010'' and inserting ``2014''; + and + (B) in subparagraph (B)-- + (i) in clause (i), by striking ``and'' at the + end; + (ii) in clause (ii), by striking the period at + the end and inserting a semicolon; and + (iii) by adding at the end the following new + clauses: + ``(iii) for 2011, 1.0 percent; and + ``(iv) for 2012, 2013, and 2014, 0.5 + percent.''; + (2) in paragraph (3)-- + (A) in subparagraph (A), in the matter preceding + clause (i), by inserting ``(or, for purposes of + subsection (a)(8), for the quality reporting period for + the year)'' after ``reporting period''; and + (B) in subparagraph (C)(i), by inserting ``, or, for + purposes of subsection (a)(8), for a quality reporting + period for the year'' after ``(a)(5), for a reporting + period for a year''; + (3) in paragraph (5)(E)(iv), by striking ``subsection + (a)(5)(A)'' and inserting ``paragraphs (5)(A) and (8)(A) of + subsection (a)''; and + (4) in paragraph (6)(C)-- + (A) in clause (i)(II), by striking ``, 2009, 2010, + and 2011'' and inserting ``and subsequent years''; and + (B) in clause (iii)-- + (i) by inserting ``(a)(8)'' after ``(a)(5)''; + and + (ii) by striking ``under subparagraph (D)(iii) + of such subsection'' and inserting ``under + subsection (a)(5)(D)(iii) or the quality reporting + period under subsection (a)(8)(D)(iii), + respectively''. + + (b) Incentive Payment Adjustment for Quality Reporting.--Section +1848(a) of the Social Security Act (42 U.S.C. 1395w-4(a)) is amended by +adding at the end the following new paragraph: + ``(8) Incentives for quality reporting.-- + ``(A) Adjustment.-- + ``(i) In general.--With respect to covered + professional services furnished by an eligible + professional during 2015 or any subsequent year, + if the eligible professional does not + satisfactorily submit data on quality measures for + covered professional services for the quality + reporting period for the year (as determined under + subsection (m)(3)(A)), the fee schedule amount for + such services furnished by such professional + during the year (including the fee schedule amount + for purposes of determining a payment based on + such amount) shall be equal to the applicable + percent of the fee schedule amount that would + otherwise apply to such services under this + subsection (determined after application of + paragraphs (3), (5), and (7), but without regard + to this paragraph). + ``(ii) Applicable percent.--For purposes of + clause (i), the term `applicable percent' means-- + ``(I) for 2015, 98.5 percent; and + ``(II) for 2016 and each subsequent + year, 98 percent. + +[[Page 124 STAT. 365]] + + ``(B) Application.-- + ``(i) Physician reporting system rules.-- + Paragraphs (5), (6), and (8) of subsection (k) + shall apply for purposes of this paragraph in the + same manner as they apply for purposes of such + subsection. + ``(ii) Incentive payment validation rules.-- + Clauses (ii) and (iii) of subsection (m)(5)(D) + shall apply for purposes of this paragraph in a + similar manner as they apply for purposes of such + subsection. + ``(C) Definitions.--For purposes of this paragraph: + ``(i) Eligible professional; covered + professional services.--The terms `eligible + professional' and `covered professional services' + have the meanings given such terms in subsection + (k)(3). + ``(ii) Physician reporting system.--The term + `physician reporting system' means the system + established under subsection (k). + ``(iii) Quality reporting period.--The term + `quality reporting period' means, with respect to + a year, a period specified by the Secretary.''. + + (c) Maintenance of Certification Programs.-- + (1) In general.--Section 1848(k)(4) of the Social Security + Act (42 U.S.C. 1395w-4(k)(4)) is amended by inserting ``or + through a Maintenance of Certification program operated by a + specialty body of the American Board of Medical Specialties that + meets the criteria for such a registry'' after ``Database)''. + (2) <<NOTE: 42 USC 1395w-4 note.>> Effective date.--The + amendment made by paragraph (1) shall apply for years after + 2010. + + (d) Integration of Physician Quality Reporting and EHR Reporting.-- +Section 1848(m) of the Social Security Act (42 U.S.C. 1395w-4(m)) is +amended by adding at the end the following new paragraph: + ``(7) Integration of physician quality reporting and ehr + reporting. <<NOTE: Plan.>> --Not later than January 1, 2012, the + Secretary shall develop a plan to integrate reporting on quality + measures under this subsection with reporting requirements under + subsection (o) relating to the meaningful use of electronic + health records. Such integration shall consist of the following: + ``(A) The selection of measures, the reporting of + which would both demonstrate-- + ``(i) meaningful use of an electronic health + record for purposes of subsection (o); and + ``(ii) quality of care furnished to an + individual. + ``(B) Such other activities as specified by the + Secretary.''. + + (e) Feedback.--Section 1848(m)(5) of the Social Security Act (42 +U.S.C. 1395w-4(m)(5)) is amended by adding at the end the following new +subparagraph: + ``(H) Feedback.--The Secretary shall provide timely + feedback to eligible professionals on the performance of + the eligible professional with respect to satisfactorily + submitting data on quality measures under this + subsection.''. + + (f) Appeals.--Such section is further amended-- + (1) in subparagraph (E), by striking ``There shall'' and + inserting ``Except as provided in subparagraph (I), there + shall''; and + +[[Page 124 STAT. 366]] + + (2) by adding at the end the following new subparagraph: + ``(I) Informal appeals process.-- + <<NOTE: Deadline.>> The Secretary shall, by not later + than January 1, 2011, establish and have in place an + informal process for eligible professionals to seek a + review of the determination that an eligible + professional did not satisfactorily submit data on + quality measures under this subsection.''. + +SEC. 3003. IMPROVEMENTS TO THE PHYSICIAN FEEDBACK PROGRAM. + + (a) In General.--Section 1848(n) of the Social Security Act (42 +U.S.C. 1395w-4(n)) is amended-- + (1) in paragraph (1)-- + (A) in subparagraph (A)-- + (i) by striking ``general.--The Secretary'' + and inserting ``general.-- + ``(i) Establishment.--The Secretary''; + (ii) in clause (i), as added by clause (i), by + striking ``the `Program')'' and all that follows + through the period at the end of the second + sentence and inserting ``the `Program').''; and + (iii) by adding at the end the following new + clauses: + ``(ii) Reports on resources.--The Secretary + shall use claims data under this title (and may + use other data) to provide confidential reports to + physicians (and, as determined appropriate by the + Secretary, to groups of physicians) that measure + the resources involved in furnishing care to + individuals under this title. + ``(iii) Inclusion of certain information.--If + determined appropriate by the Secretary, the + Secretary may include information on the quality + of care furnished to individuals under this title + by the physician (or group of physicians) in such + reports.''; and + (B) in subparagraph (B), by striking ``subparagraph + (A)'' and inserting ``subparagraph (A)(ii)''; + (2) in paragraph (4)-- + (A) in the heading, by inserting ``initial'' after + ``focus''; and + (B) in the matter preceding subparagraph (A), by + inserting ``initial'' after ``focus the''; + (3) in paragraph (6), by adding at the end the following new + sentence: ``For adjustments for reports on utilization under + paragraph (9), see subparagraph (D) of such paragraph.''; and + (4) by adding at the end the following new paragraphs: + ``(9) Reports on utilization.-- + ``(A) Development of episode grouper.-- + ``(i) In general.--The Secretary shall develop + an episode grouper that combines separate but + clinically related items and services into an + episode of care for an individual, as appropriate. + ``(ii) Timeline for development.--The episode + grouper described in subparagraph (A) shall be + developed by not later than January 1, 2012. + ``(iii) Public availability.--The Secretary + shall make the details of the episode grouper + described in subparagraph (A) available to the + public. + ``(iv) Endorsement.--The Secretary shall seek + endorsement of the episode grouper described in + +[[Page 124 STAT. 367]] + + subparagraph (A) by the entity with a contract + under section 1890(a). + ``(B) Reports on utilization.--Effective beginning + with 2012, the Secretary shall provide reports to + physicians that compare, as determined appropriate by + the Secretary, patterns of resource use of the + individual physician to such patterns of other + physicians. + ``(C) Analysis of data.--The Secretary shall, for + purposes of preparing reports under this paragraph, + establish methodologies as appropriate, such as to-- + ``(i) attribute episodes of care, in whole or + in part, to physicians; + ``(ii) identify appropriate physicians for + purposes of comparison under subparagraph (B); and + ``(iii) aggregate episodes of care attributed + to a physician under clause (i) into a composite + measure per individual. + ``(D) Data adjustment.--In preparing reports under + this paragraph, the Secretary shall make appropriate + adjustments, including adjustments-- + ``(i) to account for differences in + socioeconomic and demographic characteristics, + ethnicity, and health status of individuals (such + as to recognize that less healthy individuals may + require more intensive interventions); and + ``(ii) to eliminate the effect of geographic + adjustments in payment rates (as described in + subsection (e)). + ``(E) Public availability of methodology.--The + Secretary shall make available to the public-- + ``(i) the methodologies established under + subparagraph (C); + ``(ii) information regarding any adjustments + made to data under subparagraph (D); and + ``(iii) aggregate reports with respect to + physicians. + ``(F) Definition of physician.--In this paragraph: + ``(i) In general.--The term `physician' has + the meaning given that term in section 1861(r)(1). + ``(ii) Treatment of groups.--Such term + includes, as the Secretary determines appropriate, + a group of physicians. + ``(G) Limitations on review.--There shall be no + administrative or judicial review under section 1869, + section 1878, or otherwise of the establishment of the + methodology under subparagraph (C), including the + determination of an episode of care under such + methodology. + ``(10) Coordination with other value-based purchasing + reforms.--The Secretary shall coordinate the Program with the + value-based payment modifier established under subsection (p) + and, as the Secretary determines appropriate, other similar + provisions of this title.''. + + (b) Conforming Amendment.--Section 1890(b) of the Social Security +Act (42 U.S.C. 1395aaa(b)) is amended by adding at the end the following +new paragraph: + ``(6) Review and endorsement of episode grouper under the + physician feedback program.--The entity shall provide for the + review and, as appropriate, the endorsement of the + +[[Page 124 STAT. 368]] + + episode grouper developed by the Secretary under section + 1848(n)(9)(A). Such review shall be conducted on an expedited + basis.''. + +SEC. 3004. QUALITY REPORTING FOR LONG-TERM CARE HOSPITALS, INPATIENT + REHABILITATION HOSPITALS, AND HOSPICE PROGRAMS. + + (a) Long-term Care Hospitals.--Section 1886(m) of the Social +Security Act (42 U.S.C. 1395ww(m)), as amended by section 3401(c), is +amended by adding at the end the following new paragraph: + ``(5) Quality reporting.-- + ``(A) Reduction in update for failure to report.-- + ``(i) In general.--Under the system described + in paragraph (1), for rate year 2014 and each + subsequent rate year, in the case of a long-term + care hospital that does not submit data to the + Secretary in accordance with subparagraph (C) with + respect to such a rate year, any annual update to + a standard Federal rate for discharges for the + hospital during the rate year, and after + application of paragraph (3), shall be reduced by + 2 percentage points. + ``(ii) Special rule.--The application of this + subparagraph may result in such annual update + being less than 0.0 for a rate year, and may + result in payment rates under the system described + in paragraph (1) for a rate year being less than + such payment rates for the preceding rate year. + ``(B) Noncumulative application.--Any reduction + under subparagraph (A) shall apply only with respect to + the rate year involved and the Secretary shall not take + into account such reduction in computing the payment + amount under the system described in paragraph (1) for a + subsequent rate year. + ``(C) Submission of quality data.--For rate year + 2014 and each subsequent rate year, each long-term care + hospital shall submit to the Secretary data on quality + measures specified under subparagraph (D). Such data + shall be submitted in a form and manner, and at a time, + specified by the Secretary for purposes of this + subparagraph. + ``(D) Quality measures.-- + ``(i) In general.--Subject to clause (ii), any + measure specified by the Secretary under this + subparagraph must have been endorsed by the entity + with a contract under section 1890(a). + ``(ii) Exception.--In the case of a specified + area or medical topic determined appropriate by + the Secretary for which a feasible and practical + measure has not been endorsed by the entity with a + contract under section 1890(a), the Secretary may + specify a measure that is not so endorsed as long + as due consideration is given to measures that + have been endorsed or adopted by a consensus + organization identified by the Secretary. + ``(iii) Time frame.--Not later than October 1, + 2012, the Secretary shall publish the measures + selected under this subparagraph that will be + applicable with respect to rate year 2014. + +[[Page 124 STAT. 369]] + + ``(E) Public availability of data + submitted. <<NOTE: Procedures.>> --The Secretary shall + establish procedures for making data submitted under + subparagraph (C) available to the public. + Such <<NOTE: Review.>> procedures shall ensure that a + long-term care hospital has the opportunity to review + the data that is to be made public with respect to the + hospital prior to such data being made + public. <<NOTE: Web posting.>> The Secretary shall + report quality measures that relate to services + furnished in inpatient settings in long-term care + hospitals on the Internet website of the Centers for + Medicare & Medicaid Services.''. + + (b) Inpatient Rehabilitation Hospitals.--Section 1886(j) of the +Social Security Act (42 U.S.C. 1395ww(j)) is amended-- + (1) by redesignating paragraph (7) as paragraph (8); and + (2) by inserting after paragraph (6) the following new + paragraph: + ``(7) Quality reporting.-- + ``(A) Reduction in update for failure to report.-- + ``(i) In general.--For purposes of fiscal year + 2014 and each subsequent fiscal year, in the case + of a rehabilitation facility that does not submit + data to the Secretary in accordance with + subparagraph (C) with respect to such a fiscal + year, after determining the increase factor + described in paragraph (3)(C), and after + application of paragraph (3)(D), the Secretary + shall reduce such increase factor for payments for + discharges occurring during such fiscal year by 2 + percentage points. + ``(ii) Special rule.--The application of this + subparagraph may result in the increase factor + described in paragraph (3)(C) being less than 0.0 + for a fiscal year, and may result in payment rates + under this subsection for a fiscal year being less + than such payment rates for the preceding fiscal + year. + ``(B) Noncumulative application.--Any reduction + under subparagraph (A) shall apply only with respect to + the fiscal year involved and the Secretary shall not + take into account such reduction in computing the + payment amount under this subsection for a subsequent + fiscal year. + ``(C) Submission of quality data.--For fiscal year + 2014 and each subsequent rate year, each rehabilitation + facility shall submit to the Secretary data on quality + measures specified under subparagraph (D). Such data + shall be submitted in a form and manner, and at a time, + specified by the Secretary for purposes of this + subparagraph. + ``(D) Quality measures.-- + ``(i) In general.--Subject to clause (ii), any + measure specified by the Secretary under this + subparagraph must have been endorsed by the entity + with a contract under section 1890(a). + ``(ii) Exception.--In the case of a specified + area or medical topic determined appropriate by + the Secretary for which a feasible and practical + measure has not been endorsed by the entity with a + contract under section 1890(a), the Secretary may + specify a measure that is not so endorsed as long + as due consideration is given to measures that + have been endorsed or + +[[Page 124 STAT. 370]] + + adopted by a consensus organization identified by + the Secretary. + ``(iii) Time frame. <<NOTE: Publication.>> -- + Not later than October 1, 2012, the Secretary + shall publish the measures selected under this + subparagraph that will be applicable with respect + to fiscal year 2014. + ``(E) Public availability of data + submitted. <<NOTE: Procedures.>> --The Secretary shall + establish procedures for making data submitted under + subparagraph (C) available to the public. + Such <<NOTE: Review.>> procedures shall ensure that a + rehabilitation facility has the opportunity to review + the data that is to be made public with respect to the + facility prior to such data being made + public. <<NOTE: Web posting.>> The Secretary shall + report quality measures that relate to services + furnished in inpatient settings in rehabilitation + facilities on the Internet website of the Centers for + Medicare & Medicaid Services.''. + + (c) Hospice Programs.--Section 1814(i) of the Social Security Act +(42 U.S.C. 1395f(i)) is amended-- + (1) by redesignating paragraph (5) as paragraph (6); and + (2) by inserting after paragraph (4) the following new + paragraph: + ``(5) Quality reporting.-- + ``(A) Reduction in update for failure to report.-- + ``(i) In general.--For purposes of fiscal year + 2014 and each subsequent fiscal year, in the case + of a hospice program that does not submit data to + the Secretary in accordance with subparagraph (C) + with respect to such a fiscal year, after + determining the market basket percentage increase + under paragraph (1)(C)(ii)(VII) or paragraph + (1)(C)(iii), as applicable, and after application + of paragraph (1)(C)(iv), with respect to the + fiscal year, the Secretary shall reduce such + market basket percentage increase by 2 percentage + points. + ``(ii) Special rule.--The application of this + subparagraph may result in the market basket + percentage increase under paragraph + (1)(C)(ii)(VII) or paragraph (1)(C)(iii), as + applicable, being less than 0.0 for a fiscal year, + and may result in payment rates under this + subsection for a fiscal year being less than such + payment rates for the preceding fiscal year. + ``(B) Noncumulative application.--Any reduction + under subparagraph (A) shall apply only with respect to + the fiscal year involved and the Secretary shall not + take into account such reduction in computing the + payment amount under this subsection for a subsequent + fiscal year. + ``(C) Submission of quality data.--For fiscal year + 2014 and each subsequent fiscal year, each hospice + program shall submit to the Secretary data on quality + measures specified under subparagraph (D). Such data + shall be submitted in a form and manner, and at a time, + specified by the Secretary for purposes of this + subparagraph. + ``(D) Quality measures.-- + ``(i) In general.--Subject to clause (ii), any + measure specified by the Secretary under this + subparagraph must have been endorsed by the entity + with a contract under section 1890(a). + +[[Page 124 STAT. 371]] + + ``(ii) Exception.--In the case of a specified + area or medical topic determined appropriate by + the Secretary for which a feasible and practical + measure has not been endorsed by the entity with a + contract under section 1890(a), the Secretary may + specify a measure that is not so endorsed as long + as due consideration is given to measures that + have been endorsed or adopted by a consensus + organization identified by the Secretary. + ``(iii) Time frame. <<NOTE: Publication.>> -- + Not later than October 1, 2012, the Secretary + shall publish the measures selected under this + subparagraph that will be applicable with respect + to fiscal year 2014. + ``(E) Public availability of data submitted.-- + <<NOTE: Procedures.>> The Secretary shall establish + procedures for making data submitted under subparagraph + (C) available to the public. + Such <<NOTE: Review.>> procedures shall ensure that a + hospice program has the opportunity to review the data + that is to be made public with respect to the hospice + program prior to such data being made + public. <<NOTE: Web posting.>> The Secretary shall + report quality measures that relate to hospice care + provided by hospice programs on the Internet website of + the Centers for Medicare & Medicaid Services.''. + +SEC. 3005. QUALITY REPORTING FOR PPS-EXEMPT CANCER HOSPITALS. + + Section 1866 of the Social Security Act (42 U.S.C. 1395cc) is +amended-- + (1) in subsection (a)(1)-- + (A) in subparagraph (U), by striking ``and'' at the + end; + (B) in subparagraph (V), by striking the period at + the end and inserting ``, and''; and + (C) by adding at the end the following new + subparagraph: + ``(W) in the case of a hospital described in section + 1886(d)(1)(B)(v), to report quality data to the + Secretary in accordance with subsection (k).''; and + (2) by adding at the end the following new subsection: + + ``(k) Quality Reporting by Cancer Hospitals.-- + ``(1) In general.--For purposes of fiscal year 2014 and each + subsequent fiscal year, a hospital described in section + 1886(d)(1)(B)(v) shall submit data to the Secretary in + accordance with paragraph (2) with respect to such a fiscal + year. + ``(2) Submission of quality data.--For fiscal year 2014 and + each subsequent fiscal year, each hospital described in such + section shall submit to the Secretary data on quality measures + specified under paragraph (3). Such data shall be submitted in a + form and manner, and at a time, specified by the Secretary for + purposes of this subparagraph. + ``(3) Quality measures.-- + ``(A) In general.--Subject to subparagraph (B), any + measure specified by the Secretary under this paragraph + must have been endorsed by the entity with a contract + under section 1890(a). + ``(B) Exception.--In the case of a specified area or + medical topic determined appropriate by the Secretary + for which a feasible and practical measure has not been + +[[Page 124 STAT. 372]] + + endorsed by the entity with a contract under section + 1890(a), the Secretary may specify a measure that is not + so endorsed as long as due consideration is given to + measures that have been endorsed or adopted by a + consensus organization identified by the Secretary. + ``(C) Time frame. <<NOTE: Publication.>> --Not later + than October 1, 2012, the Secretary shall publish the + measures selected under this paragraph that will be + applicable with respect to fiscal year 2014. + ``(4) Public availability of data + submitted. <<NOTE: Procedures.>> --The Secretary shall establish + procedures for making data submitted under paragraph (4) + available to the public. <<NOTE: Review.>> Such procedures shall + ensure that a hospital described in section 1886(d)(1)(B)(v) has + the opportunity to review the data that is to be made public + with respect to the hospital prior to such data being made + public. <<NOTE: Web posting.>> The Secretary shall report + quality measures of process, structure, outcome, patients' + perspective on care, efficiency, and costs of care that relate + to services furnished in such hospitals on the Internet website + of the Centers for Medicare & Medicaid Services.''. + +SEC. 3006. PLANS FOR A VALUE-BASED PURCHASING PROGRAM FOR SKILLED + NURSING FACILITIES AND HOME HEALTH AGENCIES. + + (a) Skilled Nursing Facilities.-- + (1) In general.--The Secretary of Health and Human Services + (in this section referred to as the ``Secretary'') shall develop + a plan to implement a value-based purchasing program for + payments under the Medicare program under title XVIII of the + Social Security Act for skilled nursing facilities (as defined + in section 1819(a) of such Act (42 U.S.C. 1395i-3(a))). + (2) Details.--In developing the plan under paragraph (1), + the Secretary shall consider the following issues: + (A) The ongoing development, selection, and + modification process for measures (including under + section 1890 of the Social Security Act (42 U.S.C. + 1395aaa) and section 1890A such Act, as added by section + 3014), to the extent feasible and practicable, of all + dimensions of quality and efficiency in skilled nursing + facilities. + (i) In general.--Subject to clause (ii), any + measure specified by the Secretary under + subparagraph (A)(iii) must have been endorsed by + the entity with a contract under section 1890(a). + (ii) Exception.--In the case of a specified + area or medical topic determined appropriate by + the Secretary for which a feasible and practical + measure has not been endorsed by the entity with a + contract under section 1890(a), the Secretary may + specify a measure that is not so endorsed as long + as due consideration is given to measures that + have been endorsed or adopted by a consensus + organization identified by the Secretary. + (B) The reporting, collection, and validation of + quality data. + (C) The structure of value-based payment + adjustments, including the determination of thresholds + or improvements in quality that would substantiate a + payment adjustment, + +[[Page 124 STAT. 373]] + + the size of such payments, and the sources of funding + for the value-based bonus payments. + (D) Methods for the public disclosure of information + on the performance of skilled nursing facilities. + (E) Any other issues determined appropriate by the + Secretary. + (3) Consultation.--In developing the plan under paragraph + (1), the Secretary shall-- + (A) consult with relevant affected parties; and + (B) consider experience with such demonstrations + that the Secretary determines are relevant to the value- + based purchasing program described in paragraph (1). + (4) Report to congress.--Not later than October 1, 2011, the + Secretary shall submit to Congress a report containing the plan + developed under paragraph (1). + + (b) Home Health Agencies.-- + (1) In general.--The Secretary of Health and Human Services + (in this section referred to as the ``Secretary'') shall develop + a plan to implement a value-based purchasing program for + payments under the Medicare program under title XVIII of the + Social Security Act for home health agencies (as defined in + section 1861(o) of such Act (42 U.S.C. 1395x(o))). + (2) Details.--In developing the plan under paragraph (1), + the Secretary shall consider the following issues: + (A) The ongoing development, selection, and + modification process for measures (including under + section 1890 of the Social Security Act (42 U.S.C. + 1395aaa) and section 1890A such Act, as added by section + 3014), to the extent feasible and practicable, of all + dimensions of quality and efficiency in home health + agencies. + (B) The reporting, collection, and validation of + quality data. + (C) The structure of value-based payment + adjustments, including the determination of thresholds + or improvements in quality that would substantiate a + payment adjustment, the size of such payments, and the + sources of funding for the value-based bonus payments. + (D) Methods for the public disclosure of information + on the performance of home health agencies. + (E) Any other issues determined appropriate by the + Secretary. + (3) Consultation.--In developing the plan under paragraph + (1), the Secretary shall-- + (A) consult with relevant affected parties; and + (B) consider experience with such demonstrations + that the Secretary determines are relevant to the value- + based purchasing program described in paragraph (1). + (4) Report to congress.--Not later than October 1, 2011, the + Secretary shall submit to Congress a report containing the plan + developed under paragraph (1). + +SEC. 3007. VALUE-BASED PAYMENT MODIFIER UNDER THE PHYSICIAN FEE + SCHEDULE. + + Section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is +amended-- + (1) in subsection (b)(1), by inserting ``subject to + subsection (p),'' after ``1998,''; and + +[[Page 124 STAT. 374]] + + (2) by adding at the end the following new subsection: + + ``(p) Establishment of Value-based Payment Modifier.-- + ``(1) In general.--The Secretary shall establish a payment + modifier that provides for differential payment to a physician + or a group of physicians under the fee schedule established + under subsection (b) based upon the quality of care furnished + compared to cost (as determined under paragraphs (2) and (3), + respectively) during a performance period. Such payment modifier + shall be separate from the geographic adjustment factors + established under subsection (e). + ``(2) Quality.-- + ``(A) In general.--For purposes of paragraph (1), + quality of care shall be evaluated, to the extent + practicable, based on a composite of measures of the + quality of care furnished (as established by the + Secretary under subparagraph (B)). + ``(B) Measures.-- + ``(i) The Secretary shall establish + appropriate measures of the quality of care + furnished by a physician or group of physicians to + individuals enrolled under this part, such as + measures that reflect health outcomes. Such + measures shall be risk adjusted as determined + appropriate by the Secretary. + ``(ii) The Secretary shall seek endorsement of + the measures established under this subparagraph + by the entity with a contract under section + 1890(a). + ``(3) Costs.--For purposes of paragraph (1), costs shall be + evaluated, to the extent practicable, based on a composite of + appropriate measures of costs established by the Secretary (such + as the composite measure under the methodology established under + subsection (n)(9)(C)(iii)) that eliminate the effect of + geographic adjustments in payment rates (as described in + subsection (e)), and take into account risk factors (such as + socioeconomic and demographic characteristics, ethnicity, and + health status of individuals (such as to recognize that less + healthy individuals may require more intensive interventions) + and other factors determined appropriate by the Secretary. + ``(4) Implementation.-- + ``(A) Publication of measures, dates of + implementation, performance period.-- + <<NOTE: Deadline.>> Not later than January 1, 2012, the + Secretary shall publish the following: + ``(i) The measures of quality of care and + costs established under paragraphs (2) and (3), + respectively. + ``(ii) The dates for implementation of the + payment modifier (as determined under subparagraph + (B)). + ``(iii) The initial performance period (as + specified under subparagraph (B)(ii)). + ``(B) Deadlines for implementation.-- + ``(i) Initial implementation.--Subject to the + preceding provisions of this subparagraph, the + Secretary shall begin implementing the payment + modifier established under this subsection through + the rulemaking process during 2013 for the + physician fee schedule established under + subsection (b). + ``(ii) Initial performance period.-- + ``(I) In general.--The Secretary + shall specify an initial performance + period for application of + +[[Page 124 STAT. 375]] + + the payment modifier established under + this subsection with respect to 2015. + ``(II) Provision of information + during initial performance period.-- + During the initial performance period, + the Secretary shall, to the extent + practicable, provide information to + physicians and groups of physicians + about the quality of care furnished by + the physician or group of physicians to + individuals enrolled under this part + compared to cost (as determined under + paragraphs (2) and (3), respectively) + with respect to the performance period. + ``(iii) Application.--The Secretary shall + apply the payment modifier established under this + subsection for items and services furnished-- + ``(I) <<NOTE: Effective date.>> + beginning on January 1, 2015, with + respect to specific physicians and + groups of physicians the Secretary + determines appropriate; and + ``(II) <<NOTE: Deadline.>> + beginning not later than January 1, + 2017, with respect to all physicians and + groups of physicians. + ``(C) Budget neutrality.--The payment modifier + established under this subsection shall be implemented + in a budget neutral manner. + ``(5) Systems-based care.-- <<NOTE: Applicability.>> The + Secretary shall, as appropriate, apply the payment modifier + established under this subsection in a manner that promotes + systems-based care. + ``(6) Consideration of special circumstances of certain + providers.--In applying the payment modifier under this + subsection, the Secretary shall, as appropriate, take into + account the special circumstances of physicians or groups of + physicians in rural areas and other underserved communities. + ``(7) Application.-- <<NOTE: Time period.>> For purposes of + the initial application of the payment modifier established + under this subsection during the period beginning on January 1, + 2015, and ending on December 31, 2016, the term `physician' has + the meaning given such term in section + 1861(r). <<NOTE: Effective date. Determination.>> On or after + January 1, 2017, the Secretary may apply this subsection to + eligible professionals (as defined in subsection (k)(3)(B)) as + the Secretary determines appropriate. + ``(8) Definitions.--For purposes of this subsection: + ``(A) Costs.--The term `costs' means expenditures + per individual as determined appropriate by the + Secretary. In making the determination under the + preceding sentence, the Secretary may take into account + the amount of growth in expenditures per individual for + a physician compared to the amount of such growth for + other physicians. + ``(B) Performance period.--The term `performance + period' means a period specified by the Secretary. + ``(9) Coordination with other value-based purchasing + reforms.-- <<NOTE: Determination.>> The Secretary shall + coordinate the value-based payment modifier established under + this subsection with the Physician Feedback Program under + subsection (n) and, as the Secretary determines appropriate, + other similar provisions of this title. + +[[Page 124 STAT. 376]] + + ``(10) Limitations on review.--There shall be no + administrative or judicial review under section 1869, section + 1878, or otherwise of-- + ``(A) the establishment of the value-based payment + modifier under this subsection; + ``(B) the evaluation of quality of care under + paragraph (2), including the establishment of + appropriate measures of the quality of care under + paragraph (2)(B); + ``(C) the evaluation of costs under paragraph (3), + including the establishment of appropriate measures of + costs under such paragraph; + ``(D) the dates for implementation of the value- + based payment modifier; + ``(E) the specification of the initial performance + period and any other performance period under paragraphs + (4)(B)(ii) and (8)(B), respectively; + ``(F) the application of the value-based payment + modifier under paragraph (7); and + ``(G) the determination of costs under paragraph + (8)(A).''. + +SEC. 3008. PAYMENT ADJUSTMENT FOR CONDITIONS ACQUIRED IN HOSPITALS. + + (a) In General.--Section 1886 of the Social Security Act (42 U.S.C. +1395ww), as amended by section 3001, is amended by adding at the end the +following new subsection: + ``(p) Adjustment to Hospital Payments for Hospital Acquired +Conditions.-- + ``(1) In general.--In order to provide an incentive for + applicable hospitals to reduce hospital acquired conditions + under this title, with respect to discharges from an applicable + hospital occurring during fiscal year 2015 or a subsequent + fiscal year, the amount of payment under this section or section + 1814(b)(3), as applicable, for such discharges during the fiscal + year shall be equal to 99 percent of the amount of payment that + would otherwise apply to such discharges under this section or + section 1814(b)(3) (determined after the application of + subsections (o) and (q) and section 1814(l)(4) but without + regard to this subsection). + ``(2) Applicable hospitals.-- + ``(A) <<NOTE: Definition.>> In general.--For + purposes of this subsection, the term `applicable + hospital' means a subsection (d) hospital that meets the + criteria described in subparagraph (B). + ``(B) Criteria described.-- + ``(i) <<NOTE: Determined.>> In general.--The + criteria described in this subparagraph, with + respect to a subsection (d) hospital, is that the + subsection (d) hospital is in the top quartile of + all subsection (d) hospitals, relative to the + national average, of hospital acquired conditions + during the applicable period, as determined by the + Secretary. + ``(ii) Risk adjustment.--In carrying out + clause (i), the Secretary shall establish and + apply an appropriate risk adjustment methodology. + ``(C) Exemption. <<NOTE: Deadline. Reports.>> --In + the case of a hospital that is paid under section + 1814(b)(3), the Secretary may exempt such hospital from + the application of this subsection if the State which is + paid under such section submits an + +[[Page 124 STAT. 377]] + + annual report to the Secretary describing how a similar + program in the State for a participating hospital or + hospitals achieves or surpasses the measured results in + terms of patient health outcomes and cost savings + established under this subsection. + ``(3) <<NOTE: Definition.>> Hospital acquired conditions.-- + For purposes of this subsection, the term `hospital acquired + condition' means a condition identified for purposes of + subsection (d)(4)(D)(iv) and any other condition determined + appropriate by the Secretary that an individual acquires during + a stay in an applicable hospital, as determined by the + Secretary. + ``(4) Applicable period.--In this subsection, the term + `applicable period' means, with respect to a fiscal year, a + period specified by the Secretary. + ``(5) Reporting to hospitals.--Prior to fiscal year 2015 and + each subsequent fiscal year, the Secretary shall provide + confidential reports to applicable hospitals with respect to + hospital acquired conditions of the applicable hospital during + the applicable period. + ``(6) Reporting hospital specific information.-- + ``(A) In general. <<NOTE: Public information.>> -- + The Secretary shall make information available to the + public regarding hospital acquired conditions of each + applicable hospital. + ``(B) Opportunity to review and submit + corrections.--The Secretary shall ensure that an + applicable hospital has the opportunity to review, and + submit corrections for, the information to be made + public with respect to the hospital under subparagraph + (A) prior to such information being made public. + ``(C) Website.--Such information shall be posted on + the Hospital Compare Internet website in an easily + understandable format. + ``(7) Limitations on review.--There shall be no + administrative or judicial review under section 1869, section + 1878, or otherwise of the following: + ``(A) The criteria described in paragraph (2)(A). + ``(B) The specification of hospital acquired + conditions under paragraph (3). + ``(C) The specification of the applicable period + under paragraph (4). + ``(D) The provision of reports to applicable + hospitals under paragraph (5) and the information made + available to the public under paragraph (6).''. + + (b) Study and Report on Expansion of Healthcare Acquired Conditions +Policy to Other Providers.-- + (1) Study.--The Secretary of Health and Human Services shall + conduct a study on expanding the healthcare acquired conditions + policy under subsection (d)(4)(D) of section 1886 of the Social + Security Act (42 U.S.C. 1395ww) to payments made to other + facilities under the Medicare program under title XVIII of the + Social Security Act, including such payments made to inpatient + rehabilitation facilities, long-term care hospitals (as + described in subsection(d)(1)(B)(iv) of such section), hospital + outpatient departments, and other hospitals excluded from the + inpatient prospective payment system under such section, skilled + nursing facilities, ambulatory surgical centers, and health + clinics. Such study shall include an analysis of + +[[Page 124 STAT. 378]] + + how such policies could impact quality of patient care, patient + safety, and spending under the Medicare program. + (2) Report.--Not later than January 1, 2012, the Secretary + shall submit to Congress a report containing the results of the + study conducted under paragraph (1), together with + recommendations for such legislation and administrative action + as the Secretary determines appropriate. + + PART II--NATIONAL STRATEGY TO IMPROVE HEALTH CARE QUALITY + +SEC. 3011. NATIONAL STRATEGY. + + Title III of the Public Health Service Act (42 U.S.C. 241 et seq.) +is amended by adding at the end the following: + + ``PART S--HEALTH CARE QUALITY PROGRAMS + + ``Subpart I--National Strategy for Quality Improvement in Health Care + +``SEC. 399HH. <<NOTE: 42 USC 280j.>> NATIONAL STRATEGY FOR QUALITY + IMPROVEMENT IN HEALTH CARE. + + ``(a) Establishment of National Strategy and Priorities.-- + ``(1) National strategy.--The Secretary, through a + transparent collaborative process, shall establish a national + strategy to improve the delivery of health care services, + patient health outcomes, and population health. + ``(2) Identification of priorities.-- + ``(A) In general.--The Secretary shall identify + national priorities for improvement in developing the + strategy under paragraph (1). + ``(B) Requirements.--The Secretary shall ensure that + priorities identified under subparagraph (A) will-- + ``(i) have the greatest potential for + improving the health outcomes, efficiency, and + patient-centeredness of health care for all + populations, including children and vulnerable + populations; + ``(ii) identify areas in the delivery of + health care services that have the potential for + rapid improvement in the quality and efficiency of + patient care; + ``(iii) address gaps in quality, efficiency, + comparative effectiveness information, and health + outcomes measures and data aggregation techniques; + ``(iv) improve Federal payment policy to + emphasize quality and efficiency; + ``(v) enhance the use of health care data to + improve quality, efficiency, transparency, and + outcomes; + ``(vi) address the health care provided to + patients with high-cost chronic diseases; + ``(vii) improve research and dissemination of + strategies and best practices to improve patient + safety and reduce medical errors, preventable + admissions and readmissions, and health care- + associated infections; + ``(viii) reduce health disparities across + health disparity populations (as defined in + section 485E) and geographic areas; and + +[[Page 124 STAT. 379]] + + ``(ix) address other areas as determined + appropriate by the Secretary. + ``(C) Considerations.--In identifying priorities + under subparagraph (A), the Secretary shall take into + consideration the recommendations submitted by the + entity with a contract under section 1890(a) of the + Social Security Act and other stakeholders. + ``(D) Coordination with state agencies.--The + Secretary shall collaborate, coordinate, and consult + with State agencies responsible for administering the + Medicaid program under title XIX of the Social Security + Act and the Children's Health Insurance Program under + title XXI of such Act with respect to developing and + disseminating strategies, goals, models, and timetables + that are consistent with the national priorities + identified under subparagraph (A). + + ``(b) Strategic Plan.-- + ``(1) In general.--The national strategy shall include a + comprehensive strategic plan to achieve the priorities described + in subsection (a). + ``(2) Requirements.--The strategic plan shall include + provisions for addressing, at a minimum, the following: + ``(A) Coordination among agencies within the + Department, which shall include steps to minimize + duplication of efforts and utilization of common quality + measures, where available. Such common quality measures + shall be measures identified by the Secretary under + section 1139A or 1139B of the Social Security Act or + endorsed under section 1890 of such Act. + ``(B) Agency-specific strategic plans to achieve + national priorities. + ``(C) Establishment of annual benchmarks for each + relevant agency to achieve national priorities. + ``(D) A process for regular reporting by the + agencies to the Secretary on the implementation of the + strategic plan. + ``(E) Strategies to align public and private payers + with regard to quality and patient safety efforts. + ``(F) Incorporating quality improvement and + measurement in the strategic plan for health information + technology required by the American Recovery and + Reinvestment Act of 2009 (Public Law 111-5). + + ``(c) Periodic Update of National Strategy.--The Secretary shall +update the national strategy not less than annually. Any such update +shall include a review of short- and long-term goals. + ``(d) Submission and Availability of National Strategy and +Updates.-- + ``(1) Deadline for initial submission of national + strategy.--Not later than January 1, 2011, the Secretary shall + submit to the relevant committees of Congress the national + strategy described in subsection (a). + ``(2) Updates.-- + ``(A) In general.--The Secretary shall submit to the + relevant committees of Congress an annual update to the + strategy described in paragraph (1). + ``(B) Information submitted.--Each update submitted + under subparagraph (A) shall include-- + +[[Page 124 STAT. 380]] + + ``(i) a review of the short- and long-term + goals of the national strategy and any gaps in + such strategy; + ``(ii) an analysis of the progress, or lack of + progress, in meeting such goals and any barriers + to such progress; + ``(iii) the information reported under section + 1139A of the Social Security Act, consistent with + the reporting requirements of such section; and + ``(iv) in the case of an update required to be + submitted on or after January 1, 2014, the + information reported under section 1139B(b)(4) of + the Social Security Act, consistent with the + reporting requirements of such section. + ``(C) Satisfaction of other reporting + requirements.--Compliance with the requirements of + clauses (iii) and (iv) of subparagraph (B) shall satisfy + the reporting requirements under sections 1139A(a)(6) + and 1139B(b)(4), respectively, of the Social Security + Act. + + ``(e) Health Care Quality Internet Website.-- +<<NOTE: Deadline. Public information.>> Not later than January 1, 2011, +the Secretary shall create an Internet website to make public +information regarding-- + ``(1) the national priorities for health care quality + improvement established under subsection (a)(2); + ``(2) the agency-specific strategic plans for health care + quality described in subsection (b)(2)(B); and + ``(3) other information, as the Secretary determines to be + appropriate.''. + +SEC. 3012. <<NOTE: 42 USC 280j note.>> INTERAGENCY WORKING GROUP ON + HEALTH CARE QUALITY. + + (a) <<NOTE: President. Establishment.>> In General.--The President +shall convene a working group to be known as the Interagency Working +Group on Health Care Quality (referred to in this section as the +``Working Group''). + + (b) Goals.--The goals of the Working Group shall be to achieve the +following: + (1) Collaboration, cooperation, and consultation between + Federal departments and agencies with respect to developing and + disseminating strategies, goals, models, and timetables that are + consistent with the national priorities identified under section + 399HH(a)(2) of the Public Health Service Act (as added by + section 3011). + (2) Avoidance of inefficient duplication of quality + improvement efforts and resources, where practicable, and a + streamlined process for quality reporting and compliance + requirements. + (3) Assess alignment of quality efforts in the public sector + with private sector initiatives. + + (c) Composition.-- + (1) In general.--The Working Group shall be composed of + senior level representatives of-- + (A) the Department of Health and Human Services; + (B) the Centers for Medicare & Medicaid Services; + (C) the National Institutes of Health; + (D) the Centers for Disease Control and Prevention; + (E) the Food and Drug Administration; + (F) the Health Resources and Services + Administration; + (G) the Agency for Healthcare Research and Quality; + +[[Page 124 STAT. 381]] + + (H) the Office of the National Coordinator for + Health Information Technology; + (I) the Substance Abuse and Mental Health Services + Administration; + (J) the Administration for Children and Families; + (K) the Department of Commerce; + (L) the Office of Management and Budget; + (M) the United States Coast Guard; + (N) the Federal Bureau of Prisons; + (O) the National Highway Traffic Safety + Administration; + (P) the Federal Trade Commission; + (Q) the Social Security Administration; + (R) the Department of Labor; + (S) the United States Office of Personnel + Management; + (T) the Department of Defense; + (U) the Department of Education; + (V) the Department of Veterans Affairs; + (W) the Veterans Health Administration; and + (X) any other Federal agencies and departments with + activities relating to improving health care quality and + safety, as determined by the President. + (2) Chair and vice-chair.-- + (A) Chair.--The Working Group shall be chaired by + the Secretary of Health and Human Services. + (B) Vice chair.--Members of the Working Group, other + than the Secretary of Health and Human Services, shall + serve as Vice Chair of the Group on a rotating basis, as + determined by the Group. + + (d) Report to Congress.-- <<NOTE: Public information. Web +posting.>> Not later than December 31, 2010, and annually thereafter, +the Working Group shall submit to the relevant Committees of Congress, +and make public on an Internet website, a report describing the progress +and recommendations of the Working Group in meeting the goals described +in subsection (b). + +SEC. 3013. QUALITY MEASURE DEVELOPMENT. + + (a) Public Health Service Act.--Title IX of the Public Health +Service Act (42 U.S.C. 299 et seq.) is amended-- + (1) by redesignating part D as part E; + (2) <<NOTE: 42 USC 299c--299c-7.>> by redesignating sections + 931 through 938 as sections 941 through 948, respectively; + (3) in section 948(1), as so redesignated, by striking + ``931'' and inserting ``941''; and + (4) by inserting after section 926 the following: + + ``PART D--HEALTH CARE QUALITY IMPROVEMENT + + ``Subpart I--Quality Measure Development + +``SEC. 931. <<NOTE: 42 USC 299b-31.>> QUALITY MEASURE DEVELOPMENT. + + ``(a) Quality Measure.-- <<NOTE: Definition.>> In this subpart, the +term `quality measure' means a standard for measuring the performance +and improvement of population health or of health plans, providers of +services, and other clinicians in the delivery of health care services. + +[[Page 124 STAT. 382]] + + ``(b) Identification of Quality Measures.-- + ``(1) <<NOTE: Consultation.>> Identification.--The + Secretary, in consultation with the Director of the Agency for + Healthcare Research and Quality and the Administrator of the + Centers for Medicare & Medicaid Services, shall identify, not + less often than triennially, gaps where no quality measures + exist and existing quality measures that need improvement, + updating, or expansion, consistent with the national strategy + under section 399HH, to the extent available, for use in Federal + health programs. In identifying such gaps and existing quality + measures that need improvement, the Secretary shall take into + consideration-- + ``(A) the gaps identified by the entity with a + contract under section 1890(a) of the Social Security + Act and other stakeholders; + ``(B) quality measures identified by the pediatric + quality measures program under section 1139A of the + Social Security Act; and + ``(C) quality measures identified through the + Medicaid Quality Measurement Program under section 1139B + of the Social Security Act. + ``(2) Publication.-- <<NOTE: Public information. Web + posting. Reports.>> The Secretary shall make available to the + public on an Internet website a report on any gaps identified + under paragraph (1) and the process used to make such + identification. + + ``(c) Grants or Contracts for Quality Measure Development.-- + ``(1) In general.--The Secretary shall award grants, + contracts, or intergovernmental agreements to eligible entities + for purposes of developing, improving, updating, or expanding + quality measures identified under subsection (b). + ``(2) Prioritization in the development of quality + measures.--In awarding grants, contracts, or agreements under + this subsection, the Secretary shall give priority to the + development of quality measures that allow the assessment of-- + ``(A) health outcomes and functional status of + patients; + ``(B) the management and coordination of health care + across episodes of care and care transitions for + patients across the continuum of providers, health care + settings, and health plans; + ``(C) the experience, quality, and use of + information provided to and used by patients, + caregivers, and authorized representatives to inform + decisionmaking about treatment options, including the + use of shared decisionmaking tools and preference + sensitive care (as defined in section 936); + ``(D) the meaningful use of health information + technology; + ``(E) the safety, effectiveness, patient- + centeredness, appropriateness, and timeliness of care; + ``(F) the efficiency of care; + ``(G) the equity of health services and health + disparities across health disparity populations (as + defined in section 485E) and geographic areas; + ``(H) patient experience and satisfaction; + ``(I) the use of innovative strategies and + methodologies identified under section 933; and + +[[Page 124 STAT. 383]] + + ``(J) other areas determined appropriate by the + Secretary. + ``(3) Eligible entities.--To be eligible for a grant or + contract under this subsection, an entity shall-- + ``(A) have demonstrated expertise and capacity in + the development and evaluation of quality measures; + ``(B) have adopted procedures to include in the + quality measure development process-- + ``(i) the views of those providers or payers + whose performance will be assessed by the measure; + and + ``(ii) the views of other parties who also + will use the quality measures (such as patients, + consumers, and health care purchasers); + ``(C) collaborate with the entity with a contract + under section 1890(a) of the Social Security Act and + other stakeholders, as practicable, and the Secretary so + that quality measures developed by the eligible entity + will meet the requirements to be considered for + endorsement by the entity with a contract under such + section 1890(a); + ``(D) have transparent policies regarding governance + and conflicts of interest; and + ``(E) submit an application to the Secretary at such + time and in such manner, as the Secretary may require. + ``(4) <<NOTE: Requirements.>> Use of funds.--An entity that + receives a grant, contract, or agreement under this subsection + shall use such award to develop quality measures that meet the + following requirements: + ``(A) Such measures support measures required to be + reported under the Social Security Act, where + applicable, and in support of gaps and existing quality + measures that need improvement, as described in + subsection (b)(1)(A). + ``(B) Such measures support measures developed under + section 1139A of the Social Security Act and the + Medicaid Quality Measurement Program under section 1139B + of such Act, where applicable. + ``(C) To the extent practicable, data on such + quality measures is able to be collected using health + information technologies. + ``(D) Each quality measure is free of charge to + users of such measure. + ``(E) Each quality measure is publicly available on + an Internet website. + + ``(d) Other Activities by the Secretary.--The Secretary may use +amounts available under this section to update and test, where +applicable, quality measures endorsed by the entity with a contract +under section 1890(a) of the Social Security Act or adopted by the +Secretary. + ``(e) Coordination of Grants.--The Secretary shall ensure that +grants or contracts awarded under this section are coordinated with +grants and contracts awarded under sections 1139A(5) and 1139B(4)(A) of +the Social Security Act.''. + (b) Social Security Act.--Section 1890A of the Social Security Act, +as added by section 3014(b), is amended by adding at the end the +following new subsection: + ``(e) Development of Quality Measures.--The Administrator of the +Center for Medicare & Medicaid Services shall through contracts develop +quality measures (as determined appropriate by + +[[Page 124 STAT. 384]] + +the Administrator) for use under this Act. In developing such measures, +the Administrator shall consult with the Director of the Agency for +Healthcare Research and Quality.''. + (c) Funding.--There are authorized to be appropriated to the +Secretary of Health and Human Services to carry out this section, +$75,000,000 for each of fiscal years 2010 through 2014. Of the amounts +appropriated under the preceding sentence in a fiscal year, not less +than 50 percent of such amounts shall be used pursuant to subsection (e) +of section 1890A of the Social Security Act, as added by subsection (b), +with respect to programs under such Act. Amounts appropriated under this +subsection for a fiscal year shall remain available until expended. + +SEC. 3014. QUALITY MEASUREMENT. + + (a) New Duties for Consensus-based Entity.-- + (1) Multi-stakeholder group input.--Section 1890(b) of the + Social Security Act (42 U.S.C. 1395aaa(b)), as amended by + section 3003, is amended by adding at the end the following new + paragraphs: + ``(7) Convening multi-stakeholder groups.-- + ``(A) In general.--The entity shall convene multi- + stakeholder groups to provide input on-- + ``(i) the selection of quality measures + described in subparagraph (B), from among-- + ``(I) such measures that have been + endorsed by the entity; and + ``(II) such measures that have not + been considered for endorsement by such + entity but are used or proposed to be + used by the Secretary for the collection + or reporting of quality measures; and + ``(ii) national priorities (as identified + under section 399HH of the Public Health Service + Act) for improvement in population health and in + the delivery of health care services for + consideration under the national strategy + established under section 399HH of the Public + Health Service Act. + ``(B) Quality measures.-- + ``(i) In general.--Subject to clause (ii), the + quality measures described in this subparagraph + are quality measures-- + ``(I) for use pursuant to sections + 1814(i)(5)(D), 1833(i)(7), 1833(t)(17), + 1848(k)(2)(C), 1866(k)(3), + 1881(h)(2)(A)(iii), 1886(b)(3)(B)(viii), + 1886(j)(7)(D), 1886(m)(5)(D), + 1886(o)(2), and 1895(b)(3)(B)(v); + ``(II) for use in reporting + performance information to the public; + and + ``(III) for use in health care + programs other than for use under this + Act. + ``(ii) Exclusion.--Data sets (such as the + outcome and assessment information set for home + health services and the minimum data set for + skilled nursing facility services) that are used + for purposes of classification systems used in + establishing payment rates under this title shall + not be quality measures described in this + subparagraph. + ``(C) Requirement for transparency in process.-- + +[[Page 124 STAT. 385]] + + ``(i) In general.--In convening multi- + stakeholder groups under subparagraph (A) with + respect to the selection of quality measures, the + entity shall provide for an open and transparent + process for the activities conducted pursuant to + such convening. + ``(ii) Selection of organizations + participating in multi-stakeholder groups.--The + process described in clause (i) shall ensure that + the selection of representatives comprising such + groups provides for public nominations for, and + the opportunity for public comment on, such + selection. + ``(D) Multi-stakeholder group defined.--In this + paragraph, the term `multi-stakeholder group' means, + with respect to a quality measure, a voluntary + collaborative of organizations representing a broad + group of stakeholders interested in or affected by the + use of such quality measure. + ``(8) Transmission of multi-stakeholder input.-- + <<NOTE: Deadline.>> Not later than February 1 of each year + (beginning with 2012), the entity shall transmit to the + Secretary the input of multi-stakeholder groups provided under + paragraph (7).''. + (2) Annual report.--Section 1890(b)(5)(A) of the Social + Security Act (42 U.S.C. 1395aaa(b)(5)(A)) is amended-- + (A) in clause (ii), by striking ``and'' at the end; + (B) in clause (iii), by striking the period at the + end and inserting a semicolon; and + (C) by adding at the end the following new clauses: + ``(iv) gaps in endorsed quality measures, + which shall include measures that are within + priority areas identified by the Secretary under + the national strategy established under section + 399HH of the Public Health Service Act, and where + quality measures are unavailable or inadequate to + identify or address such gaps; + ``(v) areas in which evidence is insufficient + to support endorsement of quality measures in + priority areas identified by the Secretary under + the national strategy established under section + 399HH of the Public Health Service Act and where + targeted research may address such gaps; and + ``(vi) the matters described in clauses (i) + and (ii) of paragraph (7)(A).''. + + (b) Multi-stakeholder Group Input Into Selection of Quality +Measures.--Title XVIII of the Social Security Act (42 U.S.C. 1395 et +seq.) is amended by inserting after section 1890 the following: + + + ``quality measurement + + + ``Sec. 1890A. <<NOTE: Deadlines. 42 USC 1395aaa-1.>> (a) Multi- +stakeholder Group Input Into Selection of Quality Measures.-- +<<NOTE: Regulations.>> The Secretary shall establish a pre-rulemaking +process under which the following steps occur with respect to the +selection of quality measures described in section 1890(b)(7)(B): + ``(1) Input.--Pursuant to section 1890(b)(7), the entity + with a contract under section 1890 shall convene multi- + stakeholder groups to provide input to the Secretary on the + selection of quality measures described in subparagraph (B) of + such paragraph. + +[[Page 124 STAT. 386]] + + ``(2) Public availability of measures considered for + selection.--Not later than December 1 of each year (beginning + with 2011), the Secretary shall make available to the public a + list of quality measures described in section 1890(b)(7)(B) that + the Secretary is considering under this title. + ``(3) Transmission of multi-stakeholder input.--Pursuant to + section 1890(b)(8), not later than February 1 of each year + (beginning with 2012), the entity shall transmit to the + Secretary the input of multi-stakeholder groups described in + paragraph (1). + ``(4) Consideration of multi-stakeholder input.--The + Secretary shall take into consideration the input from multi- + stakeholder groups described in paragraph (1) in selecting + quality measures described in section 1890(b)(7)(B) that have + been endorsed by the entity with a contract under section 1890 + and measures that have not been endorsed by such entity. + ``(5) Rationale for use of quality measures.-- + <<NOTE: Federal Register, publication.>> The Secretary shall + publish in the Federal Register the rationale for the use of any + quality measure described in section 1890(b)(7)(B) that has not + been endorsed by the entity with a contract under section 1890. + ``(6) Assessment of impact.--Not later than March 1, 2012, + and at least once every three years thereafter, the Secretary + shall-- + ``(A) conduct an assessment of the quality impact of + the use of endorsed measures described in section + 1890(b)(7)(B); and + ``(B) <<NOTE: Public information.>> make such + assessment available to the public. + + ``(b) Process for Dissemination of Measures Used by the Secretary.-- + ``(1) In general.--The Secretary shall establish a process + for disseminating quality measures used by the Secretary. Such + process shall include the following: + ``(A) The incorporation of such measures, where + applicable, in workforce programs, training curricula, + and any other means of dissemination determined + appropriate by the Secretary. + ``(B) The dissemination of such quality measures + through the national strategy developed under section + 399HH of the Public Health Service Act. + ``(2) Existing methods.--To the extent practicable, the + Secretary shall utilize and expand existing dissemination + methods in disseminating quality measures under the process + established under paragraph (1). + + ``(c) Review of Quality Measures Used by the Secretary.-- + ``(1) In general.--The Secretary shall-- + ``(A) periodically (but in no case less often than + once every 3 years) review quality measures described in + section 1890(b)(7)(B); and + ``(B) with respect to each such measure, determine + whether to-- + ``(i) maintain the use of such measure; or + ``(ii) phase out such measure. + ``(2) Considerations.--In conducting the review under + paragraph (1), the Secretary shall take steps to-- + ``(A) seek to avoid duplication of measures used; + and + +[[Page 124 STAT. 387]] + + ``(B) take into consideration current innovative + methodologies and strategies for quality improvement + practices in the delivery of health care services that + represent best practices for such quality improvement + and measures endorsed by the entity with a contract + under section 1890 since the previous review by the + Secretary. + + ``(d) Rule of Construction.--Nothing in this section shall preclude +a State from using the quality measures identified under sections 1139A +and 1139B.''. + (c) Funding.--For purposes of carrying out the amendments made by +this section, the Secretary shall provide for the transfer, from the +Federal Hospital Insurance Trust Fund under section 1817 of the Social +Security Act (42 U.S.C. 1395i) and the Federal Supplementary Medical +Insurance Trust Fund under section 1841 of such Act (42 U.S.C. 1395t), +in such proportion as the Secretary determines appropriate, of +$20,000,000, to the Centers for Medicare & Medicaid Services Program +Management Account for each of fiscal years 2010 through 2014. Amounts +transferred under the preceding sentence shall remain available until +expended. + +SEC. 3015. DATA COLLECTION; PUBLIC REPORTING. + + Title III of the Public Health Service Act (42 U.S.C. 241 et seq.), +as amended by section 3011, is further amended by adding at the end the +following: + +``SEC. 399II. <<NOTE: 42 USC 280j-1.>> COLLECTION AND ANALYSIS OF DATA + FOR QUALITY AND RESOURCE USE MEASURES. + + ``(a) In General.--The Secretary shall collect and aggregate +consistent data on quality and resource use measures from information +systems used to support health care delivery to implement the public +reporting of performance information, as described in section 399JJ, and +may award grants or contracts for this purpose. The Secretary shall +ensure that such collection, aggregation, and analysis systems span an +increasingly broad range of patient populations, providers, and +geographic areas over time. + ``(b) Grants or Contracts for Data Collection.-- + ``(1) In general.--The Secretary may award grants or + contracts to eligible entities to support new, or improve + existing, efforts to collect and aggregate quality and resource + use measures described under subsection (c). + ``(2) Eligible entities.--To be eligible for a grant or + contract under this subsection, an entity shall-- + ``(A) be-- + ``(i) a multi-stakeholder entity that + coordinates the development of methods and + implementation plans for the consistent reporting + of summary quality and cost information; + ``(ii) an entity capable of submitting such + summary data for a particular population and + providers, such as a disease registry, regional + collaboration, health plan collaboration, or other + population-wide source; or + ``(iii) a Federal Indian Health Service + program or a health program operated by an Indian + tribe (as defined in section 4 of the Indian + Health Care Improvement Act); + ``(B) promote the use of the systems that provide + data to improve and coordinate patient care; + +[[Page 124 STAT. 388]] + + ``(C) support the provision of timely, consistent + quality and resource use information to health care + providers, and other groups and organizations as + appropriate, with an opportunity for providers to + correct inaccurate measures; and + ``(D) agree to report, as determined by the + Secretary, measures on quality and resource use to the + public in accordance with the public reporting process + established under section 399JJ. + + ``(c) Consistent Data Aggregation.-- <<NOTE: Standards.>> The +Secretary may award grants or contracts under this section only to +entities that enable summary data that can be integrated and compared +across multiple sources. The Secretary shall provide standards for the +protection of the security and privacy of patient data. + + ``(d) Matching Funds.--The Secretary may not award a grant or +contract under this section to an entity unless the entity agrees that +it will make available (directly or through contributions from other +public or private entities) non-Federal contributions toward the +activities to be carried out under the grant or contract in an amount +equal to $1 for each $5 of Federal funds provided under the grant or +contract. Such non-Federal matching funds may be provided directly or +through donations from public or private entities and may be in cash or +in-kind, fairly evaluated, including plant, equipment, or services. + ``(e) Authorization of Appropriations.--To carry out this section, +there are authorized to be appropriated such sums as may be necessary +for fiscal years 2010 through 2014. + +``SEC. 399JJ. <<NOTE: 42 USC 280j-2.>> PUBLIC REPORTING OF PERFORMANCE + INFORMATION. + + ``(a) Development of Performance Websites.-- <<NOTE: Web +posting.>> The Secretary shall make available to the public, through +standardized Internet websites, performance information summarizing data +on quality measures. Such information shall be tailored to respond to +the differing needs of hospitals and other institutional health care +providers, physicians and other clinicians, patients, consumers, +researchers, policymakers, States, and other stakeholders, as the +Secretary may specify. + + ``(b) Information on Conditions.--The performance information made +publicly available on an Internet website, as described in subsection +(a), shall include information regarding clinical conditions to the +extent such information is available, and the information shall, where +appropriate, be provider-specific and sufficiently disaggregated and +specific to meet the needs of patients with different clinical +conditions. + ``(c) Consultation.-- + ``(1) In general.--In carrying out this section, the + Secretary shall consult with the entity with a contract under + section 1890(a) of the Social Security Act, and other entities, + as appropriate, to determine the type of information that is + useful to stakeholders and the format that best facilitates use + of the reports and of performance reporting Internet websites. + ``(2) Consultation with stakeholders.--The entity with a + contract under section 1890(a) of the Social Security Act shall + convene multi-stakeholder groups, as described in such section, + to review the design and format of each Internet website made + available under subsection (a) and shall transmit + +[[Page 124 STAT. 389]] + + to the Secretary the views of such multi-stakeholder groups with + respect to each such design and format. + + ``(d) Coordination.--Where appropriate, the Secretary shall +coordinate the manner in which data are presented through Internet +websites described in subsection (a) and for public reporting of other +quality measures by the Secretary, including such quality measures under +title XVIII of the Social Security Act. + ``(e) Authorization of Appropriations.--To carry out this section, +there are authorized to be appropriated such sums as may be necessary +for fiscal years 2010 through 2014.''. + + PART III--ENCOURAGING DEVELOPMENT OF NEW PATIENT CARE MODELS + +SEC. 3021. ESTABLISHMENT OF CENTER FOR MEDICARE AND MEDICAID INNOVATION + WITHIN CMS. + + (a) In General.--Title XI of the Social Security Act is amended by +inserting after section 1115 the following new section: + + + ``center for medicare and medicaid innovation + + + ``Sec. 1115A. <<NOTE: 42 USC 1315a.>> (a) Center for Medicare and +Medicaid Innovation Established.-- + ``(1) In general.--There is created within the Centers for + Medicare & Medicaid Services a Center for Medicare and Medicaid + Innovation (in this section referred to as the `CMI') to carry + out the duties described in this section. The purpose of the CMI + is to test innovative payment and service delivery models to + reduce program expenditures under the applicable titles while + preserving or enhancing the quality of care furnished to + individuals under such titles. In selecting such models, the + Secretary shall give preference to models that also improve the + coordination, quality, and efficiency of health care services + furnished to applicable individuals defined in paragraph (4)(A). + ``(2) Deadline.--The Secretary shall ensure that the CMI is + carrying out the duties described in this section by not later + than January 1, 2011. + ``(3) Consultation.--In carrying out the duties under this + section, the CMI shall consult representatives of relevant + Federal agencies, and clinical and analytical experts with + expertise in medicine and health care management. The CMI shall + use open door forums or other mechanisms to seek input from + interested parties. + ``(4) Definitions.--In this section: + ``(A) Applicable individual.--The term `applicable + individual' means-- + ``(i) an individual who is entitled to, or + enrolled for, benefits under part A of title XVIII + or enrolled for benefits under part B of such + title; + ``(ii) an individual who is eligible for + medical assistance under title XIX, under a State + plan or waiver; or + ``(iii) an individual who meets the criteria + of both clauses (i) and (ii). + ``(B) Applicable title.--The term `applicable title' + means title XVIII, title XIX, or both. + +[[Page 124 STAT. 390]] + + ``(b) Testing of Models (Phase I).-- + ``(1) In general.--The CMI shall test payment and service + delivery models in accordance with selection criteria under + paragraph (2) to determine the effect of applying such models + under the applicable title (as defined in subsection (a)(4)(B)) + on program expenditures under such titles and the quality of + care received by individuals receiving benefits under such + title. + ``(2) Selection of models to be tested.-- + ``(A) <<NOTE: Determination.>> In general.--The + Secretary shall select models to be tested from models + where the Secretary determines that there is evidence + that the model addresses a defined population for which + there are deficits in care leading to poor clinical + outcomes or potentially avoidable expenditures. The + models selected under the preceding sentence may include + the models described in subparagraph (B). + ``(B) Opportunities.--The models described in this + subparagraph are the following models: + ``(i) Promoting broad payment and practice + reform in primary care, including patient-centered + medical home models for high-need applicable + individuals, medical homes that address women's + unique health care needs, and models that + transition primary care practices away from fee- + for-service based reimbursement and toward + comprehensive payment or salary-based payment. + ``(ii) Contracting directly with groups of + providers of services and suppliers to promote + innovative care delivery models, such as through + risk-based comprehensive payment or salary-based + payment. + ``(iii) Utilizing geriatric assessments and + comprehensive care plans to coordinate the care + (including through interdisciplinary teams) of + applicable individuals with multiple chronic + conditions and at least one of the following: + ``(I) An inability to perform 2 or + more activities of daily living. + ``(II) Cognitive impairment, + including dementia. + ``(iv) Promote care coordination between + providers of services and suppliers that + transition health care providers away from fee- + for-service based reimbursement and toward salary- + based payment. + ``(v) Supporting care coordination for + chronically-ill applicable individuals at high + risk of hospitalization through a health + information technology-enabled provider network + that includes care coordinators, a chronic disease + registry, and home tele-health technology. + ``(vi) Varying payment to physicians who order + advanced diagnostic imaging services (as defined + in section 1834(e)(1)(B)) according to the + physician's adherence to appropriateness criteria + for the ordering of such services, as determined + in consultation with physician specialty groups + and other relevant stakeholders. + +[[Page 124 STAT. 391]] + + ``(vii) Utilizing medication therapy + management services, such as those described in + section 935 of the Public Health Service Act. + ``(viii) Establishing community-based health + teams to support small-practice medical homes by + assisting the primary care practitioner in chronic + care management, including patient self- + management, activities. + ``(ix) Assisting applicable individuals in + making informed health care choices by paying + providers of services and suppliers for using + patient decision-support tools, including tools + that meet the standards developed and identified + under section 936(c)(2)(A) of the Public Health + Service Act, that improve applicable individual + and caregiver understanding of medical treatment + options. + ``(x) Allowing States to test and evaluate + fully integrating care for dual eligible + individuals in the State, including the management + and oversight of all funds under the applicable + titles with respect to such individuals. + ``(xi) Allowing States to test and evaluate + systems of all-payer payment reform for the + medical care of residents of the State, including + dual eligible individuals. + ``(xii) Aligning nationally recognized, + evidence-based guidelines of cancer care with + payment incentives under title XVIII in the areas + of treatment planning and follow-up care planning + for applicable individuals described in clause (i) + or (iii) of subsection (a)(4)(A) with cancer, + including the identification of gaps in applicable + quality measures. + ``(xiii) Improving post-acute care through + continuing care hospitals that offer inpatient + rehabilitation, long-term care hospitals, and home + health or skilled nursing care during an inpatient + stay and the 30 days immediately following + discharge. + ``(xiv) Funding home health providers who + offer chronic care management services to + applicable individuals in cooperation with + interdisciplinary teams. + ``(xv) Promoting improved quality and reduced + cost by developing a collaborative of high- + quality, low-cost health care institutions that is + responsible for-- + ``(I) developing, documenting, and + disseminating best practices and proven + care methods; + ``(II) implementing such best + practices and proven care methods within + such institutions to demonstrate further + improvements in quality and efficiency; + and + ``(III) providing assistance to + other health care institutions on how + best to employ such best practices and + proven care methods to improve health + care quality and lower costs. + ``(xvi) Facilitate inpatient care, including + intensive care, of hospitalized applicable + individuals at their local hospital through the + use of electronic monitoring by specialists, + including intensivists and critical care + specialists, based at integrated health systems. + +[[Page 124 STAT. 392]] + + ``(xvii) Promoting greater efficiencies and + timely access to outpatient services (such as + outpatient physical therapy services) through + models that do not require a physician or other + health professional to refer the service or be + involved in establishing the plan of care for the + service, when such service is furnished by a + health professional who has the authority to + furnish the service under existing State law. + ``(xviii) Establishing comprehensive payments + to Healthcare Innovation Zones, consisting of + groups of providers that include a teaching + hospital, physicians, and other clinical entities, + that, through their structure, operations, and + joint-activity deliver a full spectrum of + integrated and comprehensive health care services + to applicable individuals while also incorporating + innovative methods for the clinical training of + future health care professionals. + ``(C) Additional factors for consideration.--In + selecting models for testing under subparagraph (A), the + CMI may consider the following additional factors: + ``(i) Whether the model includes a regular + process for monitoring and updating patient care + plans in a manner that is consistent with the + needs and preferences of applicable individuals. + ``(ii) Whether the model places the applicable + individual, including family members and other + informal caregivers of the applicable individual, + at the center of the care team of the applicable + individual. + ``(iii) Whether the model provides for in- + person contact with applicable individuals. + ``(iv) Whether the model utilizes technology, + such as electronic health records and patient- + based remote monitoring systems, to coordinate + care over time and across settings. + ``(v) Whether the model provides for the + maintenance of a close relationship between care + coordinators, primary care practitioners, + specialist physicians, community-based + organizations, and other providers of services and + suppliers. + ``(vi) Whether the model relies on a team- + based approach to interventions, such as + comprehensive care assessments, care planning, and + self-management coaching. + ``(vii) Whether, under the model, providers of + services and suppliers are able to share + information with patients, caregivers, and other + providers of services and suppliers on a real time + basis. + ``(3) Budget neutrality.-- + ``(A) Initial period.--The Secretary shall not + require, as a condition for testing a model under + paragraph (1), that the design of such model ensure that + such model is budget neutral initially with respect to + expenditures under the applicable title. + ``(B) <<NOTE: Determination.>> Termination or + modification.--The Secretary shall terminate or modify + the design and implementation of a model unless the + Secretary determines (and the Chief Actuary of the + Centers for Medicare & Medicaid Services, + +[[Page 124 STAT. 393]] + + with respect to program spending under the applicable + title, certifies), after testing has begun, that the + model is expected to-- + ``(i) improve the quality of care (as + determined by the Administrator of the Centers for + Medicare & Medicaid Services) without increasing + spending under the applicable title; + ``(ii) reduce spending under the applicable + title without reducing the quality of care; or + ``(iii) improve the quality of care and reduce + spending. + Such termination may occur at any time after such + testing has begun and before completion of the testing. + ``(4) Evaluation.-- + ``(A) In general.--The Secretary shall conduct an + evaluation of each model tested under this subsection. + Such evaluation shall include an analysis of-- + ``(i) the quality of care furnished under the + model, including the measurement of patient-level + outcomes and patient-centeredness criteria + determined appropriate by the Secretary; and + ``(ii) the changes in spending under the + applicable titles by reason of the model. + ``(B) Information.-- <<NOTE: Public + information. Determination.>> The Secretary shall make + the results of each evaluation under this paragraph + available to the public in a timely fashion and may + establish requirements for States and other entities + participating in the testing of models under this + section to collect and report information that the + Secretary determines is necessary to monitor and + evaluate such models. + + ``(c) <<NOTE: Determination.>> Expansion of Models (Phase II).-- +Taking into account the evaluation under subsection (b)(4), the +Secretary may, through rulemaking, expand (including implementation on a +nationwide basis) the duration and the scope of a model that is being +tested under subsection (b) or a demonstration project under section +1866C, to the extent determined appropriate by the Secretary, if-- + ``(1) the Secretary determines that such expansion is + expected to-- + ``(A) reduce spending under applicable title without + reducing the quality of care; or + ``(B) improve the quality of care and reduce + spending; and + ``(2) <<NOTE: Certification.>> the Chief Actuary of the + Centers for Medicare & Medicaid Services certifies that such + expansion would reduce program spending under applicable titles. + + ``(d) Implementation.-- + ``(1) Waiver authority.--The Secretary may waive such + requirements of titles XI and XVIII and of sections 1902(a)(1), + 1902(a)(13), and 1903(m)(2)(A)(iii) as may be necessary solely + for purposes of carrying out this section with respect to + testing models described in subsection (b). + ``(2) Limitations on review.--There shall be no + administrative or judicial review under section 1869, section + 1878, or otherwise of-- + ``(A) the selection of models for testing or + expansion under this section; + +[[Page 124 STAT. 394]] + + ``(B) the selection of organizations, sites, or + participants to test those models selected; + ``(C) the elements, parameters, scope, and duration + of such models for testing or dissemination; + ``(D) determinations regarding budget neutrality + under subsection (b)(3); + ``(E) the termination or modification of the design + and implementation of a model under subsection + (b)(3)(B); and + ``(F) determinations about expansion of the duration + and scope of a model under subsection (c), including the + determination that a model is not expected to meet + criteria described in paragraph (1) or (2) of such + subsection. + ``(3) Administration.--Chapter 35 of title 44, United States + Code, shall not apply to the testing and evaluation of models or + expansion of such models under this section. + + ``(e) Application to CHIP.--The Center may carry out activities +under this section with respect to title XXI in the same manner as +provided under this section with respect to the program under the +applicable titles. + ``(f) Funding.-- + ``(1) In general.--There are appropriated, from amounts in + the Treasury not otherwise appropriated-- + ``(A) $5,000,000 for the design, implementation, and + evaluation of models under subsection (b) for fiscal + year 2010; + ``(B) $10,000,000,000 for the activities initiated + under this section for the period of fiscal years 2011 + through 2019; and + ``(C) the amount described in subparagraph (B) for + the activities initiated under this section for each + subsequent 10-year fiscal period (beginning with the 10- + year fiscal period beginning with fiscal year 2020). + Amounts appropriated under the preceding sentence shall remain + available until expended. + ``(2) Use of certain funds.--Out of amounts appropriated + under subparagraphs (B) and (C) of paragraph (1), not less than + $25,000,000 shall be made available each such fiscal year to + design, implement, and evaluate models under subsection (b). + + ``(g) Report to Congress.--Beginning in 2012, and not less than once +every other year thereafter, the Secretary shall submit to Congress a +report on activities under this section. Each such report shall describe +the models tested under subsection (b), including the number of +individuals described in subsection (a)(4)(A)(i) and of individuals +described in subsection (a)(4)(A)(ii) participating in such models and +payments made under applicable titles for services on behalf of such +individuals, any models chosen for expansion under subsection (c), and +the results from evaluations under subsection +(b)(4). <<NOTE: Determination.>> In addition, each such report shall +provide such recommendations as the Secretary determines are appropriate +for legislative action to facilitate the development and expansion of +successful payment models.''. + + (b) Medicaid Conforming Amendment.--Section 1902(a) of the Social +Security Act (42 U.S.C. 1396a(a)), as amended by section 8002(b), is +amended-- + (1) in paragraph (81), by striking ``and'' at the end; + +[[Page 124 STAT. 395]] + + (2) in paragraph (82), by striking the period at the end and + inserting ``; and''; and + (3) by inserting after paragraph (82) the following new + paragraph: + ``(83) provide for implementation of the payment models + specified by the Secretary under section 1115A(c) for + implementation on a nationwide basis unless the State + demonstrates to the satisfaction of the Secretary that + implementation would not be administratively feasible or + appropriate to the health care delivery system of the State.''. + + (c) Revisions to Health Care Quality Demonstration Program.-- +Subsections (b) and (f) of section 1866C of the Social Security Act (42 +U.S.C. 1395cc-3) are amended by striking ``5-year'' each place it +appears. + +SEC. 3022. MEDICARE SHARED SAVINGS PROGRAM. + + Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is +amended by adding at the end the following new section: + + + ``shared savings program + + + ``Sec. 1899. <<NOTE: 42 USC 1395jjj.>> (a) Establishment.-- + ``(1) In general.-- <<NOTE: Deadline.>> Not later than + January 1, 2012, the Secretary shall establish a shared savings + program (in this section referred to as the `program') that + promotes accountability for a patient population and coordinates + items and services under parts A and B, and encourages + investment in infrastructure and redesigned care processes for + high quality and efficient service delivery. Under such + program-- + ``(A) groups of providers of services and suppliers + meeting criteria specified by the Secretary may work + together to manage and coordinate care for Medicare fee- + for-service beneficiaries through an accountable care + organization (referred to in this section as an `ACO'); + and + ``(B) ACOs that meet quality performance standards + established by the Secretary are eligible to receive + payments for shared savings under subsection (d)(2). + + ``(b) Eligible ACOs.-- + ``(1) In general.--Subject to the succeeding provisions of + this subsection, as determined appropriate by the Secretary, the + following groups of providers of services and suppliers which + have established a mechanism for shared governance are eligible + to participate as ACOs under the program under this section: + ``(A) ACO professionals in group practice + arrangements. + ``(B) Networks of individual practices of ACO + professionals. + ``(C) Partnerships or joint venture arrangements + between hospitals and ACO professionals. + ``(D) Hospitals employing ACO professionals. + ``(E) Such other groups of providers of services and + suppliers as the Secretary determines appropriate. + ``(2) Requirements.--An ACO shall meet the following + requirements: + ``(A) The ACO shall be willing to become accountable + for the quality, cost, and overall care of the Medicare + fee-for-service beneficiaries assigned to it. + +[[Page 124 STAT. 396]] + + ``(B) <<NOTE: Contracts.>> The ACO shall enter into + an agreement with the Secretary to participate in the + program for not less than a 3-year period (referred to + in this section as the `agreement period'). + ``(C) The ACO shall have a formal legal structure + that would allow the organization to receive and + distribute payments for shared savings under subsection + (d)(2) to participating providers of services and + suppliers. + ``(D) The ACO shall include primary care ACO + professionals that are sufficient for the number of + Medicare fee-for-service beneficiaries assigned to the + ACO under subsection (c). At a minimum, the ACO shall + have at least 5,000 such beneficiaries assigned to it + under subsection (c) in order to be eligible to + participate in the ACO program. + ``(E) The ACO shall provide the Secretary with such + information regarding ACO professionals participating in + the ACO as the Secretary determines necessary to support + the assignment of Medicare fee-for-service beneficiaries + to an ACO, the implementation of quality and other + reporting requirements under paragraph (3), and the + determination of payments for shared savings under + subsection (d)(2). + ``(F) The ACO shall have in place a leadership and + management structure that includes clinical and + administrative systems. + ``(G) The ACO shall define processes to promote + evidence-based medicine and patient engagement, report + on quality and cost measures, and coordinate care, such + as through the use of telehealth, remote patient + monitoring, and other such enabling technologies. + ``(H) The ACO shall demonstrate to the Secretary + that it meets patient-centeredness criteria specified by + the Secretary, such as the use of patient and caregiver + assessments or the use of individualized care plans. + ``(3) Quality and other reporting requirements.-- + ``(A) In general.-- <<NOTE: Determinations.>> The + Secretary shall determine appropriate measures to assess + the quality of care furnished by the ACO, such as + measures of-- + ``(i) clinical processes and outcomes; + ``(ii) patient and, where practicable, + caregiver experience of care; and + ``(iii) utilization (such as rates of hospital + admissions for ambulatory care sensitive + conditions). + ``(B) Reporting requirements.--An ACO shall submit + data in a form and manner specified by the Secretary on + measures the Secretary determines necessary for the ACO + to report in order to evaluate the quality of care + furnished by the ACO. Such data may include care + transitions across health care settings, including + hospital discharge planning and post-hospital discharge + follow-up by ACO professionals, as the Secretary + determines appropriate. + ``(C) Quality performance standards.--The Secretary + shall establish quality performance standards to assess + the quality of care furnished by ACOs. The Secretary + shall seek to improve the quality of care furnished by + +[[Page 124 STAT. 397]] + + ACOs over time by specifying higher standards, new + measures, or both for purposes of assessing such quality + of care. + ``(D) Other reporting requirements.--The Secretary + may, as the Secretary determines appropriate, + incorporate reporting requirements and incentive + payments related to the physician quality reporting + initiative (PQRI) under section 1848, including such + requirements and such payments related to electronic + prescribing, electronic health records, and other + similar initiatives under section 1848, and may use + alternative criteria than would otherwise apply under + such section for determining whether to make such + payments. The incentive payments described in the + preceding sentence shall not be taken into consideration + when calculating any payments otherwise made under + subsection (d). + ``(4) No duplication in participation in shared savings + programs.--A provider of services or supplier that participates + in any of the following shall not be eligible to participate in + an ACO under this section: + ``(A) A model tested or expanded under section 1115A + that involves shared savings under this title, or any + other program or demonstration project that involves + such shared savings. + ``(B) The independence at home medical practice + pilot program under section 1866E. + + ``(c) Assignment of Medicare Fee-for-service Beneficiaries to +ACOs.-- <<NOTE: Determination.>> The Secretary shall determine an +appropriate method to assign Medicare fee-for-service beneficiaries to +an ACO based on their utilization of primary care services provided +under this title by an ACO professional described in subsection +(h)(1)(A). + + ``(d) Payments and Treatment of Savings.-- + ``(1) Payments.-- + ``(A) In general.--Under the program, subject to + paragraph (3), payments shall continue to be made to + providers of services and suppliers participating in an + ACO under the original Medicare fee-for-service program + under parts A and B in the same manner as they would + otherwise be made except that a participating ACO is + eligible to receive payment for shared savings under + paragraph (2) if-- + ``(i) the ACO meets quality performance + standards established by the Secretary under + subsection (b)(3); and + ``(ii) the ACO meets the requirement under + subparagraph (B)(i). + ``(B) Savings requirement and benchmark.-- + ``(i) Determining savings.--In each year of + the agreement period, an ACO shall be eligible to + receive payment for shared savings under paragraph + (2) only if the estimated average per capita + Medicare expenditures under the ACO for Medicare + fee-for-service beneficiaries for parts A and B + services, adjusted for beneficiary + characteristics, is at least the percent specified + by the Secretary below the applicable benchmark + under clause (ii). The Secretary shall determine + the appropriate percent described in the preceding + sentence to account for normal variation in + expenditures under + +[[Page 124 STAT. 398]] + + this title, based upon the number of Medicare fee- + for-service beneficiaries assigned to an ACO. + ``(ii) Establish and update benchmark.--The + Secretary shall estimate a benchmark for each + agreement period for each ACO using the most + recent available 3 years of per-beneficiary + expenditures for parts A and B services for + Medicare fee-for-service beneficiaries assigned to + the ACO. Such benchmark shall be adjusted for + beneficiary characteristics and such other factors + as the Secretary determines appropriate and + updated by the projected absolute amount of growth + in national per capita expenditures for parts A + and B services under the original Medicare fee- + for-service program, as estimated by the + Secretary. Such benchmark shall be reset at the + start of each agreement period. + ``(2) Payments for shared savings.--Subject to performance + with respect to the quality performance standards established by + the Secretary under subsection (b)(3), if an ACO meets the + requirements under paragraph (1), a percent (as determined + appropriate by the Secretary) of the difference between such + estimated average per capita Medicare expenditures in a year, + adjusted for beneficiary characteristics, under the ACO and such + benchmark for the ACO may be paid to the ACO as shared savings + and the remainder of such difference shall be retained by the + program under this title. <<NOTE: Limitations.>> The Secretary + shall establish limits on the total amount of shared savings + that may be paid to an ACO under this paragraph. + ``(3) Monitoring avoidance of at-risk patients.--If the + Secretary determines that an ACO has taken steps to avoid + patients at risk in order to reduce the likelihood of increasing + costs to the ACO the Secretary may impose an appropriate + sanction on the ACO, including termination from the program. + ``(4) Termination.--The Secretary may terminate an agreement + with an ACO if it does not meet the quality performance + standards established by the Secretary under subsection (b)(3). + + ``(e) Administration.--Chapter 35 of title 44, United States Code, +shall not apply to the program. + ``(f) Waiver Authority.--The Secretary may waive such requirements +of sections 1128A and 1128B and title XVIII of this Act as may be +necessary to carry out the provisions of this section. + ``(g) Limitations on Review.--There shall be no administrative or +judicial review under section 1869, section 1878, or otherwise of-- + ``(1) the specification of criteria under subsection + (a)(1)(B); + ``(2) the assessment of the quality of care furnished by an + ACO and the establishment of performance standards under + subsection (b)(3); + ``(3) the assignment of Medicare fee-for-service + beneficiaries to an ACO under subsection (c); + ``(4) the determination of whether an ACO is eligible for + shared savings under subsection (d)(2) and the amount of such + shared savings, including the determination of the estimated + average per capita Medicare expenditures under the ACO for + Medicare fee-for-service beneficiaries assigned to the ACO and + the average benchmark for the ACO under subsection (d)(1)(B); + +[[Page 124 STAT. 399]] + + ``(5) the percent of shared savings specified by the + Secretary under subsection (d)(2) and any limit on the total + amount of shared savings established by the Secretary under such + subsection; and + ``(6) the termination of an ACO under subsection (d)(4). + + ``(h) Definitions.--In this section: + ``(1) ACO professional.--The term `ACO professional' means-- + ``(A) a physician (as defined in section + 1861(r)(1)); and + ``(B) a practitioner described in section + 1842(b)(18)(C)(i). + ``(2) Hospital.--The term `hospital' means a subsection (d) + hospital (as defined in section 1886(d)(1)(B)). + ``(3) Medicare fee-for-service beneficiary.--The term + `Medicare fee-for-service beneficiary' means an individual who + is enrolled in the original Medicare fee-for-service program + under parts A and B and is not enrolled in an MA plan under part + C, an eligible organization under section 1876, or a PACE + program under section 1894.''. + +SEC. 3023. NATIONAL PILOT PROGRAM ON PAYMENT BUNDLING. + + Title XVIII of the Social Security Act, as amended by section 3021, +is amended by inserting after section 1886C the following new section: + + + ``national pilot program on payment bundling + + + ``Sec. 1866D. <<NOTE: 42 USC 1395cc-4.>> (a) Implementation.-- + ``(1) In general.--The Secretary shall establish a pilot + program for integrated care during an episode of care provided + to an applicable beneficiary around a hospitalization in order + to improve the coordination, quality, and efficiency of health + care services under this title. + ``(2) Definitions.--In this section: + ``(A) Applicable beneficiary.--The term `applicable + beneficiary' means an individual who-- + ``(i) is entitled to, or enrolled for, + benefits under part A and enrolled for benefits + under part B of such title, but not enrolled under + part C or a PACE program under section 1894; and + ``(ii) is admitted to a hospital for an + applicable condition. + ``(B) Applicable condition.--The term `applicable + condition' means 1 or more of 8 conditions selected by + the Secretary. In selecting conditions under the + preceding sentence, the Secretary shall take into + consideration the following factors: + ``(i) Whether the conditions selected include + a mix of chronic and acute conditions. + ``(ii) Whether the conditions selected include + a mix of surgical and medical conditions. + ``(iii) Whether a condition is one for which + there is evidence of an opportunity for providers + of services and suppliers to improve the quality + of care furnished while reducing total + expenditures under this title. + ``(iv) Whether a condition has significant + variation in-- + ``(I) the number of readmissions; + and + +[[Page 124 STAT. 400]] + + ``(II) the amount of expenditures + for post-acute care spending under this + title. + ``(v) Whether a condition is high-volume and + has high post-acute care expenditures under this + title. + ``(vi) Which conditions the Secretary + determines are most amenable to bundling across + the spectrum of care given practice patterns under + this title. + ``(C) Applicable services.--The term `applicable + services' means the following: + ``(i) Acute care inpatient services. + ``(ii) Physicians' services delivered in and + outside of an acute care hospital setting. + ``(iii) Outpatient hospital services, + including emergency department services. + ``(iv) Post-acute care services, including + home health services, skilled nursing services, + inpatient rehabilitation services, and inpatient + hospital services furnished by a long-term care + hospital. + ``(v) Other services the Secretary determines + appropriate. + ``(D) Episode of care.-- + ``(i) In general.--Subject to clause (ii), the + term `episode of care' means, with respect to an + applicable condition and an applicable + beneficiary, the period that includes-- + ``(I) the 3 days prior to the + admission of the applicable beneficiary + to a hospital for the applicable + condition; + ``(II) the length of stay of the + applicable beneficiary in such hospital; + and + ``(III) the 30 days following the + discharge of the applicable beneficiary + from such hospital. + ``(ii) Establishment of period by the + secretary.--The Secretary, as appropriate, may + establish a period (other than the period + described in clause (i)) for an episode of care + under the pilot program. + ``(E) Physicians' services.--The term `physicians' + services' has the meaning given such term in section + 1861(q). + ``(F) Pilot program.--The term `pilot program' means + the pilot program under this section. + ``(G) Provider of services.--The term `provider of + services' has the meaning given such term in section + 1861(u). + ``(H) Readmission.--The term `readmission' has the + meaning given such term in section 1886(q)(5)(E). + ``(I) Supplier.--The term `supplier' has the meaning + given such term in section 1861(d). + ``(3) Deadline for implementation.--The Secretary shall + establish the pilot program not later than January 1, 2013. + + ``(b) Developmental Phase.-- + ``(1) Determination of patient assessment instrument.--The + Secretary shall determine which patient assessment instrument + (such as the Continuity Assessment Record and Evaluation (CARE) + tool) shall be used under the pilot program to evaluate the + applicable condition of an applicable beneficiary for purposes + of determining the most + +[[Page 124 STAT. 401]] + + clinically appropriate site for the provision of post-acute care + to the applicable beneficiary. + ``(2) Development of quality measures for an episode of care + and for post-acute care.-- + ``(A) In general.--The Secretary, in consultation + with the Agency for Healthcare Research and Quality and + the entity with a contract under section 1890(a) of the + Social Security Act, shall develop quality measures for + use in the pilot program-- + ``(i) for episodes of care; and + ``(ii) for post-acute care. + ``(B) Site-neutral post-acute care quality + measures.--Any quality measures developed under + subparagraph (A)(ii) shall be site-neutral. + ``(C) Coordination with quality measure development + and endorsement procedures.--The Secretary shall ensure + that the development of quality measures under + subparagraph (A) is done in a manner that is consistent + with the measures developed and endorsed under section + 1890 and 1890A that are applicable to all post-acute + care settings. + + ``(c) Details.-- + ``(1) Duration.-- + ``(A) In general.--Subject to subparagraph (B), the + pilot program shall be conducted for a period of 5 + years. + ``(B) Extension.-- <<NOTE: Determination.>> The + Secretary may extend the duration of the pilot program + for providers of services and suppliers participating in + the pilot program as of the day before the end of the 5- + year period described in subparagraph (A), for a period + determined appropriate by the Secretary, if the + Secretary determines that such extension will result in + improving or not reducing the quality of patient care + and reducing spending under this title. + ``(2) Participating providers of services and suppliers.-- + ``(A) In general.--An entity comprised of providers + of services and suppliers, including a hospital, a + physician group, a skilled nursing facility, and a home + health agency, who are otherwise participating under + this title, may submit an application to the Secretary + to provide applicable services to applicable individuals + under this section. + ``(B) Requirements.--The Secretary shall develop + requirements for entities to participate in the pilot + program under this section. Such requirements shall + ensure that applicable beneficiaries have an adequate + choice of providers of services and suppliers under the + pilot program. + ``(3) Payment methodology.-- + ``(A) In general.-- + ``(i) Establishment of payment methods.--The + Secretary shall develop payment methods for the + pilot program for entities participating in the + pilot program. Such payment methods may include + bundled payments and bids from entities for + episodes of care. The Secretary shall make + payments to the entity for services covered under + this section. + ``(ii) No additional program expenditures.-- + Payments under this section for applicable items + and + +[[Page 124 STAT. 402]] + + services under this title (including payment for + services described in subparagraph (B)) for + applicable beneficiaries for a year shall be + established in a manner that does not result in + spending more for such entity for such + beneficiaries than would otherwise be expended for + such entity for such beneficiaries for such year + if the pilot program were not implemented, as + estimated by the Secretary. + ``(B) Inclusion of certain services.--A payment + methodology tested under the pilot program shall include + payment for the furnishing of applicable services and + other appropriate services, such as care coordination, + medication reconciliation, discharge planning, + transitional care services, and other patient-centered + activities as determined appropriate by the Secretary. + ``(C) Bundled payments.-- + ``(i) In general.--A bundled payment under the + pilot program shall-- + ``(I) be comprehensive, covering the + costs of applicable services and other + appropriate services furnished to an + individual during an episode of care (as + determined by the Secretary); and + ``(II) be made to the entity which + is participating in the pilot program. + ``(ii) Requirement for provision of applicable + services and other appropriate services.-- + Applicable services and other appropriate services + for which payment is made under this subparagraph + shall be furnished or directed by the entity which + is participating in the pilot program. + ``(D) Payment for post-acute care services after the + episode of care.-- <<NOTE: Procedures.>> The Secretary + shall establish procedures, in the case where an + applicable beneficiary requires continued post-acute + care services after the last day of the episode of care, + under which payment for such services shall be made. + ``(4) Quality measures.-- + ``(A) In general.--The Secretary shall establish + quality measures (including quality measures of process, + outcome, and structure) related to care provided by + entities participating in the pilot program. Quality + measures established under the preceding sentence shall + include measures of the following: + ``(i) Functional status improvement. + ``(ii) Reducing rates of avoidable hospital + readmissions. + ``(iii) Rates of discharge to the community. + ``(iv) Rates of admission to an emergency room + after a hospitalization. + ``(v) Incidence of health care acquired + infections. + ``(vi) Efficiency measures. + ``(vii) Measures of patient-centeredness of + care. + ``(viii) Measures of patient perception of + care. + ``(ix) Other measures, including measures of + patient outcomes, determined appropriate by the + Secretary. + ``(B) Reporting on quality measures.-- + +[[Page 124 STAT. 403]] + + ``(i) In general.--A entity shall submit data + to the Secretary on quality measures established + under subparagraph (A) during each year of the + pilot program (in a form and manner, subject to + clause (iii), specified by the Secretary). + ``(ii) Submission of data through electronic + health record.--To the extent practicable, the + Secretary shall specify that data on measures be + submitted under clause (i) through the use of an + qualified electronic health record (as defined in + section 3000(13) of the Public Health Service Act + (42 U.S.C. 300jj-11(13)) in a manner specified by + the Secretary. + + ``(d) Waiver.--The Secretary may waive such provisions of this title +and title XI as may be necessary to carry out the pilot program. + ``(e) Independent Evaluation and Reports on Pilot Program.-- + ``(1) Independent evaluation.--The Secretary shall conduct + an independent evaluation of the pilot program, including the + extent to which the pilot program has-- + ``(A) improved quality measures established under + subsection (c)(4)(A); + ``(B) improved health outcomes; + ``(C) improved applicable beneficiary access to + care; and + ``(D) reduced spending under this title. + ``(2) Reports.-- + ``(A) Interim report.--Not later than 2 years after + the implementation of the pilot program, the Secretary + shall submit to Congress a report on the initial results + of the independent evaluation conducted under paragraph + (1). + ``(B) Final report.--Not later than 3 years after + the implementation of the pilot program, the Secretary + shall submit to Congress a report on the final results + of the independent evaluation conducted under paragraph + (1). + + ``(f) Consultation.--The Secretary shall consult with +representatives of small rural hospitals, including critical access +hospitals (as defined in section 1861(mm)(1)), regarding their +participation in the pilot program. Such consultation shall include +consideration of innovative methods of implementing bundled payments in +hospitals described in the preceding sentence, taking into consideration +any difficulties in doing so as a result of the low volume of services +provided by such hospitals. + ``(g) Implementation Plan.-- + ``(1) In general.-- <<NOTE: Deadline.>> Not later than + January 1, 2016, the Secretary shall submit a plan for the + implementation of an expansion of the pilot program if the + Secretary determines that such expansion will result in + improving or not reducing the quality of patient care and + reducing spending under this title. + + ``(h) Administration.--Chapter 35 of title 44, United States Code, +shall not apply to the selection, testing, and evaluation of models or +the expansion of such models under this section.''. + +[[Page 124 STAT. 404]] + +SEC. 3024. INDEPENDENCE AT HOME DEMONSTRATION PROGRAM. + + Title XVIII of the Social Security Act is amended by inserting after +section 1866D, as inserted by section 3023, the following new section: + + + ``independence at home medical practice demonstration program + + + ``Sec. 1866D. <<NOTE: 42 USC 1395cc-5.>> (a) Establishment.-- + ``(1) In general.--The Secretary shall conduct a + demonstration program (in this section referred to as the + `demonstration program') to test a payment incentive and service + delivery model that utilizes physician and nurse practitioner + directed home-based primary care teams designed to reduce + expenditures and improve health outcomes in the provision of + items and services under this title to applicable beneficiaries + (as defined in subsection (d)). + ``(2) Requirement.--The demonstration program shall test + whether a model described in paragraph (1), which is accountable + for providing comprehensive, coordinated, continuous, and + accessible care to high-need populations at home and + coordinating health care across all treatment settings, results + in-- + ``(A) reducing preventable hospitalizations; + ``(B) preventing hospital readmissions; + ``(C) reducing emergency room visits; + ``(D) improving health outcomes commensurate with + the beneficiaries' stage of chronic illness; + ``(E) improving the efficiency of care, such as by + reducing duplicative diagnostic and laboratory tests; + ``(F) reducing the cost of health care services + covered under this title; and + ``(G) achieving beneficiary and family caregiver + satisfaction. + + ``(b) Independence at Home Medical Practice.-- + ``(1) Independence at home medical practice defined.--In + this section: + ``(A) In general.--The term `independence at home + medical practice' means a legal entity that-- + ``(i) is comprised of an individual physician + or nurse practitioner or group of physicians and + nurse practitioners that provides care as part of + a team that includes physicians, nurses, physician + assistants, pharmacists, and other health and + social services staff as appropriate who have + experience providing home-based primary care to + applicable beneficiaries, make in-home visits, and + are available 24 hours per day, 7 days per week to + carry out plans of care that are tailored to the + individual beneficiary's chronic conditions and + designed to achieve the results in subsection (a); + ``(ii) is organized at least in part for the + purpose of providing physicians' services; + ``(iii) has documented experience in providing + home-based primary care services to high-cost + chronically ill beneficiaries, as determined + appropriate by the Secretary; + +[[Page 124 STAT. 405]] + + ``(iv) furnishes services to at least 200 + applicable beneficiaries (as defined in subsection + (d)) during each year of the demonstration + program; + ``(v) has entered into an agreement with the + Secretary; + ``(vi) uses electronic health information + systems, remote monitoring, and mobile diagnostic + technology; and + ``(vii) meets such other criteria as the + Secretary determines to be appropriate to + participate in the demonstration program. + <<NOTE: Reports. Determination.>> The entity shall + report on quality measures (in such form, manner, and + frequency as specified by the Secretary, which may be + for the group, for providers of services and suppliers, + or both) and report to the Secretary (in a form, manner, + and frequency as specified by the Secretary) such data + as the Secretary determines appropriate to monitor and + evaluate the demonstration program. + ``(B) Physician.--The term `physician' includes, + except as the Secretary may otherwise provide, any + individual who furnishes services for which payment may + be made as physicians' services and has the medical + training or experience to fulfill the physician's role + described in subparagraph (A)(i). + ``(2) Participation of nurse practitioners and physician + assistants.--Nothing in this section shall be construed to + prevent a nurse practitioner or physician assistant from + participating in, or leading, a home-based primary care team as + part of an independence at home medical practice if-- + ``(A) all the requirements of this section are met; + ``(B) the nurse practitioner or physician assistant, + as the case may be, is acting consistent with State law; + and + ``(C) the nurse practitioner or physician assistant + has the medical training or experience to fulfill the + nurse practitioner or physician assistant role described + in paragraph (1)(A)(i). + ``(3) Inclusion of providers and practitioners.--Nothing in + this subsection shall be construed as preventing an independence + at home medical practice from including a provider of services + or a participating practitioner described in section + 1842(b)(18)(C) that is affiliated with the practice under an + arrangement structured so that such provider of services or + practitioner participates in the demonstration program and + shares in any savings under the demonstration program. + ``(4) Quality and performance standards.--The Secretary + shall develop quality performance standards for independence at + home medical practices participating in the demonstration + program. + + ``(c) Payment Methodology.-- + ``(1) Establishment of target spending level.--The Secretary + shall establish an estimated annual spending target, for the + amount the Secretary estimates would have been spent in the + absence of the demonstration, for items and services + +[[Page 124 STAT. 406]] + + covered under parts A and B furnished to applicable + beneficiaries for each qualifying independence at home medical + practice under this section. Such spending targets shall be + determined on a per capita basis. Such spending targets shall + include a risk corridor that takes into account normal variation + in expenditures for items and services covered under parts A and + B furnished to such beneficiaries with the size of the corridor + being related to the number of applicable beneficiaries + furnished services by each independence at home medical + practice. The spending targets may also be adjusted for other + factors as the Secretary determines appropriate. + ``(2) Incentive payments.--Subject to performance on quality + measures, a qualifying independence at home medical practice is + eligible to receive an incentive payment under this section if + actual expenditures for a year for the applicable beneficiaries + it enrolls are less than the estimated spending target + established under paragraph (1) for such year. An incentive + payment for such year shall be equal to a portion (as determined + by the Secretary) of the amount by which actual expenditures + (including incentive payments under this paragraph) for + applicable beneficiaries under parts A and B for such year are + estimated to be less than 5 percent less than the estimated + spending target for such year, as determined under paragraph + (1). + + ``(d) Applicable Beneficiaries.-- + ``(1) Definition.--In this section, the term `applicable + beneficiary' means, with respect to a qualifying independence at + home medical practice, an individual who the practice has + determined-- + ``(A) is entitled to benefits under part A and + enrolled for benefits under part B; + ``(B) is not enrolled in a Medicare Advantage plan + under part C or a PACE program under section 1894; + ``(C) has 2 or more chronic illnesses, such as + congestive heart failure, diabetes, other dementias + designated by the Secretary, chronic obstructive + pulmonary disease, ischemic heart disease, stroke, + Alzheimer's Disease and neurodegenerative diseases, and + other diseases and conditions designated by the + Secretary which result in high costs under this title; + ``(D) within the past 12 months has had a + nonelective hospital admission; + ``(E) within the past 12 months has received acute + or subacute rehabilitation services; + ``(F) has 2 or more functional dependencies + requiring the assistance of another person (such as + bathing, dressing, toileting, walking, or feeding); and + ``(G) meets such other criteria as the Secretary + determines appropriate. + ``(2) Patient election to participate.-- + <<NOTE: Determination.>> The Secretary shall determine an + appropriate method of ensuring that applicable beneficiaries + have agreed to enroll in an independence at home medical + practice under the demonstration program. Enrollment in the + demonstration program shall be voluntary. + ``(3) Beneficiary access to services.--Nothing in this + section shall be construed as encouraging physicians or nurse + +[[Page 124 STAT. 407]] + + practitioners to limit applicable beneficiary access to services + covered under this title and applicable beneficiaries shall not + be required to relinquish access to any benefit under this title + as a condition of receiving services from an independence at + home medical practice. + + ``(e) Implementation.-- + ``(1) Starting date.--The demonstration program shall begin + no later than January 1, 2012. An agreement with an independence + at home medical practice under the demonstration program may + cover not more than a 3-year period. + ``(2) No physician duplication in demonstration + participation.--The Secretary shall not pay an independence at + home medical practice under this section that participates in + section 1899. + ``(3) No beneficiary duplication in demonstration + participation.--The Secretary shall ensure that no applicable + beneficiary enrolled in an independence at home medical practice + under this section is participating in the programs under + section 1899. + ``(4) Preference.--In approving an independence at home + medical practice, the Secretary shall give preference to + practices that are-- + ``(A) located in high-cost areas of the country; + ``(B) have experience in furnishing health care + services to applicable beneficiaries in the home; and + ``(C) use electronic medical records, health + information technology, and individualized plans of + care. + ``(5) Limitation on number of practices.--In selecting + qualified independence at home medical practices to participate + under the demonstration program, the Secretary shall limit the + number of such practices so that the number of applicable + beneficiaries that may participate in the demonstration program + does not exceed 10,000. + ``(6) Waiver.--The Secretary may waive such provisions of + this title and title XI as the Secretary determines necessary in + order to implement the demonstration program. + ``(7) Administration.--Chapter 35 of title 44, United States + Code, shall not apply to this section. + + ``(f) Evaluation and Monitoring.-- + ``(1) In general.--The Secretary shall evaluate each + independence at home medical practice under the demonstration + program to assess whether the practice achieved the results + described in subsection (a). + ``(2) Monitoring applicable beneficiaries.--The Secretary + may monitor data on expenditures and quality of services under + this title after an applicable beneficiary discontinues + receiving services under this title through a qualifying + independence at home medical practice. + + ``(g) Reports to Congress.--The Secretary shall conduct an +independent evaluation of the demonstration program and submit to +Congress a final report, including best practices under the +demonstration program. Such report shall include an analysis of the +demonstration program on coordination of care, expenditures under this +title, applicable beneficiary access to services, and the quality of +health care services provided to applicable beneficiaries. + ``(h) Funding.--For purposes of administering and carrying out the +demonstration program, other than for payments for items + +[[Page 124 STAT. 408]] + +and services furnished under this title and incentive payments under +subsection (c), in addition to funds otherwise appropriated, there shall +be transferred to the Secretary for the Center for Medicare & Medicaid +Services Program Management Account from the Federal Hospital Insurance +Trust Fund under section 1817 and the Federal Supplementary Medical +Insurance Trust Fund under section 1841 (in proportions determined +appropriate by the Secretary) $5,000,000 for each of fiscal years 2010 +through 2015. Amounts transferred under this subsection for a fiscal +year shall be available until expended. + ``(i) Termination.-- + ``(1) Mandatory termination.--The Secretary shall terminate + an agreement with an independence at home medical practice if-- + ``(A) the Secretary estimates or determines that + such practice will not receive an incentive payment for + the second of 2 consecutive years under the + demonstration program; or + ``(B) such practice fails to meet quality standards + during any year of the demonstration program. + ``(2) Permissive termination.--The Secretary may terminate + an agreement with an independence at home medical practice for + such other reasons determined appropriate by the Secretary.''. + +SEC. 3025. HOSPITAL READMISSIONS REDUCTION PROGRAM. + + (a) In General.--Section 1886 of the Social Security Act (42 U.S.C. +1395ww), as amended by sections 3001 and 3008, is amended by adding at +the end the following new subsection: + ``(q) Hospital Readmissions Reduction Program.-- + ``(1) In general.--With respect to payment for discharges + from an applicable hospital (as defined in paragraph (5)(C)) + occurring during a fiscal year beginning on or after October 1, + 2012, in order to account for excess readmissions in the + hospital, the Secretary shall reduce the payments that would + otherwise be made to such hospital under subsection (d) (or + section 1814(b)(3), as the case may be) for such a discharge by + an amount equal to the product of-- + ``(A) the base operating DRG payment amount (as + defined in paragraph (2)) for the discharge; and + ``(B) the adjustment factor (described in paragraph + (3)(A)) for the hospital for the fiscal year. + ``(2) Base operating drg payment amount defined.-- + ``(A) In general.-- <<NOTE: Definition.>> Except as + provided in subparagraph (B), in this subsection, the + term `base operating DRG payment amount' means, with + respect to a hospital for a fiscal year-- + ``(i) the payment amount that would otherwise + be made under subsection (d) (determined without + regard to subsection (o)) for a discharge if this + subsection did not apply; reduced by + ``(ii) any portion of such payment amount that + is attributable to payments under paragraphs + (5)(A), (5)(B), (5)(F), and (12) of subsection + (d). + ``(B) Special rules for certain hospitals.-- + ``(i) Sole community hospitals and medicare- + dependent, small rural hospitals.--In the case of + +[[Page 124 STAT. 409]] + + a medicare-dependent, small rural hospital (with + respect to discharges occurring during fiscal + years 2012 and 2013) or a sole community hospital, + in applying subparagraph (A)(i), the payment + amount that would otherwise be made under + subsection (d) shall be determined without regard + to subparagraphs (I) and (L) of subsection (b)(3) + and subparagraphs (D) and (G) of subsection + (d)(5). + ``(ii) Hospitals paid under section 1814.-- + <<NOTE: Reports. Deadline.>> In the case of a + hospital that is paid under section 1814(b)(3), + the Secretary may exempt such hospitals provided + that States paid under such section submit an + annual report to the Secretary describing how a + similar program in the State for a participating + hospital or hospitals achieves or surpasses the + measured results in terms of patient health + outcomes and cost savings established herein with + respect to this section. + ``(3) Adjustment factor.-- + ``(A) In general.--For purposes of paragraph (1), + the adjustment factor under this paragraph for an + applicable hospital for a fiscal year is equal to the + greater of-- + ``(i) the ratio described in subparagraph (B) + for the hospital for the applicable period (as + defined in paragraph (5)(D)) for such fiscal year; + or + ``(ii) the floor adjustment factor specified + in subparagraph (C). + ``(B) Ratio.--The ratio described in this + subparagraph for a hospital for an applicable period is + equal to 1 minus the ratio of-- + ``(i) the aggregate payments for excess + readmissions (as defined in paragraph (4)(A)) with + respect to an applicable hospital for the + applicable period; and + ``(ii) the aggregate payments for all + discharges (as defined in paragraph (4)(B)) with + respect to such applicable hospital for such + applicable period. + ``(C) Floor adjustment factor.--For purposes of + subparagraph (A), the floor adjustment factor specified + in this subparagraph for-- + ``(i) fiscal year 2013 is 0.99; + ``(ii) fiscal year 2014 is 0.98; or + ``(iii) fiscal year 2015 and subsequent fiscal + years is 0.97. + ``(4) Aggregate payments, excess readmission ratio + defined.--For purposes of this subsection: + ``(A) Aggregate payments for excess readmissions.-- + The term `aggregate payments for excess readmissions' + means, for a hospital for an applicable period, the sum, + for applicable conditions (as defined in paragraph + (5)(A)), of the product, for each applicable condition, + of-- + ``(i) the base operating DRG payment amount + for such hospital for such applicable period for + such condition; + ``(ii) the number of admissions for such + condition for such hospital for such applicable + period; and + ``(iii) the excess readmissions ratio (as + defined in subparagraph (C)) for such hospital for + such applicable period minus 1. + +[[Page 124 STAT. 410]] + + ``(B) Aggregate payments for all discharges.--The + term `aggregate payments for all discharges' means, for + a hospital for an applicable period, the sum of the base + operating DRG payment amounts for all discharges for all + conditions from such hospital for such applicable + period. + ``(C) Excess readmission ratio.-- + ``(i) In general.--Subject to clause (ii), the + term `excess readmissions ratio' means, with + respect to an applicable condition for a hospital + for an applicable period, the ratio (but not less + than 1.0) of-- + ``(I) the risk adjusted readmissions + based on actual readmissions, as + determined consistent with a readmission + measure methodology that has been + endorsed under paragraph (5)(A)(ii)(I), + for an applicable hospital for such + condition with respect to such + applicable period; to + ``(II) the risk adjusted expected + readmissions (as determined consistent + with such a methodology) for such + hospital for such condition with respect + to such applicable period. + ``(ii) Exclusion of certain readmissions.--For + purposes of clause (i), with respect to a + hospital, excess readmissions shall not include + readmissions for an applicable condition for which + there are fewer than a minimum number (as + determined by the Secretary) of discharges for + such applicable condition for the applicable + period and such hospital. + ``(5) Definitions.--For purposes of this subsection: + ``(A) Applicable condition.--The term `applicable + condition' means, subject to subparagraph (B), a + condition or procedure selected by the Secretary among + conditions and procedures for which-- + ``(i) readmissions (as defined in subparagraph + (E)) that represent conditions or procedures that + are high volume or high expenditures under this + title (or other criteria specified by the + Secretary); and + ``(ii) measures of such readmissions-- + ``(I) have been endorsed by the + entity with a contract under section + 1890(a); and + ``(II) such endorsed measures have + exclusions for readmissions that are + unrelated to the prior discharge (such + as a planned readmission or transfer to + another applicable hospital). + ``(B) Expansion of applicable + conditions. <<NOTE: Effective date.>> --Beginning with + fiscal year 2015, the Secretary shall, to the extent + practicable, expand the applicable conditions beyond the + 3 conditions for which measures have been endorsed as + described in subparagraph (A)(ii)(I) as of the date of + the enactment of this subsection to the additional 4 + conditions that have been identified by the Medicare + Payment Advisory Commission in its report to Congress in + June 2007 and to other conditions and procedures as + determined appropriate by the Secretary. In expanding + such applicable conditions, the Secretary shall seek the + endorsement described in subparagraph (A)(ii)(I) but may + apply such measures without such an endorsement in the + case of a specified area or medical topic determined + appropriate by + +[[Page 124 STAT. 411]] + + the Secretary for which a feasible and practical measure + has not been endorsed by the entity with a contract + under section 1890(a) as long as due consideration is + given to measures that have been endorsed or adopted by + a consensus organization identified by the Secretary. + ``(C) Applicable hospital.--The term `applicable + hospital' means a subsection (d) hospital or a hospital + that is paid under section 1814(b)(3), as the case may + be. + ``(D) Applicable period.--The term `applicable + period' means, with respect to a fiscal year, such + period as the Secretary shall specify. + ``(E) Readmission.--The term `readmission' means, in + the case of an individual who is discharged from an + applicable hospital, the admission of the individual to + the same or another applicable hospital within a time + period specified by the Secretary from the date of such + discharge. Insofar as the discharge relates to an + applicable condition for which there is an endorsed + measure described in subparagraph (A)(ii)(I), such time + period (such as 30 days) shall be consistent with the + time period specified for such measure. + ``(6) Reporting hospital specific information.-- + ``(A) In general.-- <<NOTE: Public + information.>> The Secretary shall make information + available to the public regarding readmission rates of + each subsection (d) hospital under the program. + ``(B) Opportunity to review and submit + corrections.--The Secretary shall ensure that a + subsection (d) hospital has the opportunity to review, + and submit corrections for, the information to be made + public with respect to the hospital under subparagraph + (A) prior to such information being made public. + ``(C) Website.--Such information shall be posted on + the Hospital Compare Internet website in an easily + understandable format. + ``(7) Limitations on review.--There shall be no + administrative or judicial review under section 1869, section + 1878, or otherwise of the following: + ``(A) The determination of base operating DRG + payment amounts. + ``(B) The methodology for determining the adjustment + factor under paragraph (3), including excess + readmissions ratio under paragraph (4)(C), aggregate + payments for excess readmissions under paragraph (4)(A), + and aggregate payments for all discharges under + paragraph (4)(B), and applicable periods and applicable + conditions under paragraph (5). + ``(C) The measures of readmissions as described in + paragraph (5)(A)(ii). + ``(8) Readmission rates for all patients.-- + ``(A) Calculation of readmission.--The Secretary + shall calculate readmission rates for all patients (as + defined in subparagraph (D)) for a specified hospital + (as defined in subparagraph (D)(ii)) for an applicable + condition (as defined in paragraph (5)(B)) and other + conditions deemed appropriate by the Secretary for an + applicable period (as defined in paragraph (5)(D)) in + the same manner as used to calculate such readmission + rates for hospitals with + +[[Page 124 STAT. 412]] + + respect to this title and posted on the CMS Hospital + Compare website. + ``(B) Posting of hospital specific all patient + readmission rates.-- <<NOTE: Web posting.>> The + Secretary shall make information on all patient + readmission rates calculated under subparagraph (A) + available on the CMS Hospital Compare website in a form + and manner determined appropriate by the Secretary. The + Secretary may also make other information determined + appropriate by the Secretary available on such website. + ``(C) Hospital submission of all patient data.-- + ``(i) Except as provided for in clause (ii), + each specified hospital (as defined in + subparagraph (D)(ii)) shall submit to the + Secretary, in a form, manner and time specified by + the Secretary, data and information determined + necessary by the Secretary for the Secretary to + calculate the all patient readmission rates + described in subparagraph (A). + ``(ii) Instead of a specified hospital + submitting to the Secretary the data and + information described in clause (i), such data and + information may be submitted to the Secretary, on + behalf of such a specified hospital, by a state or + an entity determined appropriate by the Secretary. + ``(D) Definitions.--For purposes of this paragraph: + ``(i) The term `all patients' means patients + who are treated on an inpatient basis and + discharged from a specified hospital (as defined + in clause (ii)). + ``(ii) The term `specified hospital' means a + subsection (d) hospital, hospitals described in + clauses (i) through (v) of subsection (d)(1)(B) + and, as determined feasible and appropriate by the + Secretary, other hospitals not otherwise described + in this subparagraph.''. + + (b) Quality Improvement.--Part S of title III of the Public Health +Service Act, as amended by section 3015, is further amended by adding at +the end the following: + +``SEC. 399KK. <<NOTE: 42 USC 280j-3.>> QUALITY IMPROVEMENT PROGRAM FOR + HOSPITALS WITH A HIGH SEVERITY ADJUSTED READMISSION RATE. + + ``(a) Establishment.-- + ``(1) In general.-- <<NOTE: Deadline.>> Not later than 2 + years after the date of enactment of this section, the Secretary + shall make available a program for eligible hospitals to improve + their readmission rates through the use of patient safety + organizations (as defined in section 921(4)). + ``(2) Eligible hospital defined.--In this subsection, the + term `eligible hospital' means a hospital that the Secretary + determines has a high rate of risk adjusted readmissions for the + conditions described in section 1886(q)(8)(A) of the Social + Security Act and has not taken appropriate steps to reduce such + readmissions and improve patient safety as evidenced through + historically high rates of readmissions, as determined by the + Secretary. + ``(3) Risk adjustment.--The Secretary shall utilize + appropriate risk adjustment measures to determine eligible + hospitals. + + ``(b) Report to the Secretary.-- <<NOTE: Determination.>> As +determined appropriate by the Secretary, eligible hospitals and patient +safety organizations + +[[Page 124 STAT. 413]] + +working with those hospitals shall report to the Secretary on the +processes employed by the hospital to improve readmission rates and the +impact of such processes on readmission rates.''. + +SEC. 3026. <<NOTE: 42 USC 1395b-1 note.>> COMMUNITY-BASED CARE + TRANSITIONS PROGRAM. + + (a) In General.--The Secretary shall establish a Community-Based +Care Transitions Program under which the Secretary provides funding to +eligible entities that furnish improved care transition services to +high-risk Medicare beneficiaries. + (b) Definitions.--In this section: + (1) Eligible entity.--The term ``eligible entity'' means the + following: + (A) A subsection (d) hospital (as defined in section + 1886(d)(1)(B) of the Social Security Act (42 U.S.C. + 1395ww(d)(1)(B))) identified by the Secretary as having + a high readmission rate, such as under section 1886(q) + of the Social Security Act, as added by section 3025. + (B) An appropriate community-based organization that + provides care transition services under this section + across a continuum of care through arrangements with + subsection (d) hospitals (as so defined) to furnish the + services described in subsection (c)(2)(B)(i) and whose + governing body includes sufficient representation of + multiple health care stakeholders (including consumers). + (2) High-risk medicare beneficiary.--The term ``high-risk + Medicare beneficiary'' means a Medicare beneficiary who has + attained a minimum hierarchical condition category score, as + determined by the Secretary, based on a diagnosis of multiple + chronic conditions or other risk factors associated with a + hospital readmission or substandard transition into post- + hospitalization care, which may include 1 or more of the + following: + (A) Cognitive impairment. + (B) Depression. + (C) A history of multiple readmissions. + (D) Any other chronic disease or risk factor as + determined by the Secretary. + (3) Medicare beneficiary.--The term ``Medicare beneficiary'' + means an individual who is entitled to benefits under part A of + title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) + and enrolled under part B of such title, but not enrolled under + part C of such title. + (4) Program.--The term ``program'' means the program + conducted under this section. + (5) Readmission.--The term ``readmission'' has the meaning + given such term in section 1886(q)(5)(E) of the Social Security + Act, as added by section 3025. + (6) Secretary.--The term ``Secretary'' means the Secretary + of Health and Human Services. + + (c) Requirements.-- + (1) Duration.-- + (A) In general.--The program shall be conducted for + a 5-year period, beginning January 1, 2011. + (B) Expansion.-- + <<NOTE: Determination. Certification.>> The Secretary + may expand the duration and the scope of the program, to + the extent determined appropriate by the Secretary, if + the Secretary determines (and the Chief Actuary of the + Centers for Medicare & Medicaid Services, with respect + to spending under this + +[[Page 124 STAT. 414]] + + title, certifies) that such expansion would reduce + spending under this title without reducing quality. + (2) Application; participation.-- + (A) In general.-- + (i) Application.--An eligible entity seeking + to participate in the program shall submit an + application to the Secretary at such time, in such + manner, and containing such information as the + Secretary may require. + (ii) Partnership.--If an eligible entity is a + hospital, such hospital shall enter into a + partnership with a community-based organization to + participate in the program. + (B) Intervention proposal.--Subject to subparagraph + (C), an application submitted under subparagraph (A)(i) + shall include a detailed proposal for at least 1 care + transition intervention, which may include the + following: + (i) Initiating care transition services for a + high-risk Medicare beneficiary not later than 24 + hours prior to the discharge of the beneficiary + from the eligible entity. + (ii) Arranging timely post-discharge follow-up + services to the high-risk Medicare beneficiary to + provide the beneficiary (and, as appropriate, the + primary caregiver of the beneficiary) with + information regarding responding to symptoms that + may indicate additional health problems or a + deteriorating condition. + (iii) Providing the high-risk Medicare + beneficiary (and, as appropriate, the primary + caregiver of the beneficiary) with assistance to + ensure productive and timely interactions between + patients and post-acute and outpatient providers. + (iv) Assessing and actively engaging with a + high-risk Medicare beneficiary (and, as + appropriate, the primary caregiver of the + beneficiary) through the provision of self- + management support and relevant information that + is specific to the beneficiary's condition. + (v) Conducting comprehensive medication review + and management (including, if appropriate, + counseling and self-management support). + (C) Limitation.--A care transition intervention + proposed under subparagraph (B) may not include payment + for services required under the discharge planning + process described in section 1861(ee) of the Social + Security Act (42 U.S.C. 1395x(ee)). + (3) Selection.--In selecting eligible entities to + participate in the program, the Secretary shall give priority to + eligible entities that-- + (A) participate in a program administered by the + Administration on Aging to provide concurrent care + transitions interventions with multiple hospitals and + practitioners; or + (B) provide services to medically underserved + populations, small communities, and rural areas. + + (d) Implementation.--Notwithstanding any other provision of law, the +Secretary may implement the provisions of this section by program +instruction or otherwise. + +[[Page 124 STAT. 415]] + + (e) Waiver Authority.--The Secretary may waive such requirements of +titles XI and XVIII of the Social Security Act as may be necessary to +carry out the program. + (f) Funding.--For purposes of carrying out this section, the +Secretary of Health and Human Services shall provide for the transfer, +from the Federal Hospital Insurance Trust Fund under section 1817 of the +Social Security Act (42 U.S.C. 1395i) and the Federal Supplementary +Medical Insurance Trust Fund under section 1841 of such Act (42 U.S.C. +1395t), in such proportion as the Secretary determines appropriate, of +$500,000,000, to the Centers for Medicare & Medicaid Services Program +Management Account for the period of fiscal years 2011 through 2015. +Amounts transferred under the preceding sentence shall remain available +until expended. + +SEC. 3027. EXTENSION OF GAINSHARING DEMONSTRATION. + + (a) In General.--Subsection (d)(3) of section 5007 of the Deficit +Reduction Act of 2005 (Public Law 109-171) <<NOTE: 42 USC 1395ww +note.>> is amended by inserting ``(or September 30, 2011, in the case of +a demonstration project in operation as of October 1, 2008)'' after +``December 31, 2009''. + + (b) Funding.-- + (1) In general.--Subsection (f)(1) of such section is + amended by inserting ``and for fiscal year 2010, $1,600,000,'' + after ``$6,000,000,''. + (2) Availability.--Subsection (f)(2) of such section is + amended by striking ``2010'' and inserting ``2014 or until + expended''. + + (c) Reports.-- + (1) Quality improvement and savings.--Subsection (e)(3) of + such section is amended by striking ``December 1, 2008'' and + inserting ``March 31, 2011''. + (2) Final report.--Subsection (e)(4) of such section is + amended by striking ``May 1, 2010'' and inserting ``March 31, + 2013''. + + Subtitle B--Improving Medicare for Patients and Providers + +PART I--ENSURING BENEFICIARY ACCESS TO PHYSICIAN CARE AND OTHER SERVICES + +SEC. 3101. INCREASE IN THE PHYSICIAN PAYMENT UPDATE. + + Section 1848(d) of the Social Security Act (42 U.S.C. 1395w-4(d)) is +amended by adding at the end the following new paragraph: + ``(10) Update for 2010.-- + ``(A) In general.--Subject to paragraphs (7)(B), + (8)(B), and (9)(B), in lieu of the update to the single + conversion factor established in paragraph (1)(C) that + would otherwise apply for 2010, the update to the single + conversion factor shall be 0.5 percent. + ``(B) No effect on computation of conversion factor + for 2011 and subsequent years.--The conversion factor + under this subsection shall be computed under paragraph + (1)(A) for 2011 and subsequent years as if subparagraph + (A) had never applied.''. + +[[Page 124 STAT. 416]] + +SEC. 3102. EXTENSION OF THE WORK GEOGRAPHIC INDEX FLOOR AND REVISIONS TO + THE PRACTICE EXPENSE GEOGRAPHIC ADJUSTMENT UNDER THE + MEDICARE PHYSICIAN FEE SCHEDULE. + + (a) Extension of Work GPCI Floor.--Section 1848(e)(1)(E) of the +Social Security Act (42 U.S.C. 1395w-4(e)(1)(E)) is amended by striking +``before January 1, 2010'' and inserting ``before January 1, 2011''. + (b) Practice Expense Geographic Adjustment for 2010 and Subsequent +Years.--Section 1848(e)(1) of the Social Security Act ( <<NOTE: 42 USC +1395w-4.>> 42 U.S.C. 1395w4(e)(1)) is amended-- + (1) in subparagraph (A), by striking ``and (G)'' and + inserting ``(G), and (H)''; and + (2) by adding at the end the following new subparagraph: + ``(H) Practice expense geographic adjustment for + 2010 and subsequent years.-- + ``(i) For 2010.--Subject to clause (iii), for + services furnished during 2010, the employee wage + and rent portions of the practice expense + geographic index described in subparagraph (A)(i) + shall reflect \3/4\ of the difference between the + relative costs of employee wages and rents in each + of the different fee schedule areas and the + national average of such employee wages and rents. + ``(ii) For 2011.--Subject to clause (iii), for + services furnished during 2011, the employee wage + and rent portions of the practice expense + geographic index described in subparagraph (A)(i) + shall reflect \1/2\ of the difference between the + relative costs of employee wages and rents in each + of the different fee schedule areas and the + national average of such employee wages and rents. + ``(iii) Hold harmless.--The practice expense + portion of the geographic adjustment factor + applied in a fee schedule area for services + furnished in 2010 or 2011 shall not, as a result + of the application of clause (i) or (ii), be + reduced below the practice expense portion of the + geographic adjustment factor under subparagraph + (A)(i) (as calculated prior to the application of + such clause (i) or (ii), respectively) for such + area for such year. + ``(iv) Analysis.--The Secretary shall analyze + current methods of establishing practice expense + geographic adjustments under subparagraph (A)(i) + and evaluate data that fairly and reliably + establishes distinctions in the costs of operating + a medical practice in the different fee schedule + areas. Such analysis shall include an evaluation + of the following: + ``(I) The feasibility of using + actual data or reliable survey data + developed by medical organizations on + the costs of operating a medical + practice, including office rents and + non-physician staff wages, in different + fee schedule areas. + ``(II) The office expense portion of + the practice expense geographic + adjustment described in subparagraph + (A)(i), including the extent to which + +[[Page 124 STAT. 417]] + + types of office expenses are determined + in local markets instead of national + markets. + ``(III) The weights assigned to each + of the categories within the practice + expense geographic adjustment described + in subparagraph (A)(i). + ``(v) <<NOTE: Deadline.>> Revision for 2012 + and subsequent years.--As a result of the analysis + described in clause (iv), the Secretary shall, not + later than January 1, 2012, make appropriate + adjustments to the practice expense geographic + adjustment described in subparagraph (A)(i) to + ensure accurate geographic adjustments across fee + schedule areas, including-- + ``(I) basing the office rents + component and its weight on office + expenses that vary among fee schedule + areas; and + ``(II) considering a representative + range of professional and non- + professional personnel employed in a + medical office based on the use of the + American Community Survey data or other + reliable data for wage adjustments. + Such adjustments shall be made without regard to + adjustments made pursuant to clauses (i) and (ii) + and shall be made in a budget neutral manner.''. + +SEC. 3103. EXTENSION OF EXCEPTIONS PROCESS FOR MEDICARE THERAPY CAPS. + + Section 1833(g)(5) of the Social Security Act (42 U.S.C. +1395l(g)(5)) is amended by striking ``December 31, 2009'' and inserting +``December 31, 2010''. + +SEC. 3104. EXTENSION OF PAYMENT FOR TECHNICAL COMPONENT OF CERTAIN + PHYSICIAN PATHOLOGY SERVICES. + + Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits +Improvement and Protection Act of 2000 (as enacted into law by section +1(a)(6) of Public Law 106-554), as amended by section 732 of the +Medicare Prescription Drug, Improvement, and Modernization Act of 2003 +(42 U.S.C. 1395w-4 note), section 104 of division B of the Tax Relief +and Health Care Act of 2006 (42 U.S.C. 1395w-4 note), section 104 of the +Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110- +173), and section 136 of the Medicare Improvements for Patients and +Providers Act of 2008 (Public Law 110-275), is amended by striking ``and +2009'' and inserting ``2009, and 2010''. + +SEC. 3105. EXTENSION OF AMBULANCE ADD-ONS. + + (a) Ground Ambulance.--Section 1834(l)(13)(A) of the Social Security +Act (42 U.S.C. 1395m(l)(13)(A)) is amended-- + (1) in the matter preceding clause (i)-- + (A) by striking ``2007, and for'' and inserting + ``2007, for''; and + (B) by striking ``2010'' and inserting ``2010, and + for such services furnished on or after April 1, 2010, + and before January 1, 2011,''; and + (2) in each of clauses (i) and (ii), by inserting ``, and on + or after April 1, 2010, and before January 1, 2011'' after + ``January 1, 2010'' each place it appears. + + (b) Air Ambulance.--Section 146(b)(1) of the Medicare Improvements +for Patients and Providers Act of 2008 <<NOTE: 42 USC 1395m +note.>> (Public Law + +[[Page 124 STAT. 418]] + +110-275) is amended by striking ``December 31, 2009'' and inserting +``December 31, 2009, and during the period beginning on April 1, 2010, +and ending on January 1, 2011''. + + (c) Super Rural Ambulance.--Section 1834(l)(12)(A) of the Social +Security Act (42 U.S.C. 1395m(l)(12)(A)) is amended by striking ``2010'' +and inserting ``2010, and on or after April 1, 2010, and before January +1, 2011''. + +SEC. 3106. EXTENSION OF CERTAIN PAYMENT RULES FOR LONG-TERM CARE + HOSPITAL SERVICES AND OF MORATORIUM ON THE ESTABLISHMENT OF + CERTAIN HOSPITALS AND FACILITIES. + + (a) Extension of Certain Payment Rules.--Section 114(c) of the +Medicare, Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395ww +note), as amended by section 4302(a) of the American Recovery and +Reinvestment Act (Public Law 111-5), is further amended by striking ``3- +year period'' each place it appears and inserting ``4-year period''. + (b) Extension of Moratorium.--Section 114(d)(1) of such Act (42 +U.S.C. 1395ww note), in the matter preceding subparagraph (A), is +amended by striking ``3-year period'' and inserting ``4-year period''. + +SEC. 3107. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL HEALTH ADD-ON. + + Section 138(a)(1) of the Medicare Improvements for Patients and +Providers Act of 2008 (Public Law 110-275) <<NOTE: 42 USC 1395w-4 +note.>> is amended by striking ``December 31, 2009'' and inserting +``December 31, 2010''. + +SEC. 3108. PERMITTING PHYSICIAN ASSISTANTS TO ORDER POST-HOSPITAL + EXTENDED CARE SERVICES. + + (a) Ordering Post-Hospital Extended Care Services.-- + (1) In general.--Section 1814(a)(2) of the Social Security + Act (42 U.S.C. 1395f(a)(2)), in the matter preceding + subparagraph (A), is amended by striking ``or clinical nurse + specialist'' and inserting ``, a clinical nurse specialist, or a + physician assistant (as those terms are defined in section + 1861(aa)(5))'' after ``nurse practitioner''. + (2) Conforming amendment.--Section 1814(a) of the Social + Security Act (42 U.S.C. 1395f(a)) is amended, in the second + sentence, by striking ``or clinical nurse specialist'' and + inserting ``clinical nurse specialist, or physician assistant'' + after ``nurse practitioner,''. + + (b) <<NOTE: 42 USC 1395f note.>> Effective Date.--The amendments +made by this section shall apply to items and services furnished on or +after January 1, 2011. + +SEC. 3109. EXEMPTION OF CERTAIN PHARMACIES FROM ACCREDITATION + REQUIREMENTS. + + (a) In General.--Section 1834(a)(20) of the Social Security Act (42 +U.S.C. 1395m(a)(20)), as added by section 154(b)(1)(A) of the Medicare +Improvements for Patients and Providers Act of 2008 (Public Law 100- +275), is amended-- + (1) in subparagraph (F)(i)-- + (A) by inserting ``and subparagraph (G)'' after + ``clause (ii)''; and + (B) by inserting ``, except that the Secretary shall + not require a pharmacy to have submitted to the + Secretary + +[[Page 124 STAT. 419]] + + such evidence of accreditation prior to January 1, + 2011'' before the semicolon at the end; and + (2) by adding at the end the following new subparagraph: + ``(G) Application of accreditation requirement to + certain pharmacies.-- + ``(i) In general.--With respect to items and + services furnished on or after January 1, 2011, in + implementing quality standards under this + paragraph-- + ``(I) subject to subclause (II), in + applying such standards and the + accreditation requirement of + subparagraph (F)(i) with respect to + pharmacies described in clause (ii) + furnishing such items and services, such + standards and accreditation requirement + shall not apply to such pharmacies; and + ``(II) the Secretary may apply to + such pharmacies an alternative + accreditation requirement established by + the Secretary if the Secretary + determines such alternative + accreditation requirement is more + appropriate for such pharmacies. + ``(ii) <<NOTE: Criteria.>> Pharmacies + described.--A pharmacy described in this clause is + a pharmacy that meets each of the following + criteria: + ``(I) The total billings by the + pharmacy for such items and services + under this title are less than 5 percent + of total pharmacy sales, as determined + based on the average total pharmacy + sales for the previous 3 calendar years, + 3 fiscal years, or other yearly period + specified by the Secretary. + ``(II) The pharmacy has been + enrolled under section 1866(j) as a + supplier of durable medical equipment, + prosthetics, orthotics, and supplies, + has been issued (which may include the + renewal of) a provider number for at + least 5 years, and for which a final + adverse action (as defined in section + 424.57(a) of title 42, Code of Federal + Regulations) has not been imposed in the + past 5 years. + ``(III) The pharmacy submits to the + Secretary an attestation, in a form and + manner, and at a time, specified by the + Secretary, that the pharmacy meets the + criteria described in subclauses (I) and + (II). Such attestation shall be subject + to section 1001 of title 18, United + States Code. + ``(IV) The pharmacy agrees to submit + materials as requested by the Secretary, + or during the course of an audit + conducted on a random sample of + pharmacies selected annually, to verify + that the pharmacy meets the criteria + described in subclauses (I) and (II). + Materials submitted under the preceding + sentence shall include a certification + by an accountant on behalf of the + pharmacy or the submission of tax + returns filed by the pharmacy during the + relevant periods, as requested by the + Secretary.''. + + (b) <<NOTE: 42 USC 1395m note.>> Administration.--Notwithstanding +any other provision of law, the Secretary may implement the amendments +made by subsection (a) by program instruction or otherwise. + +[[Page 124 STAT. 420]] + + (c) <<NOTE: 42 USC 1395m note.>> Rule of Construction.--Nothing in +the provisions of or amendments made by this section shall be construed +as affecting the application of an accreditation requirement for +pharmacies to qualify for bidding in a competitive acquisition area +under section 1847 of the Social Security Act (42 U.S.C. 1395w-3). + +SEC. 3110. PART B SPECIAL ENROLLMENT PERIOD FOR DISABLED TRICARE + BENEFICIARIES. + + (a) In General.-- + (1) In general.--Section 1837 of the Social Security Act (42 + U.S.C. 1395p) is amended by adding at the end the following new + subsection: + + ``(l)(1) In the case of any individual who is a covered beneficiary +(as defined in section 1072(5) of title 10, United States Code) at the +time the individual is entitled to part A under section 226(b) or +section 226A and who is eligible to enroll but who has elected not to +enroll (or to be deemed enrolled) during the individual's initial +enrollment period, there shall be a special enrollment period described +in paragraph (2). + ``(2) The special enrollment period described in this paragraph, +with respect to an individual, is the 12-month period beginning on the +day after the last day of the initial enrollment period of the +individual or, if later, the 12-month period beginning with the month +the individual is notified of enrollment under this section. + ``(3) In the case of an individual who enrolls during the special +enrollment period provided under paragraph (1), the coverage period +under this part shall begin on the first day of the month in which the +individual enrolls, or, at the option of the individual, the first month +after the end of the individual's initial enrollment period. + ``(4) An individual may only enroll during the special enrollment +period provided under paragraph (1) one time during the individual's +lifetime. + ``(5) The Secretary shall ensure that the materials relating to +coverage under this part that are provided to an individual described in +paragraph (1) prior to the individual's initial enrollment period +contain information concerning the impact of not enrolling under this +part, including the impact on health care benefits under the TRICARE +program under chapter 55 of title 10, United States Code. + ``(6) The Secretary of Defense shall collaborate with the Secretary +of Health and Human Services and the Commissioner of Social Security to +provide for the accurate identification of individuals described in +paragraph (1). The Secretary of Defense shall provide such individuals +with notification with respect to this subsection. The Secretary of +Defense shall collaborate with the Secretary of Health and Human +Services and the Commissioner of Social Security to ensure appropriate +follow up pursuant to any notification provided under the preceding +sentence.''. + (2) <<NOTE: 42 USC 1395p note.>> Effective date.--The + amendment made by paragraph (1) shall apply to elections made + with respect to initial enrollment periods that end after the + date of the enactment of this Act. + + (b) Waiver of Increase of Premium.--Section 1839(b) of the Social +Security Act (42 U.S.C. 1395r(b)) is amended by striking ``section +1837(i)(4)'' and inserting ``subsection (i)(4) or (l) of section 1837''. + +[[Page 124 STAT. 421]] + +SEC. 3111. PAYMENT FOR BONE DENSITY TESTS. + + (a) Payment.-- + (1) In general.--Section 1848 of the Social Security Act (42 + U.S.C. 1395w-4) is amended-- + (A) in subsection (b)-- + (i) in paragraph (4)(B), by inserting ``, and + for 2010 and 2011, dual-energy x-ray + absorptiometry services (as described in paragraph + (6))'' before the period at the end; and + (ii) by adding at the end the following new + paragraph: + ``(6) Treatment of bone mass scans.--For dual-energy x-ray + absorptiometry services (identified in 2006 by HCPCS codes 76075 + and 76077 (and any succeeding codes)) furnished during 2010 and + 2011, instead of the payment amount that would otherwise be + determined under this section for such years, the payment amount + shall be equal to 70 percent of the product of-- + ``(A) the relative value for the service (as + determined in subsection (c)(2)) for 2006; + ``(B) the conversion factor (established under + subsection (d)) for 2006; and + ``(C) the geographic adjustment factor (established + under subsection (e)(2)) for the service for the fee + schedule area for 2010 and 2011, respectively.''; and + (B) in subsection (c)(2)(B)(iv)-- + (i) in subclause (II), by striking ``and'' at + the end; + (ii) in subclause (III), by striking the + period at the end and inserting ``; and''; and + (iii) by adding at the end the following new + subclause: + ``(IV) subsection (b)(6) shall not + be taken into account in applying clause + (ii)(II) for 2010 or 2011.''. + (2) <<NOTE: 42 USC 1395w-4 note.>> Implementation.-- + Notwithstanding any other provision of law, the Secretary may + implement the amendments made by paragraph (1) by program + instruction or otherwise. + + (b) Study and Report by the Institute of Medicine.-- + (1) In general.--The Secretary of Health and Human Services + is authorized to enter into an agreement with the Institute of + Medicine of the National Academies to conduct a study on the + ramifications of Medicare payment reductions for dual-energy x- + ray absorptiometry (as described in section 1848(b)(6) of the + Social Security Act, as added by subsection (a)(1)) during 2007, + 2008, and 2009 on beneficiary access to bone mass density tests. + (2) Report.--An agreement entered into under paragraph (1) + shall provide for the Institute of Medicine to submit to the + Secretary and to Congress a report containing the results of the + study conducted under such paragraph. + +SEC. 3112. REVISION TO THE MEDICARE IMPROVEMENT FUND. + + Section 1898(b)(1)(A) of the Social Security Act (42 U.S.C. 1395iii) +is amended by striking ``$22,290,000,000'' and inserting ``$0''. + +[[Page 124 STAT. 422]] + +SEC. 3113. <<NOTE: 42 USC 1395l note.>> TREATMENT OF CERTAIN COMPLEX + DIAGNOSTIC LABORATORY TESTS. + + (a) Demonstration Project.-- + (1) In general.--The Secretary of Health and Human Services + (in this section referred to as the ``Secretary'') shall conduct + a demonstration project under part B title XVIII of the Social + Security Act under which separate payments are made under such + part for complex diagnostic laboratory tests provided to + individuals under such part. Under the demonstration project, + the Secretary shall establish appropriate payment rates for such + tests. + (2) Covered complex diagnostic laboratory test defined.--In + this section, the term ``complex diagnostic laboratory test'' + means a diagnostic laboratory test-- + (A) that is an analysis of gene protein expression, + topographic genotyping, or a cancer chemotherapy + sensitivity assay; + (B) that is determined by the Secretary to be a + laboratory test for which there is not an alternative + test having equivalent performance characteristics; + (C) which is billed using a Health Care Procedure + Coding System (HCPCS) code other than a not otherwise + classified code under such Coding System; + (D) which is approved or cleared by the Food and + Drug Administration or is covered under title XVIII of + the Social Security Act; and + (E) is described in section 1861(s)(3) of the Social + Security Act (42 U.S.C. 1395x(s)(3)). + (3) Separate payment defined.--In this section, the term + ``separate payment'' means direct payment to a laboratory + (including a hospital-based or independent laboratory) that + performs a complex diagnostic laboratory test with respect to a + specimen collected from an individual during a period in which + the individual is a patient of a hospital if the test is + performed after such period of hospitalization and if separate + payment would not otherwise be made under title XVIII of the + Social Security Act by reason of sections 1862(a)(14) and + 1866(a)(1)(H)(i) of the such Act (42 U.S.C. 1395y(a)(14); 42 + U.S.C. 1395cc(a)(1)(H)(i)). + + (b) Duration.--Subject to subsection (c)(2), the Secretary shall +conduct the demonstration project under this section for the 2-year +period beginning on July 1, 2011. + (c) Payments and Limitation.--Payments under the demonstration +project under this section shall-- + (1) be made from the Federal Supplemental Medical Insurance + Trust Fund under section 1841 of the Social Security Act (42 + U.S.C. 1395t); and + (2) may not exceed $100,000,000. + + (d) Report.--Not later than 2 years after the completion of the +demonstration project under this section, the Secretary shall submit to +Congress a report on the project. Such report shall include-- + (1) an assessment of the impact of the demonstration project + on access to care, quality of care, health outcomes, and + expenditures under title XVIII of the Social Security Act + (including any savings under such title); and + +[[Page 124 STAT. 423]] + + (2) such recommendations as the Secretary determines + appropriate. + + (e) Implementation Funding.--For purposes of administering this +section (including preparing and submitting the report under subsection +(d)), the Secretary shall provide for the transfer, from the Federal +Supplemental Medical Insurance Trust Fund under section 1841 of the +Social Security Act (42 U.S.C. 1395t), to the Centers for Medicare & +Medicaid Services Program Management Account, of $5,000,000. Amounts +transferred under the preceding sentence shall remain available until +expended. + +SEC. 3114. IMPROVED ACCESS FOR CERTIFIED NURSE-MIDWIFE SERVICES. + + Section 1833(a)(1)(K) of the Social Security Act (42 U.S.C. +1395l(a)(1)(K)) is amended by inserting ``(or 100 percent for services +furnished on or after January 1, 2011)'' after ``1992, 65 percent''. + + PART II--RURAL PROTECTIONS + +SEC. 3121. EXTENSION OF OUTPATIENT HOLD HARMLESS PROVISION. + + (a) In General.--Section 1833(t)(7)(D)(i) of the Social Security Act +(42 U.S.C. 1395l(t)(7)(D)(i)) is amended-- + (1) in subclause (II)-- + (A) in the first sentence, by striking ``2010''and + inserting ``2011''; and + (B) in the second sentence, by striking ``or 2009'' + and inserting ``, 2009, or 2010''; and + (2) in subclause (III), by striking ``January 1, 2010'' and + inserting ``January 1, 2011''. + + (b) Permitting All Sole Community Hospitals To Be Eligible for Hold +Harmless.--Section 1833(t)(7)(D)(i)(III) of the Social Security Act (42 +U.S.C. 1395l(t)(7)(D)(i)(III)) is amended by adding at the end the +following new sentence: <<NOTE: Time period. Applicability.>> ``In the +case of covered OPD services furnished on or after January 1, 2010, and +before January 1, 2011, the preceding sentence shall be applied without +regard to the 100-bed limitation.''. + +SEC. 3122. <<NOTE: 42 USC 1395l note.>> EXTENSION OF MEDICARE REASONABLE + COSTS PAYMENTS FOR CERTAIN CLINICAL DIAGNOSTIC LABORATORY + TESTS FURNISHED TO HOSPITAL PATIENTS IN CERTAIN RURAL AREAS. + + Section 416(b) of the Medicare Prescription Drug, Improvement, and +Modernization Act of 2003 (42 U.S.C. 1395l-4), as amended by section 105 +of division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. +1395l note) and section 107 of the Medicare, Medicaid, and SCHIP +Extension Act of 2007 (42 U.S.C. 1395l note), is amended by inserting +``or during the 1-year period beginning on July 1, 2010'' before the +period at the end. + +SEC. 3123. <<NOTE: 42 USC 1395ww note.>> EXTENSION OF THE RURAL + COMMUNITY HOSPITAL DEMONSTRATION PROGRAM. + + (a) One-year Extension.--Section 410A of the Medicare Prescription +Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173; +117 Stat. 2272) is amended by adding at the end the following new +subsection: + ``(g) One-Year Extension of Demonstration Program.-- + ``(1) In general.--Subject to the succeeding provisions of + this subsection, the Secretary shall conduct the demonstration + +[[Page 124 STAT. 424]] + + program under this section for an additional 1-year period (in + this section referred to as the `1-year extension period') that + begins on the date immediately following the last day of the + initial 5-year period under subsection (a)(5). + ``(2) Expansion of demonstration states.--Notwithstanding + subsection (a)(2), during the 1-year extension period, the + Secretary shall expand the number of States with low population + densities determined by the Secretary under such subsection to + 20. In determining which States to include in such expansion, + the Secretary shall use the same criteria and data that the + Secretary used to determine the States under such subsection for + purposes of the initial 5-year period. + ``(3) Increase in maximum number of hospitals participating + in the demonstration program.--Notwithstanding subsection + (a)(4), during the 1-year extension period, not more than 30 + rural community hospitals may participate in the demonstration + program under this section. + ``(4) No affect on hospitals in demonstration program on + date of enactment.--In the case of a rural community hospital + that is participating in the demonstration program under this + section as of the last day of the initial 5-year period, the + Secretary shall provide for the continued participation of such + rural community hospital in the demonstration program during the + 1-year extension period unless the rural community hospital + makes an election, in such form and manner as the Secretary may + specify, to discontinue such participation.''. + + (b) Conforming Amendments.--Subsection (a)(5) of section 410A of the +Medicare Prescription Drug, Improvement, and Modernization Act of 2003 +(Public Law 108-173; 117 Stat. 2272) is amended by inserting ``(in this +section referred to as the `initial 5-year period') and, as provided in +subsection (g), for the 1-year extension period'' after ``5-year +period''. + (c) Technical Amendments.-- + (1) Subsection (b) of section 410A of the Medicare + Prescription Drug, Improvement, and Modernization Act of 2003 + (Public Law 108-173; 117 Stat. 2272) is amended-- + (A) in paragraph (1)(B)(ii), by striking ``2)'' and + inserting ``2))''; and + (B) in paragraph (2), by inserting ``cost'' before + ``reporting period'' the first place such term appears + in each of subparagraphs (A) and (B). + (2) Subsection (f)(1) of section 410A of the Medicare + Prescription Drug, Improvement, and Modernization Act of 2003 + (Public Law 108-173; 117 Stat. 2272) is amended-- + (A) in subparagraph (A)(ii), by striking ``paragraph + (2)'' and inserting ``subparagraph (B)''; and + (B) in subparagraph (B), by striking ``paragraph + (1)(B)'' and inserting ``subparagraph (A)(ii)''. + +SEC. 3124. EXTENSION OF THE MEDICARE-DEPENDENT HOSPITAL (MDH) PROGRAM. + + (a) Extension of Payment Methodology.--Section 1886(d)(5)(G) of the +Social Security Act (42 U.S.C. 1395ww(d)(5)(G)) is amended-- + (1) in clause (i), by striking ``October 1, 2011'' and + inserting ``October 1, 2012''; and + +[[Page 124 STAT. 425]] + + (2) in clause (ii)(II), by striking ``October 1, 2011'' and + inserting ``October 1, 2012''. + + (b) Conforming Amendments.-- + (1) Extension of target amount.--Section 1886(b)(3)(D) of + the Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is amended-- + (A) in the matter preceding clause (i), by striking + ``October 1, 2011'' and inserting ``October 1, 2012''; + and + (B) in clause (iv), by striking ``through fiscal + year 2011'' and inserting ``through fiscal year 2012''. + (2) Permitting hospitals to decline reclassification.-- + Section 13501(e)(2) of the Omnibus Budget Reconciliation Act of + 1993 (42 U.S.C. 1395ww note) is amended by striking ``through + fiscal year 2011'' and inserting ``through fiscal year 2012''. + +SEC. 3125. TEMPORARY IMPROVEMENTS TO THE MEDICARE INPATIENT HOSPITAL + PAYMENT ADJUSTMENT FOR LOW-VOLUME HOSPITALS. + + Section 1886(d)(12) of the Social Security Act (42 U.S.C. +1395ww(d)(12)) is amended-- + (1) in subparagraph (A), by inserting ``or (D)'' after + ``subparagraph (B)''; + (2) in subparagraph (B), in the matter preceding clause (i), + by striking ``The Secretary'' and inserting ``For discharges + occurring in fiscal years 2005 through 2010 and for discharges + occurring in fiscal year 2013 and subsequent fiscal years, the + Secretary''; + (3) in subparagraph (C)(i)-- + (A) by inserting ``(or, with respect to fiscal years + 2011 and 2012, 15 road miles)'' after ``25 road miles''; + and + (B) by inserting ``(or, with respect to fiscal years + 2011 and 2012, 1,500 discharges of individuals entitled + to, or enrolled for, benefits under part A)'' after + ``800 discharges''; and + (4) by adding at the end the following new subparagraph: + ``(D) Temporary applicable percentage increase.--For + discharges occurring in fiscal years 2011 and 2012, the + Secretary shall determine an applicable percentage + increase for purposes of subparagraph (A) using a + continuous linear sliding scale ranging from 25 percent + for low-volume hospitals with 200 or fewer discharges of + individuals entitled to, or enrolled for, benefits under + part A in the fiscal year to 0 percent for low-volume + hospitals with greater than 1,500 discharges of such + individuals in the fiscal year.''. + +SEC. 3126. IMPROVEMENTS TO THE DEMONSTRATION PROJECT ON COMMUNITY HEALTH + INTEGRATION MODELS IN CERTAIN RURAL COUNTIES. + + (a) Removal of Limitation on Number of Eligible Counties Selected.-- +Subsection (d)(3) of section 123 of the Medicare Improvements for +Patients and Providers Act of 2008 (42 U.S.C. 1395i-4 note) is amended +by striking ``not more than 6''. + (b) Removal of References to Rural Health Clinic Services and +Inclusion of Physicians' Services in Scope of Demonstration Project.-- +Such section 123 is amended-- + +[[Page 124 STAT. 426]] + + (1) in subsection (d)(4)(B)(i)(3), by striking subclause + (III); and + (2) in subsection (j)-- + (A) in paragraph (8), by striking subparagraph (B) + and inserting the following: + ``(B) Physicians' services (as defined in section + 1861(q) of the Social Security Act (42 U.S.C. + 1395x(q)).''; + (B) by striking paragraph (9); and + (C) by redesignating paragraph (10) as paragraph + (9). + +SEC. 3127. MEDPAC STUDY ON ADEQUACY OF MEDICARE PAYMENTS FOR HEALTH CARE + PROVIDERS SERVING IN RURAL AREAS. + + (a) Study.--The Medicare Payment Advisory Commission shall conduct a +study on the adequacy of payments for items and services furnished by +providers of services and suppliers in rural areas under the Medicare +program under title XVIII of the Social Security Act (42 U.S.C. 1395 et +seq.). Such study shall include an analysis of-- + (1) any adjustments in payments to providers of services and + suppliers that furnish items and services in rural areas; + (2) access by Medicare beneficiaries to items and services + in rural areas; + (3) the adequacy of payments to providers of services and + suppliers that furnish items and services in rural areas; and + (4) the quality of care furnished in rural areas. + + (b) Report.--Not later than January 1, 2011, the Medicare Payment +Advisory Commission shall submit to Congress a report containing the +results of the study conducted under subsection (a). Such report shall +include recommendations on appropriate modifications to any adjustments +in payments to providers of services and suppliers that furnish items +and services in rural areas, together with recommendations for such +legislation and administrative action as the Medicare Payment Advisory +Commission determines appropriate. + +SEC. 3128. TECHNICAL CORRECTION RELATED TO CRITICAL ACCESS HOSPITAL + SERVICES. + + (a) In General.--Subsections (g)(2)(A) and (l)(8) of section 1834 of +the Social Security Act (42 U.S.C. 1395m) are each amended by inserting +``101 percent of'' before ``the reasonable costs''. + (b) <<NOTE: 42 USC 1395m note.>> Effective Date.--The amendments +made by subsection (a) shall take effect as if included in the enactment +of section 405(a) of the Medicare Prescription Drug, Improvement, and +Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2266). + +SEC. 3129. EXTENSION OF AND REVISIONS TO MEDICARE RURAL HOSPITAL + FLEXIBILITY PROGRAM. + + (a) Authorization.--Section 1820(j) of the Social Security Act (42 +U.S.C. 1395i-4(j)) is amended-- + (1) by striking ``2010, and for'' and inserting ``2010, + for''; and + (2) by inserting ``and for making grants to all States under + subsection (g), such sums as may be necessary in each of fiscal + years 2011 and 2012, to remain available until expended'' before + the period at the end. + + (b) Use of Funds.--Section 1820(g)(3) of the Social Security Act (42 +U.S.C. 1395i-4(g)(3)) is amended-- + +[[Page 124 STAT. 427]] + + (1) in subparagraph (A), by inserting ``and to assist such + hospitals in participating in delivery system reforms under the + provisions of and amendments made by the Patient Protection and + Affordable Care Act, such as value-based purchasing programs, + accountable care organizations under section 1899, the National + pilot program on payment bundling under section 1866D, and other + delivery system reform programs determined appropriate by the + Secretary'' before the period at the end; and + (2) in subparagraph (E)-- + (A) by striking ``, and to offset'' and inserting + ``, to offset''; and + (B) by inserting ``and to participate in delivery + system reforms under the provisions of and amendments + made by the Patient Protection and Affordable Care Act, + such as value-based purchasing programs, accountable + care organizations under section 1899, the National + pilot program on payment bundling under section 1866D, + and other delivery system reform programs determined + appropriate by the Secretary'' before the period at the + end. + + (c) <<NOTE: 42 USC 1395i-4 note.>> Effective Date.--The amendments +made by this section shall apply to grants made on or after January 1, +2010. + + PART III--IMPROVING PAYMENT ACCURACY + +SEC. 3131. PAYMENT ADJUSTMENTS FOR HOME HEALTH CARE. + + (a) Rebasing Home Health Prospective Payment Amount.-- + (1) In general.--Section 1895(b)(3)(A) of the Social + Security Act (42 U.S.C. 1395fff(b)(3)(A)) is amended-- + (A) in clause (i)(III), by striking ``For periods'' + and inserting ``Subject to clause (iii), for periods''; + and + (B) by adding at the end the following new clause: + ``(iii) Adjustment for 2013 and subsequent + years.-- + ``(I) In general.--Subject to + subclause (II), for 2013 and subsequent + years, the amount (or amounts) that + would otherwise be applicable under + clause (i)(III) shall be adjusted by a + percentage determined appropriate by the + Secretary to reflect such factors as + changes in the number of visits in an + episode, the mix of services in an + episode, the level of intensity of + services in an episode, the average cost + of providing care per episode, and other + factors that the Secretary considers to + be relevant. In conducting the analysis + under the preceding sentence, the + Secretary may consider differences + between hospital-based and freestanding + agencies, between for-profit and + nonprofit agencies, and between the + resource costs of urban and rural + agencies. Such adjustment shall be made + before the update under subparagraph (B) + is applied for the year. + ``(II) Transition.--The Secretary + shall provide for a 4-year phase-in (in + equal increments) of the adjustment + under subclause (I), with such + adjustment being fully implemented for + 2016. During each year of such phase-in, + the amount of any + +[[Page 124 STAT. 428]] + + adjustment under subclause (I) for the + year may not exceed 3.5 percent of the + amount (or amounts) applicable under + clause (i)(III) as of the date of + enactment of the Patient Protection and + Affordable Care Act.''. + (2) MedPAC study and report.-- + (A) Study.--The Medicare Payment Advisory Commission + shall conduct a study on the implementation of the + amendments made by paragraph (1). Such study shall + include an analysis of the impact of such amendments + on-- + (i) access to care; + (ii) quality outcomes; + (iii) the number of home health agencies; and + (iv) rural agencies, urban agencies, for- + profit agencies, and nonprofit agencies. + (B) Report.--Not later than January 1, 2015, the + Medicare Payment Advisory Commission shall submit to + Congress a report on the study conducted under + subparagraph (A), together with recommendations for such + legislation and administrative action as the Commission + determines appropriate. + + (b) Program-specific Outlier Cap.--Section 1895(b) of the Social +Security Act (42 U.S.C. 1395fff(b)) is amended-- + (1) in paragraph (3)(C), by striking ``the aggregate'' and + all that follows through the period at the end and inserting ``5 + percent of the total payments estimated to be made based on the + prospective payment system under this subsection for the + period.''; and + (2) in paragraph (5)-- + (A) by striking ``Outliers.--The Secretary'' and + inserting the following: ``Outliers.-- + ``(A) In general.--Subject to subparagraph (B), the + Secretary''; + (B) in subparagraph (A), as added by subparagraph + (A), by striking ``5 percent'' and inserting ``2.5 + percent''; and + (C) by adding at the end the following new + subparagraph: + ``(B) Program specific outlier cap.--The estimated + total amount of additional payments or payment + adjustments made under subparagraph (A) with respect to + a home health agency for a year (beginning with 2011) + may not exceed an amount equal to 10 percent of the + estimated total amount of payments made under this + section (without regard to this paragraph) with respect + to the home health agency for the year.''. + + (c) Application of the Medicare Rural Home Health Add-on Policy.-- +Section 421 of the Medicare Prescription Drug, Improvement, and +Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2283), as +amended by section 5201(b) of the Deficit Reduction Act of 2005 (Public +Law 109-171; 120 Stat. 46), <<NOTE: 42 USC 1395fff note.>> is amended-- + (1) in the section heading, by striking ``one-year'' and + inserting ``temporary''; and + (2) in subsection (a)-- + +[[Page 124 STAT. 429]] + + (A) by striking ``, and episodes'' and inserting ``, + episodes''; + (B) by inserting ``and episodes and visits ending on + or after April 1, 2010, and before January 1, 2016,'' + after ``January 1, 2007,''; and + (C) by inserting ``(or, in the case of episodes and + visits ending on or after April 1, 2010, and before + January 1, 2016, 3 percent)'' before the period at the + end. + + (d) <<NOTE: 42 USC 1395fff note.>> Study and Report on the +Development of Home Health Payment Reforms in Order To Ensure Access to +Care and Quality Services.-- + (1) In general.--The Secretary of Health and Human Services + (in this section referred to as the ``Secretary'') shall conduct + a study to evaluate the costs and quality of care among + efficient home health agencies relative to other such agencies + in providing ongoing access to care and in treating Medicare + beneficiaries with varying severity levels of illness. Such + study shall include an analysis of the following: + (A) Methods to revise the home health prospective + payment system under section 1895 of the Social Security + Act (42 U.S.C. 1395fff) to more accurately account for + the costs related to patient severity of illness or to + improving beneficiary access to care, including-- + (i) payment adjustments for services that may + be under- or over-valued; + (ii) necessary changes to reflect the resource + use relative to providing home health services to + low-income Medicare beneficiaries or Medicare + beneficiaries living in medically underserved + areas; + (iii) ways the outlier payment may be improved + to more accurately reflect the cost of treating + Medicare beneficiaries with high severity levels + of illness; + (iv) the role of quality of care incentives + and penalties in driving provider and patient + behavior; + (v) improvements in the application of a wage + index; and + (vi) other areas determined appropriate by the + Secretary. + (B) The validity and reliability of responses on the + OASIS instrument with particular emphasis on questions + that relate to higher payment under the home health + prospective payment system and higher outcome scores + under Home Care Compare. + (C) Additional research or payment revisions under + the home health prospective payment system that may be + necessary to set the payment rates for home health + services based on costs of high-quality and efficient + home health agencies or to improve Medicare beneficiary + access to care. + (D) A timetable for implementation of any + appropriate changes based on the analysis of the matters + described in subparagraphs (A), (B), and (C). + (E) Other areas determined appropriate by the + Secretary. + (2) Considerations.--In conducting the study under paragraph + (1), the Secretary shall consider whether certain factors + +[[Page 124 STAT. 430]] + + should be used to measure patient severity of illness and access + to care, such as-- + (A) population density and relative patient access + to care; + (B) variations in service costs for providing care + to individuals who are dually eligible under the + Medicare and Medicaid programs; + (C) the presence of severe or chronic diseases, as + evidenced by multiple, discontinuous home health + episodes; + (D) poverty status, as evidenced by the receipt of + Supplemental Security Income under title XVI of the + Social Security Act; + (E) the absence of caregivers; + (F) language barriers; + (G) atypical transportation costs; + (H) security costs; and + (I) other factors determined appropriate by the + Secretary. + (3) Report.--Not later than March 1, 2011, the Secretary + shall submit to Congress a report on the study conducted under + paragraph (1), together with recommendations for such + legislation and administrative action as the Secretary + determines appropriate. + (4) Consultations.--In conducting the study under paragraph + (1) and preparing the report under paragraph (3), the Secretary + shall consult with-- + (A) stakeholders representing home health agencies; + (B) groups representing Medicare beneficiaries; + (C) the Medicare Payment Advisory Commission; + (D) the Inspector General of the Department of + Health and Human Services; and + (E) the Comptroller General of the United States. + +SEC. 3132. HOSPICE REFORM. + + (a) Hospice Care Payment Reforms.-- + (1) In general.--Section 1814(i) of the Social Security Act + (42 U.S.C. 1395f(i)), as amended by section 3004(c), is + amended-- + (A) by redesignating paragraph (6) as paragraph (7); + and + (B) by inserting after paragraph (5) the following + new paragraph: + ``(6)(A) <<NOTE: Data and information collection.>> The + Secretary shall collect additional data and information as the + Secretary determines appropriate to revise payments for hospice + care under this subsection pursuant to subparagraph (D) and for + other purposes as determined appropriate by the + Secretary. <<NOTE: Deadline.>> The Secretary shall begin to + collect such data by not later than January 1, 2011. + ``(B) The additional data and information to be collected + under subparagraph (A) may include data and information on-- + ``(i) charges and payments; + ``(ii) the number of days of hospice care which are + attributable to individuals who are entitled to, or + enrolled for, benefits under part A; and + ``(iii) with respect to each type of service + included in hospice care-- + +[[Page 124 STAT. 431]] + + ``(I) the number of days of hospice care + attributable to the type of service; + ``(II) the cost of the type of service; and + ``(III) the amount of payment for the type of + service; + ``(iv) charitable contributions and other revenue of + the hospice program; + ``(v) the number of hospice visits; + ``(vi) the type of practitioner providing the visit; + and + ``(vii) the length of the visit and other basic + information with respect to the visit. + ``(C) The Secretary may collect the additional data and + information under subparagraph (A) on cost reports, claims, or + other mechanisms as the Secretary determines to be appropriate. + ``(D)(i) <<NOTE: Deadline. Regulation.>> Notwithstanding the + preceding paragraphs of this subsection, not earlier than + October 1, 2013, the Secretary shall, by regulation, implement + revisions to the methodology for determining the payment rates + for routine home care and other services included in hospice + care under this part, as the Secretary determines to be + appropriate. Such revisions may be based on an analysis of data + and information collected under subparagraph (A). Such revisions + may include adjustments to per diem payments that reflect + changes in resource intensity in providing such care and + services during the course of the entire episode of hospice + care. + ``(ii) Revisions in payment implemented pursuant to clause + (i) shall result in the same estimated amount of aggregate + expenditures under this title for hospice care furnished in the + fiscal year in which such revisions in payment are implemented + as would have been made under this title for such care in such + fiscal year if such revisions had not been implemented. + ``(E) The Secretary shall consult with hospice programs and + the Medicare Payment Advisory Commission regarding the + additional data and information to be collected under + subparagraph (A) and the payment revisions under subparagraph + (D).''. + (2) Conforming amendments.--Section 1814(i)(1)(C) of the + Social Security Act (42 U.S.C. 1395f(i)(1)(C)) is amended-- + (A) in clause (ii)-- + (i) in the matter preceding subclause (I), by + inserting ``(before the first fiscal year in which + the payment revisions described in paragraph + (6)(D) are implemented)'' after ``subsequent + fiscal year''; and + (ii) in subclause (VII), by inserting + ``(before the first fiscal year in which the + payment revisions described in paragraph (6)(D) + are implemented), subject to clause (iv),'' after + ``subsequent fiscal year''; and + (B) by adding at the end the following new clause: + ``(iii) With respect to routine home care and + other services included in hospice care furnished + during fiscal years subsequent to the first fiscal + year in which payment revisions described in + paragraph (6)(D) are implemented, the payment + rates for such care and services shall be the + payment rates in effect under this clause during + the preceding fiscal year increased by, subject to + clause (iv), the market basket percentage increase + +[[Page 124 STAT. 432]] + + (as defined in section 1886(b)(3)(B)(iii)) for the + fiscal year.''. + + (b) Adoption of MedPAC Hospice Program Eligibility Recertification +Recommendations.--Section 1814(a)(7) of the Social Security Act (42 +U.S.C. 1395f(a)(7)) is amended-- + (1) in subparagraph (B), by striking ``and'' at the end; and + (2) by adding at the end the following new subparagraph: + ``(D) on and after January 1, 2011-- + ``(i) a hospice physician or nurse + practitioner has a face-to-face encounter with the + individual to determine continued eligibility of + the individual for hospice care prior to the + 180th-day recertification and each subsequent + recertification under subparagraph (A)(ii) and + attests that such visit took place (in accordance + with procedures established by the Secretary); and + ``(ii) in the case of hospice care provided an + individual for more than 180 days by a hospice + program for which the number of such cases for + such program comprises more than a percent + (specified by the Secretary) of the total number + of such cases for all programs under this title, + the hospice care provided to such individual is + medically reviewed (in accordance with procedures + established by the Secretary); and''. + +SEC. 3133. IMPROVEMENT TO MEDICARE DISPROPORTIONATE SHARE HOSPITAL (DSH) + PAYMENTS. + + Section 1886 of the Social Security Act (42 U.S.C. 1395ww), as +amended by sections 3001, 3008, and 3025, is amended-- + (1) in subsection (d)(5)(F)(i), by striking ``For'' and + inserting ``Subject to subsection (r), for''; and + (2) by adding at the end the following new subsection: + + ``(r) Adjustments to Medicare DSH Payments.-- + ``(1) Empirically justified dsh payments.--For fiscal year + 2015 and each subsequent fiscal year, instead of the amount of + disproportionate share hospital payment that would otherwise be + made under subsection (d)(5)(F) to a subsection (d) hospital for + the fiscal year, the Secretary shall pay to the subsection (d) + hospital 25 percent of such amount (which represents the + empirically justified amount for such payment, as determined by + the Medicare Payment Advisory Commission in its March 2007 + Report to the Congress). + ``(2) Additional payment.--In addition to the payment made + to a subsection (d) hospital under paragraph (1), for fiscal + year 2015 and each subsequent fiscal year, the Secretary shall + pay to such subsection (d) hospitals an additional amount equal + to the product of the following factors: + ``(A) Factor one.--A factor equal to the difference + between-- + ``(i) the aggregate amount of payments that + would be made to subsection (d) hospitals under + subsection (d)(5)(F) if this subsection did not + apply for such fiscal year (as estimated by the + Secretary); and + ``(ii) the aggregate amount of payments that + are made to subsection (d) hospitals under + paragraph (1) for such fiscal year (as so + estimated). + ``(B) Factor two.-- + +[[Page 124 STAT. 433]] + + ``(i) Fiscal years 2015, 2016, and 2017.--For + each of fiscal years 2015, 2016, and 2017, a + factor equal to 1 minus the percent change + (divided by 100) in the percent of individuals + under the age of 65 who are uninsured, as + determined by comparing the percent of such + individuals-- + ``(I) who are uninsured in 2012, the + last year before coverage expansion + under the Patient Protection and + Affordable Care Act (as calculated by + the Secretary based on the most recent + estimates available from the Director of + the Congressional Budget Office before a + vote in either House on such Act that, + if determined in the affirmative, would + clear such Act for enrollment); and + ``(II) who are uninsured in the most + recent period for which data is + available (as so calculated). + ``(ii) 2018 and subsequent years.--For fiscal + year 2018 and each subsequent fiscal year, a + factor equal to 1 minus the percent change + (divided by 100) in the percent of individuals who + are uninsured, as determined by comparing the + percent of individuals-- + ``(I) who are uninsured in 2012 (as + estimated by the Secretary, based on + data from the Census Bureau or other + sources the Secretary determines + appropriate, and certified by the Chief + Actuary of the Centers for Medicare & + Medicaid Services); and + ``(II) who are uninsured in the most + recent period for which data is + available (as so estimated and + certified). + ``(C) Factor three.--A factor equal to the percent, + for each subsection (d) hospital, that represents the + quotient of-- + ``(i) the amount of uncompensated care for + such hospital for a period selected by the + Secretary (as estimated by the Secretary, based on + appropriate data (including, in the case where the + Secretary determines that alternative data is + available which is a better proxy for the costs of + subsection (d) hospitals for treating the + uninsured, the use of such alternative data)); and + ``(ii) the aggregate amount of uncompensated + care for all subsection (d) hospitals that receive + a payment under this subsection for such period + (as so estimated, based on such data). + ``(3) Limitations on review.--There shall be no + administrative or judicial review under section 1869, section + 1878, or otherwise of the following: + ``(A) Any estimate of the Secretary for purposes of + determining the factors described in paragraph (2). + ``(B) Any period selected by the Secretary for such + purposes.''. + +[[Page 124 STAT. 434]] + +SEC. 3134. MISVALUED CODES UNDER THE PHYSICIAN FEE SCHEDULE. + + (a) In General.--Section 1848(c)(2) of the Social Security Act (42 +U.S.C. 1395w-4(c)(2)) is amended by adding at the end the following new +subparagraphs: + ``(K) Potentially misvalued codes.-- + ``(i) In general.--The Secretary shall-- + ``(I) periodically identify services + as being potentially misvalued using + criteria specified in clause (ii); and + ``(II) review and make appropriate + adjustments to the relative values + established under this paragraph for + services identified as being potentially + misvalued under subclause (I). + ``(ii) Identification of potentially misvalued + codes.--For purposes of identifying potentially + misvalued services pursuant to clause (i)(I), the + Secretary shall examine (as the Secretary + determines to be appropriate) codes (and families + of codes as appropriate) for which there has been + the fastest growth; codes (and families of codes + as appropriate) that have experienced substantial + changes in practice expenses; codes for new + technologies or services within an appropriate + period (such as 3 years) after the relative values + are initially established for such codes; multiple + codes that are frequently billed in conjunction + with furnishing a single service; codes with low + relative values, particularly those that are often + billed multiple times for a single treatment; + codes which have not been subject to review since + the implementation of the RBRVS (the so-called + `Harvard-valued codes'); and such other codes + determined to be appropriate by the Secretary. + ``(iii) Review and adjustments.-- + ``(I) The Secretary may use existing + processes to receive recommendations on + the review and appropriate adjustment of + potentially misvalued services described + in clause (i)(II). + ``(II) The Secretary may conduct + surveys, other data collection + activities, studies, or other analyses + as the Secretary determines to be + appropriate to facilitate the review and + appropriate adjustment described in + clause (i)(II). + ``(III) The Secretary may use + analytic contractors to identify and + analyze services identified under clause + (i)(I), conduct surveys or collect data, + and make recommendations on the review + and appropriate adjustment of services + described in clause (i)(II). + ``(IV) The Secretary may coordinate + the review and appropriate adjustment + described in clause (i)(II) with the + periodic review described in + subparagraph (B). + ``(V) As part of the review and + adjustment described in clause (i)(II), + including with respect to codes with low + relative values described in clause + (ii), the Secretary may make appropriate + coding revisions (including using + existing processes + +[[Page 124 STAT. 435]] + + for consideration of coding changes) + which may include consolidation of + individual services into bundled codes + for payment under the fee schedule under + subsection (b). + ``(VI) The provisions of + subparagraph (B)(ii)(II) shall apply to + adjustments to relative value units made + pursuant to this subparagraph in the + same manner as such provisions apply to + adjustments under subparagraph + (B)(ii)(II). + ``(L) Validating relative value units.-- + ``(i) In general.--The Secretary shall + establish a process to validate relative value + units under the fee schedule under subsection (b). + ``(ii) Components and elements of work.--The + process described in clause (i) may include + validation of work elements (such as time, mental + effort and professional judgment, technical skill + and physical effort, and stress due to risk) + involved with furnishing a service and may include + validation of the pre-, post-, and intra-service + components of work. + ``(iii) Scope of codes.--The validation of + work relative value units shall include a sampling + of codes for services that is the same as the + codes listed under subparagraph (K)(ii). + ``(iv) Methods.--The Secretary may conduct the + validation under this subparagraph using methods + described in subclauses (I) through (V) of + subparagraph (K)(iii) as the Secretary determines + to be appropriate. + ``(v) Adjustments.--The Secretary shall make + appropriate adjustments to the work relative value + units under the fee schedule under subsection (b). + The provisions of subparagraph (B)(ii)(II) shall + apply to adjustments to relative value units made + pursuant to this subparagraph in the same manner + as such provisions apply to adjustments under + subparagraph (B)(ii)(II).''. + + (b) <<NOTE: 42 USC 1395w-4 note.>> Implementation.-- + (1) Administration.-- + (A) Chapter 35 of title 44, United States Code and + the provisions of the Federal Advisory Committee Act (5 + U.S.C. App.) shall not apply to this section or the + amendment made by this section. + (B) Notwithstanding any other provision of law, the + Secretary may implement subparagraphs (K) and (L) of + 1848(c)(2) of the Social Security Act, as added by + subsection (a), by program instruction or otherwise. + (C) Section 4505(d) of the Balanced Budget Act of + 1997 <<NOTE: Repeal.>> is repealed. + (D) Except for provisions related to confidentiality + of information, the provisions of the Federal + Acquisition Regulation shall not apply to this section + or the amendment made by this section. + (2) Focusing cms resources on potentially overvalued + codes. <<NOTE: Repeal.>> --Section 1868(a) of the Social + Security Act (42 U.S.C. 1395ee(a)) is repealed. + +[[Page 124 STAT. 436]] + +SEC. 3135. MODIFICATION OF EQUIPMENT UTILIZATION FACTOR FOR ADVANCED + IMAGING SERVICES. + + (a) Adjustment in Practice Expense To Reflect Higher Presumed +Utilization.--Section 1848 of the Social Security Act (42 U.S.C. 1395w- +4) is amended-- + (1) in subsection (b)(4)-- + (A) in subparagraph (B), by striking ``subparagraph + (A)'' and inserting ``this paragraph''; and + (B) by adding at the end the following new + subparagraph: + ``(C) <<NOTE: Time periods.>> Adjustment in practice + expense to reflect higher presumed utilization.-- + Consistent with the methodology for computing the number + of practice expense relative value units under + subsection (c)(2)(C)(ii) with respect to advanced + diagnostic imaging services (as defined in section + 1834(e)(1)(B)) furnished on or after January 1, 2010, + the Secretary shall adjust such number of units so it + reflects-- + ``(i) in the case of services furnished on or + after January 1, 2010, and before January 1, 2013, + a 65 percent (rather than 50 percent) presumed + rate of utilization of imaging equipment; + ``(ii) in the case of services furnished on or + after January 1, 2013, and before January 1, 2014, + a 70 percent (rather than 50 percent) presumed + rate of utilization of imaging equipment; and + ``(iii) in the case of services furnished on + or after January 1, 2014, a 75 percent (rather + than 50 percent) presumed rate of utilization of + imaging equipment.''; and + (2) in subsection (c)(2)(B)(v), by adding at the end the + following new subclauses: + ``(III) Change in presumed + utilization level of certain advanced + diagnostic imaging services for 2010 + through 2012.--Effective for fee + schedules established beginning with + 2010 and ending with 2012, reduced + expenditures attributable to the + presumed rate of utilization of imaging + equipment of 65 percent under subsection + (b)(4)(C)(i) instead of a presumed rate + of utilization of such equipment of 50 + percent. + ``(IV) Change in presumed + utilization level of certain advanced + diagnostic imaging services for 2013.-- + Effective for fee schedules established + for 2013, reduced expenditures + attributable to the presumed rate of + utilization of imaging equipment of 70 + percent under subsection (b)(4)(C)(ii) + instead of a presumed rate of + utilization of such equipment of 50 + percent. + ``(V) Change in presumed utilization + level of certain advanced diagnostic + imaging services for 2014 and subsequent + years.--Effective for fee schedules + established beginning with 2014, reduced + expenditures attributable to the + presumed + +[[Page 124 STAT. 437]] + + rate of utilization of imaging equipment + of 75 percent under subsection + (b)(4)(C)(iii) instead of a presumed + rate of utilization of such equipment of + 50 percent.''. + + (b) Adjustment in Technical Component ``discount'' on Single-session +Imaging to Consecutive Body Parts.--Section 1848 of the Social Security +Act (42 U.S.C. 1395w-4), as amended by subsection (a), is amended-- + (1) in subsection (b)(4), by adding at the end the following + new subparagraph: + ``(D) Adjustment in technical component discount on + single-session imaging involving consecutive body + parts.--For services furnished on or after July 1, 2010, + the Secretary shall increase the reduction in payments + attributable to the multiple procedure payment reduction + applicable to the technical component for imaging under + the final rule published by the Secretary in the Federal + Register on November 21, 2005 (part 405 of title 42, + Code of Federal Regulations) from 25 percent to 50 + percent.''; and + (2) in subsection (c)(2)(B)(v), by adding at the end the + following new subclause: + ``(VI) Additional reduced payment + for multiple imaging procedures.-- + Effective for fee schedules established + beginning with 2010 (but not applied for + services furnished prior to July 1, + 2010), reduced expenditures attributable + to the increase in the multiple + procedure payment reduction from 25 to + 50 percent (as described in subsection + (b)(4)(D)).''. + + (c) Analysis by the Chief Actuary of the Centers for Medicare & +Medicaid Services. <<NOTE: Deadline. Public information. Time +period.>> --Not later than January 1, 2013, the Chief Actuary of the +Centers for Medicare & Medicaid Services shall make publicly available +an analysis of whether, for the period of 2010 through 2019, the +cumulative expenditure reductions under title XVIII of the Social +Security Act that are attributable to the adjustments under the +amendments made by this section are projected to exceed $3,000,000,000. + +SEC. 3136. REVISION OF PAYMENT FOR POWER-DRIVEN WHEELCHAIRS. + + (a) In General.--Section 1834(a)(7)(A) of the Social Security Act +(42 U.S.C. 1395m(a)(7)(A)) is amended-- + (1) in clause (i)-- + (A) in subclause (II), by inserting ``subclause + (III) and'' after ``Subject to''; and + (B) by adding at the end the following new + subclause: + ``(III) Special rule for power- + driven wheelchairs.--For purposes of + payment for power-driven wheelchairs, + subclause (II) shall be applied by + substituting `15 percent' and `6 + percent' for `10 percent' and `7.5 + percent', respectively.''; and + (2) in clause (iii)-- + (A) in the heading, by inserting ``complex, + rehabilitative'' before ``power-driven''; and + (B) by inserting ``complex, rehabilitative'' before + ``power-driven''. + +[[Page 124 STAT. 438]] + + (b) Technical Amendment.--Section 1834(a)(7)(C)(ii)(II) of the +Social Security Act (42 U.S.C. 1395m(a)(7)(C)(ii)(II)) is amended by +striking ``(A)(ii) or''. + (c) <<NOTE: 42 USC 1395m note.>> Effective Date.-- + (1) <<NOTE: Applicability.>> In general.--Subject to + paragraph (2), the amendments made by subsection (a) shall take + effect on January 1, 2011, and shall apply to power-driven + wheelchairs furnished on or after such date. + (2) Application to competitive bidding.--The amendments made + by subsection (a) shall not apply to payment made for items and + services furnished pursuant to contracts entered into under + section 1847 of the Social Security Act (42 U.S.C. 1395w-3) + prior to January 1, 2011, pursuant to the implementation of + subsection (a)(1)(B)(i)(I) of such section 1847. + +SEC. 3137. HOSPITAL WAGE INDEX IMPROVEMENT. + + (a) Extension of Section 508 Hospital Reclassifications.-- + (1) In general.--Subsection (a) of section 106 of division B + of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395 + note), as amended by section 117 of the Medicare, Medicaid, and + SCHIP Extension Act of 2007 (Public Law 110-173) and section 124 + of the Medicare Improvements for Patients and Providers Act of + 2008 (Public Law 110-275), <<NOTE: 42 USC 1395ww note.>> is + amended by striking ``September 30, 2009'' and inserting + ``September 30, 2010''. + (2) <<NOTE: 42 USC 1395ww note.>> Use of particular wage + index in fiscal year 2010.--For purposes of implementation of + the amendment made by this subsection during fiscal year 2010, + the Secretary shall use the hospital wage index that was + promulgated by the Secretary in the Federal Register on August + 27, 2009 (74 Fed. Reg. 43754), and any subsequent corrections. + + (b) <<NOTE: 42 USC 1395ww note.>> Plan for Reforming the Medicare +Hospital Wage Index System.-- + (1) In general. <<NOTE: Deadline. Reports.>> --Not later + than December 31, 2011, the Secretary of Health and Human + Services (in this section referred to as the ``Secretary'') + shall submit to Congress a report that includes a plan to reform + the hospital wage index system under section 1886 of the Social + Security Act. + (2) Details.--In developing the plan under paragraph (1), + the Secretary shall take into account the goals for reforming + such system set forth in the Medicare Payment Advisory + Commission June 2007 report entitled ``Report to Congress: + Promoting Greater Efficiency in Medicare'', including + establishing a new hospital compensation index system that-- + (A) uses Bureau of Labor Statistics data, or other + data or methodologies, to calculate relative wages for + each geographic area involved; + (B) minimizes wage index adjustments between and + within metropolitan statistical areas and statewide + rural areas; + (C) includes methods to minimize the volatility of + wage index adjustments that result from implementation + of policy, while maintaining budget neutrality in + applying such adjustments; + (D) takes into account the effect that + implementation of the system would have on health care + providers and on each region of the country; + +[[Page 124 STAT. 439]] + + (E) addresses issues related to occupational mix, + such as staffing practices and ratios, and any evidence + on the effect on quality of care or patient safety as a + result of the implementation of the system; and + (F) provides for a transition. + (3) Consultation.--In developing the plan under paragraph + (1), the Secretary shall consult with relevant affected parties. + + (c) Use of Particular Criteria for Determining +Reclassifications. <<NOTE: Effective date.>> --Notwithstanding any other +provision of law, in making decisions on applications for +reclassification of a subsection (d) hospital (as defined in paragraph +(1)(B) of section 1886(d) of the Social Security Act (42 U.S.C. +1395ww(d)) for the purposes described in paragraph (10)(D)(v) of such +section for fiscal year 2011 and each subsequent fiscal year (until the +first fiscal year beginning on or after the date that is 1 year after +the Secretary of Health and Human Services submits the report to +Congress under subsection (b)), the Geographic Classification Review +Board established under paragraph (10) of such section shall use the +average hourly wage comparison criteria used in making such decisions as +of September 30, 2008. The preceding sentence shall be effected in a +budget neutral manner. + +SEC. 3138. TREATMENT OF CERTAIN CANCER HOSPITALS. + + Section 1833(t) of the Social Security Act (42 U.S.C. 1395l(t)) is +amended by adding at the end the following new paragraph: + ``(18) Authorization of adjustment for cancer hospitals.-- + ``(A) Study.--The Secretary shall conduct a study to + determine if, under the system under this subsection, + costs incurred by hospitals described in section + 1886(d)(1)(B)(v) with respect to ambulatory payment + classification groups exceed those costs incurred by + other hospitals furnishing services under this + subsection (as determined appropriate by the Secretary). + In conducting the study under this subparagraph, the + Secretary shall take into consideration the cost of + drugs and biologicals incurred by such hospitals. + ``(B) Authorization of adjustment.--Insofar as the + Secretary determines under subparagraph (A) that costs + incurred by hospitals described in section + 1886(d)(1)(B)(v) exceed those costs incurred by other + hospitals furnishing services under this subsection, the + Secretary shall provide for an appropriate adjustment + under paragraph (2)(E) to reflect those higher costs + effective for services furnished on or after January 1, + 2011.''. + +SEC. 3139. PAYMENT FOR BIOSIMILAR BIOLOGICAL PRODUCTS. + + (a) In General.--Section 1847A of the Social Security Act (42 U.S.C. +1395w-3a) is amended-- + (1) in subsection (b)-- + (A) in paragraph (1)-- + (i) in subparagraph (A), by striking ``or'' at + the end; + (ii) in subparagraph (B), by striking the + period at the end and inserting ``; or''; and + (iii) by adding at the end the following new + subparagraph: + +[[Page 124 STAT. 440]] + + ``(C) in the case of a biosimilar biological product + (as defined in subsection (c)(6)(H)), the amount + determined under paragraph (8).''; and + (B) by adding at the end the following new + paragraph: + ``(8) Biosimilar biological product.--The amount specified + in this paragraph for a biosimilar biological product described + in paragraph (1)(C) is the sum of-- + ``(A) the average sales price as determined using + the methodology described under paragraph (6) applied to + a biosimilar biological product for all National Drug + Codes assigned to such product in the same manner as + such paragraph is applied to drugs described in such + paragraph; and + ``(B) 6 percent of the amount determined under + paragraph (4) for the reference biological product (as + defined in subsection (c)(6)(I)).''; and + (2) in subsection (c)(6), by adding at the end the following + new subparagraph: + ``(H) Biosimilar biological product.--The term + `biosimilar biological product' means a biological + product approved under an abbreviated application for a + license of a biological product that relies in part on + data or information in an application for another + biological product licensed under section 351 of the + Public Health Service Act. + ``(I) Reference biological product.--The term + `reference biological product' means the biological + product licensed under such section 351 that is referred + to in the application described in subparagraph (H) of + the biosimilar biological product.''. + + (b) <<NOTE: Applicability. 42 USC 1395w-3a note.>> Effective Date.-- +The amendments made by subsection (a) shall apply to payments for +biosimilar biological products beginning with the first day of the +second calendar quarter after enactment of legislation providing for a +biosimilar pathway (as determined by the Secretary). + +SEC. 3140. <<NOTE: 42 USC 1395d note.>> MEDICARE HOSPICE CONCURRENT CARE + DEMONSTRATION PROGRAM. + + (a) Establishment.-- + (1) In general.--The Secretary of Health and Human Services + (in this section referred to as the ``Secretary'') shall + establish a Medicare Hospice Concurrent Care demonstration + program at participating hospice programs under which Medicare + beneficiaries are furnished, during the same period, hospice + care and any other items or services covered under title XVIII + of the Social Security Act (42 U.S.C. 1395 et seq.) from funds + otherwise paid under such title to such hospice programs. + (2) Duration.--The demonstration program under this section + shall be conducted for a 3-year period. + (3) Sites.--The Secretary shall select not more than 15 + hospice programs at which the demonstration program under this + section shall be conducted. Such hospice programs shall be + located in urban and rural areas. + + (b) Independent Evaluation and Reports.-- + (1) Independent evaluation.--The Secretary shall provide for + the conduct of an independent evaluation of the demonstration + program under this section. Such independent evaluation shall + determine whether the demonstration program + +[[Page 124 STAT. 441]] + + has improved patient care, quality of life, and cost- + effectiveness for Medicare beneficiaries participating in the + demonstration program. + (2) Reports.--The Secretary shall submit to Congress a + report containing the results of the evaluation conducted under + paragraph (1), together with such recommendations as the + Secretary determines appropriate. + + (c) Budget Neutrality.--With respect to the 3-year period of the +demonstration program under this section, the Secretary shall ensure +that the aggregate expenditures under title XVIII for such period shall +not exceed the aggregate expenditures that would have been expended +under such title if the demonstration program under this section had not +been implemented. + +SEC. 3141. <<NOTE: 42 USC 1395ww note.>> APPLICATION OF BUDGET + NEUTRALITY ON A NATIONAL BASIS IN THE CALCULATION OF THE + MEDICARE HOSPITAL WAGE INDEX FLOOR. + + In the case of discharges occurring on or after October 1, 2010, for +purposes of applying section 4410 of the Balanced Budget Act of 1997 (42 +U.S.C. 1395ww note) and paragraph (h)(4) of section 412.64 of title 42, +Code of Federal Regulations, the Secretary of Health and Human Services +shall administer subsection (b) of such section 4410 and paragraph (e) +of such section 412.64 in the same manner as the Secretary administered +such subsection (b) and paragraph (e) for discharges occurring during +fiscal year 2008 (through a uniform, national adjustment to the area +wage index). + +SEC. 3142. HHS STUDY ON URBAN MEDICARE-DEPENDENT HOSPITALS. + + (a) Study.-- + (1) In general.--The Secretary of Health and Human Services + (in this section referred to as the ``Secretary'') shall conduct + a study on the need for an additional payment for urban + Medicare-dependent hospitals for inpatient hospital services + under section 1886 of the Social Security Act (42 U.S.C. + 1395ww). Such study shall include an analysis of-- + (A) the Medicare inpatient margins of urban + Medicare-dependent hospitals, as compared to other + hospitals which receive 1 or more additional payments or + adjustments under such section (including those payments + or adjustments described in paragraph (2)(A)); and + (B) whether payments to medicare-dependent, small + rural hospitals under subsection (d)(5)(G) of such + section should be applied to urban Medicare-dependent + hospitals. + (2) Urban medicare-dependent hospital defined.--For purposes + of this section, the term ``urban Medicare-dependent hospital'' + means a subsection (d) hospital (as defined in subsection + (d)(1)(B) of such section) that-- + (A) does not receive any additional payment or + adjustment under such section, such as payments for + indirect medical education costs under subsection + (d)(5)(B) of such section, disproportionate share + payments under subsection (d)(5)(A) of such section, + payments to a rural referral center under subsection + (d)(5)(C) of such section, payments to a critical access + hospital under section 1814(l) of such Act (42 U.S.C. + 1395f(l)), payments to a sole community hospital under + subsection (d)(5)(D) of such section 1886, or payments + to a medicare-dependent, small rural hospital under + subsection (d)(5)(G) of such section 1886; and + +[[Page 124 STAT. 442]] + + (B) for which more than 60 percent of its inpatient + days or discharges during 2 of the 3 most recently + audited cost reporting periods for which the Secretary + has a settled cost report were attributable to + inpatients entitled to benefits under part A of title + XVIII of such Act. + + (b) Report.--Not later than 9 months after the date of enactment of +this Act, the Secretary shall submit to Congress a report containing the +results of the study conducted under subsection (a), together with +recommendations for such legislation and administrative action as the +Secretary determines appropriate. + +SEC. 3143. <<NOTE: 42 USC 1395d note.>> PROTECTING HOME HEALTH BENEFITS. + + Nothing in the provisions of, or amendments made by, this Act shall +result in the reduction of guaranteed home health benefits under title +XVIII of the Social Security Act. + + Subtitle C--Provisions Relating to Part C + +SEC. 3201. MEDICARE ADVANTAGE PAYMENT. + + (a) MA Benchmark Based on Plan's Competitive Bids.-- + (1) In general.--Section 1853(j) of the Social Security Act + (42 U.S.C. 1395w-23(j)) is amended-- + (A) by striking ``Amounts.--For purposes'' and + inserting ``Amounts.-- + ``(1) In general.--For purposes''; + (B) by redesignating paragraphs (1) and (2) as + subparagraphs (A) and (B), respectively, and indenting + the subparagraphs appropriately; + (C) in subparagraph (A), as redesignated by + subparagraph (B)-- + (i) by redesignating subparagraphs (A) and (B) + as clauses (i) and (ii), respectively, and + indenting the clauses appropriately; and + (ii) in clause (i), as redesignated by clause + (i), by striking ``an amount equal to'' and all + that follows through the end and inserting ``an + amount equal to-- + ``(I) for years before 2007, \1/12\ + of the annual MA capitation rate under + section 1853(c)(1) for the area for the + year, adjusted as appropriate for the + purpose of risk adjustment; + ``(II) for 2007 through 2011, \1/12\ + of the applicable amount determined + under subsection (k)(1) for the area for + the year; + ``(III) for 2012, the sum of-- + ``(aa) \2/3\ of the quotient + of-- + ``(AA) the applicable + amount determined under + subsection (k)(1) for the + area for the year; and + ``(BB) 12; and + ``(bb) \1/3\ of the MA + competitive benchmark amount + (determined under paragraph (2)) + for the area for the month; + ``(IV) for 2013, the sum of-- + ``(aa) \1/3\ of the quotient + of-- + +[[Page 124 STAT. 443]] + + ``(AA) the applicable + amount determined under + subsection (k)(1) for the + area for the year; and + ``(BB) 12; and + ``(bb) \2/3\ of the MA + competitive benchmark amount (as + so determined) for the area for + the month; + ``(V) for 2014, the MA competitive + benchmark amount for the area for a + month in 2013 (as so determined), + increased by the national per capita MA + growth percentage, described in + subsection (c)(6) for 2014, but not + taking into account any adjustment under + subparagraph (C) of such subsection for + a year before 2004; and + ``(VI) for 2015 and each subsequent + year, the MA competitive benchmark + amount (as so determined) for the area + for the month; or''; + (iii) in clause (ii), as redesignated by + clause (i), by striking ``subparagraph (A)'' and + inserting ``clause (i)''; + (D) by adding at the end the following new + paragraphs: + ``(2) Computation of ma competitive benchmark amount.-- + ``(A) In general.--Subject to subparagraph (B) and + paragraph (3), for months in each year (beginning with + 2012) for each MA payment area the Secretary shall + compute an MA competitive benchmark amount equal to the + weighted average of the unadjusted MA statutory non-drug + monthly bid amount (as defined in section 1854(b)(2)(E)) + for each MA plan in the area, with the weight for each + plan being equal to the average number of beneficiaries + enrolled under such plan in the reference month (as + defined in section 1858(f)(4), except that, in applying + such definition for purposes of this paragraph, `to + compute the MA competitive benchmark amount under + section 1853(j)(2)' shall be substituted for `to compute + the percentage specified in subparagraph (A) and other + relevant percentages under this part'). + ``(B) Weighting rules.-- + ``(i) Single plan rule.--In the case of an MA + payment area in which only a single MA plan is + being offered, the weight under subparagraph (A) + shall be equal to 1. + ``(ii) Use of simple average among multiple + plans if no plans offered in previous year.--In + the case of an MA payment area in which no MA plan + was offered in the previous year and more than 1 + MA plan is offered in the current year, the + Secretary shall use a simple average of the + unadjusted MA statutory non-drug monthly bid + amount (as so defined) for purposes of computing + the MA competitive benchmark amount under + subparagraph (A). + ``(3) Cap on ma competitive benchmark amount.--In no case + shall the MA competitive benchmark amount for an area for a + month in a year be greater than the applicable amount + +[[Page 124 STAT. 444]] + + that would (but for the application of this subsection) be + determined under subsection (k)(1) for the area for the month in + the year.''; and + (E) in subsection (k)(2)(B)(ii)(III), by striking + ``(j)(1)(A)'' and inserting ``(j)(1)(A)(i)''. + (2) Conforming amendments.-- + (A) Section 1853(k)(2) of the Social Security Act + (42 U.S.C. 1395w-23(k)(2)) is amended-- + (i) in subparagraph (A), by striking ``through + 2010'' and inserting ``and subsequent years''; and + (ii) in subparagraph (C)-- + (I) in clause (iii), by striking + ``and'' at the end; + (II) in clause (iv), by striking the + period at the end and inserting ``; + and''; and + (III) by adding at the end the + following new clause: + ``(v) for 2011 and subsequent years, 0.00.''. + (B) Section 1854(b) of the Social Security Act (42 + U.S.C. 1395w-24(b)) is amended-- + (i) in paragraph (3)(B)(i), by striking + ``1853(j)(1)'' and inserting ``1853(j)(1)(A)''; + and + (ii) in paragraph (4)(B)(i), by striking + ``1853(j)(2)'' and inserting ``1853(j)(1)(B)''. + (C) Section 1858(f) of the Social Security + Act <<NOTE: 42 USC 1395w-27a.>> (42 U.S.C. 1395w-27(f)) + is amended-- + (i) in paragraph (1), by striking + ``1853(j)(2)'' and inserting ``1853(j)(1)(B)''; + and + (ii) in paragraph (3)(A), by striking + ``1853(j)(1)(A)'' and inserting + ``1853(j)(1)(A)(i)''. + (D) Section 1860C-1(d)(1)(A) of the Social Security + Act (42 U.S.C. 1395w-29(d)(1)(A)) is amended by striking + ``1853(j)(1)(A)'' and inserting ``1853(j)(1)(A)(i)''. + + (b) Reduction of National Per Capita Growth Percentage for 2011.-- +Section 1853(c)(6) of the Social Security Act (42 U.S.C. 1395w-23(c)(6)) +is amended-- + (1) in clause (v), by striking ``and'' at the end; + (2) in clause (vi)-- + (A) by striking ``for a year after 2002'' and + inserting ``for 2003 through 2010''; and + (B) by striking the period at the end and inserting + a comma; and + (C) by adding at the end the following new clauses: + ``(vii) for 2011, 3 percentage points; and + ``(viii) for a year after 2011, 0 percentage + points.''. + + (c) Enhancement of Beneficiary Rebates.--Section 1854(b)(1)(C)(i) of +the Social Security Act (42 U.S.C. 1395w-24(b)(1)(C)(i)) is amended by +inserting ``(or 100 percent in the case of plan years beginning on or +after January 1, 2014)'' after ``75 percent''. + (d) Bidding Rules.-- + (1) Requirements for information + submitted. <<NOTE: Certification.>> --Section 1854(a)(6)(A) of + the Social Security Act (42 U.S.C. 1395w-24(a)(6)(A)) is + amended, in the flush matter following clause (v), by adding at + the end the following sentence: ``Information to be submitted + under this paragraph shall be certified by a qualified member of + the American Academy of Actuaries + +[[Page 124 STAT. 445]] + + and shall meet actuarial guidelines and rules established by the + Secretary under subparagraph (B)(v).''. + (2) Establishment of actuarial guidelines.--Section + 1854(a)(6)(B) of the Social Security Act (42 U.S.C. 1395w- + 24(a)(6)(B)) is amended-- + (A) in clause (i), by striking ``(iii) and (iv)'' + and inserting ``(iii), (iv), and (v)''; and + (B) by adding at the end the following new clause: + ``(v) Establishment of actuarial guidelines.-- + ``(I) In general.--In order to + establish fair MA competitive benchmarks + under section 1853(j)(1)(A)(i), the + Secretary, acting through the Chief + Actuary of the Centers for Medicare & + Medicaid Services (in this clause + referred to as the `Chief Actuary'), + shall establish-- + ``(aa) actuarial guidelines + for the submission of bid + information under this + paragraph; and + ``(bb) bidding rules that + are appropriate to ensure + accurate bids and fair + competition among MA plans. + ``(II) Denial of bid amounts.--The + Secretary shall deny monthly bid amounts + submitted under subparagraph (A) that do + not meet the actuarial guidelines and + rules established under subclause (I). + ``(III) Refusal to accept certain + bids due to misrepresentations and + failures to adequately meet + requirements. <<NOTE: Determinations. Rep + orts.>> --In the case where the + Secretary determines that information + submitted by an MA organization under + subparagraph (A) contains consistent + misrepresentations and failures to + adequately meet requirements of the + organization, the Secretary may refuse + to accept any additional such bid + amounts from the organization for the + plan year and the Chief Actuary shall, + if the Chief Actuary determines that the + actuaries of the organization were + complicit in those misrepresentations + and failures, report those actuaries to + the Actuarial Board for Counseling and + Discipline.''. + (3) <<NOTE: 42 USC 1395w-24 note.>> Effective date.--The + amendments made by this subsection shall apply to bid amounts + submitted on or after January 1, 2012. + + (e) MA Local Plan Service Areas.-- + (1) In general.--Section 1853(d) of the Social Security Act + (42 U.S.C. 1395w-23(d)) is amended-- + (A) in the subsection heading, by striking ``MA + Region'' and inserting ``MA Region; MA Local Plan + Service Area''; + (B) in paragraph (1), by striking subparagraph (A) + and inserting the following: + ``(A) with respect to an MA local plan-- + ``(i) for years before 2012, an MA local area + (as defined in paragraph (2)); and + +[[Page 124 STAT. 446]] + + ``(ii) for 2012 and succeeding years, a + service area that is an entire urban or rural + area, as applicable (as described in paragraph + (5)); and''; and + (C) by adding at the end the following new + paragraph: + ``(5) MA local plan service area.--For 2012 and succeeding + years, the service area for an MA local plan shall be an entire + urban or rural area in each State as follows: + ``(A) Urban areas.-- + ``(i) In general.--Subject to clause (ii) and + subparagraphs (C) and (D), the service area for an + MA local plan in an urban area shall be the Core + Based Statistical Area (in this paragraph referred + to as a `CBSA') or, if applicable, a conceptually + similar alternative classification, as defined by + the Director of the Office of Management and + Budget. + ``(ii) CBSA covering more than one state.--In + the case of a CBSA (or alternative classification) + that covers more than one State, the Secretary + shall divide the CBSA (or alternative + classification) into separate service areas with + respect to each State covered by the CBSA (or + alternative classification). + ``(B) Rural areas.--Subject to subparagraphs (C) and + (D), the service area for an MA local plan in a rural + area shall be a county that does not qualify for + inclusion in a CBSA (or alternative classification), as + defined by the Director of the Office of Management and + Budget. + ``(C) Refinements to service areas.--For 2015 and + succeeding years, in order to reflect actual patterns of + health care service utilization, the Secretary may + adjust the boundaries of service areas for MA local + plans in urban areas and rural areas under subparagraphs + (A) and (B), respectively, but may only do so based on + recent analyses of actual patterns of care. + ``(D) Additional authority to make limited + exceptions to service area requirements for ma local + plans.--The Secretary may, in addition to any + adjustments under subparagraph (C), make limited + exceptions to service area requirements otherwise + applicable under this part for MA local plans that have + in effect (as of the date of enactment of the Patient + Protection and Affordable Care Act)-- + ``(i) agreements with another MA organization + or MA plan that preclude the offering of benefits + throughout an entire service area; or + ``(ii) limitations in their structural + capacity to support adequate networks throughout + an entire service area as a result of the delivery + system model of the MA local plan.''. + (2) Conforming amendments.-- + (A) In general.-- + (i) Section 1851(b)(1) of the Social Security + Act (42 U.S.C. 1395w-21(b)(1)) is amended by + striking subparagraph (C). + (ii) Section 1853(b)(1)(B)(i) of such Act (42 + U.S.C. 1395w-23(b)(1)(B)(i))-- + +[[Page 124 STAT. 447]] + + (I) in the matter preceding + subclause (I), by striking ``MA payment + area'' and inserting ``MA local area (as + defined in subsection (d)(2))''; and + (II) in subclause (I), by striking + ``MA payment area'' and inserting ``MA + local area (as so defined)''. + (iii) Section 1853(b)(4) of such Act (42 + U.S.C. 1395w-23(b)(4)) is amended by striking + ``Medicare Advantage payment area'' and inserting + ``MA local area (as so defined)''. + (iv) Section 1853(c)(1) of such Act (42 U.S.C. + 1395w-23(c)(1)) is amended-- + (I) in the matter preceding + subparagraph (A), by striking ``a + Medicare Advantage payment area that + is''; and + (II) in subparagraph (D)(i), by + striking ``MA payment area'' and + inserting ``MA local area (as defined in + subsection (d)(2))''. + (v) Section 1854 of such Act (42 U.S.C. 1395w- + 24) is amended by striking subsection (h). + (B) <<NOTE: 42 USC 1395w-21 note.>> Effective + date.--The amendments made by this paragraph shall take + effect on January 1, 2012. + + (f) Performance Bonuses.-- + (1) MA plans.-- + (A) In general.--Section 1853 of the Social Security + Act (42 U.S.C. 1395w-23) is amended by adding at the end + the following new subsection: + + ``(n) Performance Bonuses.-- + ``(1) Care coordination and management performance bonus.-- + ``(A) In general. <<NOTE: Effective + date. Payments.>> --For years beginning with 2014, + subject to subparagraph (B), in the case of an MA plan + that conducts 1 or more programs described in + subparagraph (C) with respect to the year, the Secretary + shall, in addition to any other payment provided under + this part, make monthly payments, with respect to + coverage of an individual under this part, to the MA + plan in an amount equal to the product of-- + ``(i) 0.5 percent of the national monthly per + capita cost for expenditures for individuals + enrolled under the original medicare fee-for- + service program for the year; and + ``(ii) the total number of programs described + in clauses (i) through (ix) of subparagraph (C) + that the Secretary determines the plan is + conducting for the year under such subparagraph. + ``(B) Limitation.--In no case may the total amount + of payment with respect to a year under subparagraph (A) + be greater than 2 percent of the national monthly per + capita cost for expenditures for individuals enrolled + under the original medicare fee-for-service program for + the year, as determined prior to the application of risk + adjustment under paragraph (4). + ``(C) Programs described.--The following programs + are described in this paragraph: + ``(i) Care management programs that-- + ``(I) target individuals with 1 or + more chronic conditions; + +[[Page 124 STAT. 448]] + + ``(II) identify gaps in care; and + ``(III) facilitate improved care by + using additional resources like nurses, + nurse practitioners, and physician + assistants. + ``(ii) Programs that focus on patient + education and self-management of health + conditions, including interventions that-- + ``(I) help manage chronic + conditions; + ``(II) reduce declines in health + status; and + ``(III) foster patient and provider + collaboration. + ``(iii) Transitional care interventions that + focus on care provided around a hospital inpatient + episode, including programs that target post- + discharge patient care in order to reduce + unnecessary health complications and readmissions. + ``(iv) Patient safety programs, including + provisions for hospital-based patient safety + programs in contracts that the Medicare Advantage + organization offering the MA plan has with + hospitals. + ``(v) Financial policies that promote + systematic coordination of care by primary care + physicians across the full spectrum of specialties + and sites of care, such as medical homes, + capitation arrangements, or pay-for-performance + programs. + ``(vi) Programs that address, identify, and + ameliorate health care disparities among principal + at-risk subpopulations. + ``(vii) Medication therapy management programs + that are more extensive than is required under + section 1860D-4(c) (as determined by the + Secretary). + ``(viii) Health information technology + programs, including clinical decision support and + other tools to facilitate data collection and + ensure patient-centered, appropriate care. + ``(ix) Such other care management and + coordination programs as the Secretary determines + appropriate. + ``(D) Conduct of program in urban and rural areas.-- + An MA plan may conduct a program described in + subparagraph (C) in a manner appropriate for an urban or + rural area, as applicable. + ``(E) Reporting of data.--Each Medicare Advantage + organization shall provide to the Secretary the + information needed to determine whether they are + eligible for a care coordination and management + performance bonus at a time and in a manner specified by + the Secretary. + ``(F) Periodic auditing. <<NOTE: Deadline.>> --The + Secretary shall provide for the annual auditing of + programs described in subparagraph (C) for which an MA + plan receives a care coordination and management + performance bonus under this paragraph. The Comptroller + General shall monitor auditing activities conducted + under this subparagraph. + ``(2) Quality performance bonuses.-- + ``(A) Quality bonus. <<NOTE: Effective + date. Payments.>> --For years beginning with 2014, the + Secretary shall, in addition to any other payment + provided under this part, make monthly payments, with + respect to coverage of an individual under this part, to + an MA plan that achieves at least a 3 star rating (or + +[[Page 124 STAT. 449]] + + comparable rating) on a rating system described in + subparagraph (C) in an amount equal to-- + ``(i) in the case of a plan that achieves a 3 + star rating (or comparable rating) on such system + 2 percent of the national monthly per capita cost + for expenditures for individuals enrolled under + the original medicare fee-for-service program for + the year; and + ``(ii) in the case of a plan that achieves a 4 + or 5 star rating (or comparable rating on such + system, 4 percent of such national monthly per + capita cost for the year. + ``(B) Improved quality bonus. <<NOTE: Effective + date. Payments.>> --For years beginning with 2014, in + the case of an MA plan that does not receive a quality + bonus under subparagraph (A) and is an improved quality + MA plan with respect to the year (as identified by the + Secretary), the Secretary shall, in addition to any + other payment provided under this part, make monthly + payments, with respect to coverage of an individual + under this part, to the MA plan in an amount equal to 1 + percent of such national monthly per capita cost for the + year. + ``(C) Use of rating system.--For purposes of + subparagraph (A), a rating system described in this + paragraph is-- + ``(i) a rating system that uses up to 5 stars + to rate clinical quality and enrollee satisfaction + and performance at the Medicare Advantage contract + or MA plan level; or + ``(ii) such other system established by the + Secretary that provides for the determination of a + comparable quality performance rating to the + rating system described in clause (i). + ``(D) Data used in determining score.-- + ``(i) In general.--The rating of an MA plan + under the rating system described in subparagraph + (C) with respect to a year shall be based on based + on the most recent data available. + ``(ii) Plans that fail to report data.--An MA + plan which does not report data that enables the + Secretary to rate the plan for purposes of + subparagraph (A) or identify the plan for purposes + of subparagraph (B) shall be counted, for purposes + of such rating or identification, as having the + lowest plan performance rating and the lowest + percentage improvement, respectively. + ``(3) Quality bonus for new and low enrollment ma plans.-- + ``(A) New ma plans. <<NOTE: Effective + date. Payments.>> --For years beginning with 2014, in + the case of an MA plan that first submits a bid under + section 1854(a)(1)(A) for 2012 or a subsequent year, + only receives enrollments made during the coverage + election periods described in section 1851(e), and is + not able to receive a bonus under subparagraph (A) or + (B) of paragraph (2) for the year, the Secretary shall, + in addition to any other payment provided under this + part, make monthly payments, with respect to coverage of + an individual under this part, to the MA plan in an + amount equal to 2 percent of national monthly per capita + cost for expenditures for + +[[Page 124 STAT. 450]] + + individuals enrolled under the original medicare fee- + for-service program for the year. In its fourth year of + operation, the MA plan shall be paid in the same manner + as other MA plans with comparable enrollment. + ``(B) Low enrollment plans. <<NOTE: Effective + date. Determination.>> --For years beginning with 2014, + in the case of an MA plan that has low enrollment (as + defined by the Secretary) and would not otherwise be + able to receive a bonus under subparagraph (A) or (B) of + paragraph (2) or subparagraph (A) of this paragraph for + the year (referred to in this subparagraph as a `low + enrollment plan'), the Secretary shall use a regional or + local mean of the rating of all MA plans in the region + or local area, as determined appropriate by the + Secretary, on measures used to determine whether MA + plans are eligible for a quality or an improved quality + bonus, as applicable, to determine whether the low + enrollment plan is eligible for a bonus under such a + subparagraph. + ``(4) Risk adjustment.--The Secretary shall risk adjust a + performance bonus under this subsection in the same manner as + the Secretary risk adjusts beneficiary rebates described in + section 1854(b)(1)(C). + ``(5) Notification.--The Secretary, in the annual + announcement required under subsection (b)(1)(B) for 2014 and + each succeeding year, shall notify the Medicare Advantage + organization of any performance bonus (including a care + coordination and management performance bonus under paragraph + (1), a quality performance bonus under paragraph (2), and a + quality bonus for new and low enrollment plans under paragraph + (3)) that the organization will receive under this subsection + with respect to the year. <<NOTE: Web posting.>> The Secretary + shall provide for the publication of the information described + in the previous sentence on the Internet website of the Centers + for Medicare & Medicaid Services.'' + (B) Conforming amendment.--Section 1853(a)(1)(B) of + the Social Security Act (42 U.S.C. 1395w-23(a)(1)(B)) is + amended-- + (i) in clause (i), by inserting ``and any + performance bonus under subsection (n)'' before + the period at the end; and + (ii) in clause (ii), by striking ``(G)'' and + inserting ``(G), plus the amount (if any) of any + performance bonus under subsection (n)''. + (2) Application of performance bonuses to ma regional + plans.--Section 1858 of the Social Security Act (42 U.S.C. + 1395w-27a) is amended-- + (A) in subsection (f)(1), by striking ``subsection + (e)'' and inserting ``subsections (e) and (i)''; and + (B) by adding at the end the following new + subsection: + + ``(i) Application of Performance Bonuses to MA Regional +Plans. <<NOTE: Effective date.>> --For years beginning with 2014, the +Secretary shall apply the performance bonuses under section 1853(n) +(relating to bonuses for care coordination and management, quality +performance, and new and low enrollment MA plans) to MA regional plans +in a similar manner as such performance bonuses apply to MA plans under +such subsection.''. + + (g) Grandfathering Supplemental Benefits for Current Enrollees After +Implementation of Competitive Bidding.-- + +[[Page 124 STAT. 451]] + +Section 1853 of the Social Security Act (42 U.S.C. 1395w-23), as amended +by subsection (f), is amended by adding at the end the following new +subsection: + ``(o) Grandfathering Supplemental Benefits for Current Enrolles +After Implementation of Competitive Bidding.-- + ``(1) Identification of areas.--The Secretary shall identify + MA local areas in which, with respect to 2009, average bids + submitted by an MA organization under section 1854(a) for MA + local plans in the area are not greater than 75 percent of the + adjusted average per capita cost for the year involved, + determined under section 1876(a)(4), for the area for + individuals who are not enrolled in an MA plan under this part + for the year, but adjusted to exclude costs attributable to + payments under section 1848(o), 1886(n), and 1886(h). + ``(2) Election to provide rebates to grandfathered + enrollees.-- + ``(A) In general. <<NOTE: Effective date.>> --For + years beginning with 2012, each Medicare Advantage + organization offering an MA local plan in an area + identified by the Secretary under paragraph (1) may + elect to provide rebates to grandfathered enrollees + under section 1854(b)(1)(C). In the case where an MA + organization makes such an election, the monthly per + capita dollar amount of such rebates shall not exceed + the applicable amount for the year (as defined in + subparagraph (B)). + ``(B) Applicable amount. <<NOTE: Definition.>> --For + purposes of this subsection, the term `applicable + amount' means-- + ``(i) for 2012, the monthly per capita dollar + amount of such rebates provided to enrollees under + the MA local plan with respect to 2011; and + ``(ii) for a subsequent year, 95 percent of + the amount determined under this subparagraph for + the preceding year. + ``(3) Special rules for plans in identified + areas. <<NOTE: Applicability.>> --Notwithstanding any other + provision of this part, the following shall apply with respect + to each Medicare Advantage organization offering an MA local + plan in an area identified by the Secretary under paragraph (1) + that makes an election described in paragraph (2): + ``(A) Payments.--The amount of the monthly payment + under this section to the Medicare Advantage + organization, with respect to coverage of a + grandfathered enrollee under this part in the area for a + month, shall be equal to-- + ``(i) for 2012 and 2013, the sum of-- + ``(I) the bid amount under section + 1854(a) for the MA local plan; and + ``(II) the applicable amount (as + defined in paragraph (2)(B)) for the MA + local plan for the year. + ``(ii) for 2014 and subsequent years, the sum + of-- + ``(I) the MA competitive benchmark + amount under subsection (j)(1)(A)(i) for + the area for the month, adjusted, only + to the extent the Secretary determines + necessary, to account for induced + utilization as a result of rebates + provided to grandfathered enrollees + (except that such adjustment shall not + exceed 0.5 percent of such MA + competitive benchmark amount); and + +[[Page 124 STAT. 452]] + + ``(II) the applicable amount (as so + defined) for the MA local plan for the + year. + ``(B) Requirement to submit bids under competitive + bidding.--The Medicare Advantage organization shall + submit a single bid amount under section 1854(a) for the + MA local plan. The Medicare Advantage organization shall + remove from such bid amount any effects of induced + demand for care that may result from the higher rebates + available to grandfathered enrollees under this + subsection. + ``(C) Nonapplication of bonus payments and any other + rebates.--The Medicare Advantage organization offering + the MA local plan shall not be eligible for any bonus + payment under subsection (n) or any rebate under this + part (other than as provided under this subsection) with + respect to grandfathered enrollees. + ``(D) Nonapplication of uniform bid and premium + amounts to grandfathered enrollees.--Section 1854(c) + shall not apply with respect to the MA local plan. + ``(E) Nonapplication of limitation on application of + plan rebates toward payment of part b premium.-- + Notwithstanding clause (iii) of section 1854(b)(1)(C), + in the case of a grandfathered enrollee, a rebate under + such section may be used for the purpose described in + clause (ii)(III) of such section. + ``(F) Risk adjustment.--The Secretary shall risk + adjust rebates to grandfathered enrollees under this + subsection in the same manner as the Secretary risk + adjusts beneficiary rebates described in section + 1854(b)(1)(C). + ``(4) Definition of grandfathered enrollee.--In this + subsection, the term `grandfathered enrollee' means an + individual who is enrolled (effective as of the date of + enactment of this subsection) in an MA local plan in an area + that is identified by the Secretary under paragraph (1).''. + + (h) Transitional Extra Benefits.--Section 1853 of the Social +Security Act (42 U.S.C. 1395w-23), as amended by subsections (f) and +(g), is amended by adding at the end the following new subsection: + ``(p) Transitional Extra Benefits.-- + ``(1) In general. <<NOTE: Effective date.>> --For years + beginning with 2012, the Secretary shall provide transitional + rebates under section 1854(b)(1)(C) for the provision of extra + benefits (as specified by the Secretary) to enrollees described + in paragraph (2). + ``(2) Enrollees described.--An enrollee described in this + paragraph is an individual who-- + ``(A) enrolls in an MA local plan in an applicable + area; and + ``(B) experiences a significant reduction in extra + benefits described in clause (ii) of section + 1854(b)(1)(C) as a result of competitive bidding under + this part (as determined by the Secretary). + ``(3) Applicable areas. <<NOTE: Definition.>> --In this + subsection, the term `applicable area' means the following: + ``(A) The 2 largest metropolitan statistical areas, + if the Secretary determines that the total amount of + such extra benefits for each enrollee for the month in + those areas is greater than $100. + ``(B) A county where-- + +[[Page 124 STAT. 453]] + + ``(i) the MA area-specific non-drug monthly + benchmark amount for a month in 2011 is equal to + the legacy urban floor amount (as described in + subsection (c)(1)(B)(iii)), as determined by the + Secretary for the area for 2011; + ``(ii) the percentage of Medicare Advantage + eligible beneficiaries in the county who are + enrolled in an MA plan for 2009 is greater than 30 + percent (as determined by the Secretary); and + ``(iii) average bids submitted by an MA + organization under section 1854(a) for MA local + plans in the county for 2011 are not greater than + the adjusted average per capita cost for the year + involved, determined under section 1876(a)(4), for + the county for individuals who are not enrolled in + an MA plan under this part for the year, but + adjusted to exclude costs attributable to payments + under section 1848(o), 1886(n), and 1886(h). + ``(C) If the Secretary determines appropriate, a + county contiguous to an area or county described in + subparagraph (A) or (B), respectively. + ``(4) Review of plan bids.--In the case of a bid submitted + by an MA organization under section 1854(a) for an MA local plan + in an applicable area, the Secretary shall review such bid in + order to ensure that extra benefits (as specified by the + Secretary) are provided to enrollees described in paragraph (2). + ``(5) Funding. <<NOTE: Determination.>> --The Secretary + shall provide for the transfer from the Federal Hospital + Insurance Trust Fund under section 1817 and the Federal + Supplementary Medical Insurance Trust Fund established under + section 1841, in such proportion as the Secretary determines + appropriate, of an amount not to exceed $5,000,000,000 for the + period of fiscal years 2012 through 2019 for the purpose of + providing transitional rebates under section 1854(b)(1)(C) for + the provision of extra benefits under this subsection.''. + + (i) Nonapplication of Competitive Bidding and Related Provisions and +Clarification of MA Payment Area for PACE Programs.-- + (1) Nonapplication of competitive bidding and related + provisions for pace programs.--Section 1894 of the Social + Security Act (42 U.S.C. 1395eee) is amended-- + (A) by redesignating subsections (h) and (i) as + subsections (i) and (j), respectively; + (B) by inserting after subsection (g) the following + new subsection: + + ``(h) Nonapplication of Competitive Bidding and Related Provisions +Under Part C.--With respect to a PACE program under this section, the +following provisions (and regulations relating to such provisions) shall +not apply: + ``(1) Section 1853(j)(1)(A)(i), relating to MA area-specific + non-drug monthly benchmark amount being based on competitive + bids. + ``(2) Section 1853(d)(5), relating to the establishment of + MA local plan service areas. + ``(3) Section 1853(n), relating to the payment of + performance bonuses. + +[[Page 124 STAT. 454]] + + ``(4) Section 1853(o), relating to grandfathering + supplemental benefits for current enrollees after implementation + of competitive bidding. + ``(5) Section 1853(p), relating to transitional extra + benefits.''. + (2) Special rule for ma payment area for pace programs.-- + Section 1853(d) of the Social Security Act (42 U.S.C. 1395w- + 23(d)), as amended by subsection (e), is amended by adding at + the end the following new paragraph: + ``(6) Special rule for ma payment area for pace + programs. <<NOTE: Effective date.>> --For years beginning with + 2012, in the case of a PACE program under section 1894, the MA + payment area shall be the MA local area (as defined in paragraph + (2)).''. + +SEC. 3202. BENEFIT PROTECTION AND SIMPLIFICATION. + + (a) Limitation on Variation of Cost Sharing for Certain Benefits.-- + (1) In general.--Section 1852(a)(1)(B) of the Social + Security Act (42 U.S.C. 1395w-22(a)(1)(B)) is amended-- + (A) in clause (i), by inserting ``, subject to + clause (iii),'' after ``and B or''; and + (B) by adding at the end the following new clauses: + ``(iii) Limitation on variation of cost + sharing for certain benefits.--Subject to clause + (v), cost-sharing for services described in clause + (iv) shall not exceed the cost-sharing required + for those services under parts A and B. + ``(iv) Services described.--The following + services are described in this clause: + ``(I) Chemotherapy administration + services. + ``(II) Renal dialysis services (as + defined in section 1881(b)(14)(B)). + ``(III) Skilled nursing care. + ``(IV) Such other services that the + Secretary determines appropriate + (including services that the Secretary + determines require a high level of + predictability and transparency for + beneficiaries). + ``(v) Exception.--In the case of services + described in clause (iv) for which there is no + cost-sharing required under parts A and B, cost- + sharing may be required for those services in + accordance with clause (i).''. + (2) <<NOTE: 42 USC 1395w-22 note.>> Effective date.--The + amendments made by this subsection shall apply to plan years + beginning on or after January 1, 2011. + + (b) Application of Rebates, Performance Bonuses, and Premiums.-- + (1) Application of rebates.--Section 1854(b)(1)(C) of the + Social Security Act (42 U.S.C. 1395w-24(b)(1)(C)) is amended-- + (A) in clause (ii), by striking ``rebate.--A + rebate'' and inserting ``rebate for plan years before + 2012.--For plan years before 2012, a rebate''; + (B) by redesignating clauses (iii) and (iv) as + clauses (iv) and (v); and + (C) by inserting after clause (ii) the following new + clause: + ``(iii) Form of rebate for plan year 2012 and + subsequent plan years. <<NOTE: Effective + date.>> --For plan years beginning on or after + January 1, 2012, a rebate required under + +[[Page 124 STAT. 455]] + + this subparagraph may not be used for the purpose + described in clause (ii)(III) and shall be + provided through the application of the amount of + the rebate in the following priority order: + ``(I) First, to use the most + significant share to meaningfully reduce + cost-sharing otherwise applicable for + benefits under the original medicare + fee-for-service program under parts A + and B and for qualified prescription + drug coverage under part D, including + the reduction of any deductibles, + copayments, and maximum limitations on + out-of-pocket expenses otherwise + applicable. <<NOTE: Applicability.>> Any + reduction of maximum limitations on out- + of-pocket expenses under the preceding + sentence shall apply to all benefits + under the original medicare fee-for- + service program option. The Secretary + may provide guidance on meaningfully + reducing cost-sharing under this + subclause, except that such guidance may + not require a particular amount of cost- + sharing or reduction in cost-sharing. + ``(II) Second, to use the next most + significant share to meaningfully + provide coverage of preventive and + wellness health care benefits (as + defined by the Secretary) which are not + benefits under the original medicare + fee-for-service program, such as smoking + cessation, a free flu shot, and an + annual physical examination. + ``(III) Third, to use the remaining + share to meaningfully provide coverage + of other health care benefits which are + not benefits under the original medicare + fee-for-service program, such as eye + examinations and dental coverage, and + are not benefits described in subclause + (II).''. + (2) Application of performance bonuses.--Section 1853(n) of + the Social Security Act, as added by section 3201(f), is amended + by adding at the end the following new paragraph: + ``(6) <<NOTE: Effective date.>> Application of performance + bonuses.--For plan years beginning on or after January 1, 2014, + any performance bonus paid to an MA plan under this subsection + shall be used for the purposes, and in the priority order, + described in subclauses (I) through (III) of section + 1854(b)(1)(C)(iii).''. + (3) Application of ma monthly supplementary beneficiary + premium.--Section 1854(b)(2)(C) of the Social Security Act (42 + U.S.C. 1395w-24(b)(2)(C)) is amended-- + (A) by striking ``Premium.--The term'' and inserting + ``premium.-- + ``(i) In general.--The term''; and + (B) by adding at the end the following new clause: + ``(ii) Application of ma monthly supplementary + beneficiary premium. <<NOTE: Effective date.>> -- + For plan years beginning on or after January 1, + 2012, any MA monthly supplementary beneficiary + premium charged to an individual enrolled in an MA + plan shall be used for the purposes, and in the + priority order, described in subclauses (I) + through (III) of paragraph (1)(C)(iii).''. + +[[Page 124 STAT. 456]] + +SEC. 3203. APPLICATION OF CODING INTENSITY ADJUSTMENT DURING MA PAYMENT + TRANSITION. + + Section 1853(a)(1)(C) of the Social Security Act (42 U.S.C. 1395w- +23(a)(1)(C)) is amended by adding at the end the following new clause: + ``(iii) Application of coding intensity + adjustment for 2011 and subsequent years.-- + ``(I) Requirement to apply in 2011 + through 2013.--In order to ensure + payment accuracy, the Secretary shall + conduct an analysis of the differences + described in clause (ii)(I). The + Secretary shall ensure that the results + of such analysis are incorporated into + the risk scores for 2011, 2012, and + 2013. + ``(II) Authority to apply in 2014 + and subsequent years.--The Secretary + may, as appropriate, incorporate the + results of such analysis into the risk + scores for 2014 and subsequent years.''. + +SEC. 3204. SIMPLIFICATION OF ANNUAL BENEFICIARY ELECTION PERIODS. + + (a) Annual 45-day Period for Disenrollment From MA Plans To Elect To +Receive Benefits Under the Original Medicare Fee-for-service Program.-- + (1) In general.--Section 1851(e)(2)(C) of the Social + Security Act <<NOTE: 42 USC 1395w-21.>> (42 U.S.C. 1395w- + 1(e)(2)(C)) is amended to read as follows: + ``(C) Annual 45-day period for disenrollment from ma + plans to elect to receive benefits under the original + medicare fee-for-service program. <<NOTE: Effective + date.>> --Subject to subparagraph (D), at any time + during the first 45 days of a year (beginning with + 2011), an individual who is enrolled in a Medicare + Advantage plan may change the election under subsection + (a)(1), but only with respect to coverage under the + original medicare fee-for-service program under parts A + and B, and may elect qualified prescription drug + coverage in accordance with section 1860D-1.''. + (2) <<NOTE: 42 USC 1395w-21 note.>> Effective date.--The + amendment made by paragraph (1) shall apply with respect to 2011 + and succeeding years. + + (b) Timing of the Annual, Coordinated Election Period Under Parts C +and D.--Section 1851(e)(3)(B) of the Social Security Act <<NOTE: 42 +USC 1395w-21.>> (42 U.S.C. 1395w-1(e)(3)(B)) is amended-- + (1) in clause (iii), by striking ``and'' at the end; + (2) in clause (iv)-- + (A) by striking ``and succeeding years'' and + inserting ``, 2008, 2009, and 2010''; and + (B) by striking the period at the end and inserting + ``; and''; and + (3) by adding at the end the following new clause: + ``(v) with respect to 2012 and succeeding + years, the period beginning on October 15 and + ending on December 7 of the year before such + year.''. + +[[Page 124 STAT. 457]] + +SEC. 3205. EXTENSION FOR SPECIALIZED MA PLANS FOR SPECIAL NEEDS + INDIVIDUALS. + + (a) Extension of SNP Authority.--Section 1859(f)(1) of the Social +Security Act (42 U.S.C. 1395w-28(f)(1)), as amended by section 164(a) of +the Medicare Improvements for Patients and Providers Act of 2008 (Public +Law 110-275), is amended by striking ``2011'' and inserting ``2014''. + (b) Authority To Apply Frailty Adjustment Under PACE Payment +Rules.--Section 1853(a)(1)(B) of the Social Security Act (42 U.S.C. +1395w-23(a)(1)(B)) is amended by adding at the end the following new +clause: + ``(iv) Authority to apply frailty adjustment + under pace payment rules for certain specialized + ma plans for special needs individuals.-- + ``(I) In general.--Notwithstanding + the preceding provisions of this + paragraph, for plan year 2011 and + subsequent plan years, in the case of a + plan described in subclause (II), the + Secretary may apply the payment rules + under section 1894(d) (other than + paragraph (3) of such section) rather + than the payment rules that would + otherwise apply under this part, but + only to the extent necessary to reflect + the costs of treating high + concentrations of frail individuals. + ``(II) Plan described.--A plan + described in this subclause is a + specialized MA plan for special needs + individuals described in section + 1859(b)(6)(B)(ii) that is fully + integrated with capitated contracts with + States for Medicaid benefits, including + long-term care, and that have similar + average levels of frailty (as determined + by the Secretary) as the PACE + program.''. + + (c) Transition and Exception Regarding Restriction on Enrollment.-- +Section 1859(f) of the Social Security Act (42 U.S.C. 1395w-28(f)) is +amended by adding at the end the following new paragraph: + ``(6) Transition and exception regarding restriction on + enrollment.-- + ``(A) In general. <<NOTE: Procedures.>> --Subject to + subparagraph (C), the Secretary shall establish + procedures for the transition of applicable individuals + to-- + ``(i) a Medicare Advantage plan that is not a + specialized MA plan for special needs individuals + (as defined in subsection (b)(6)); or + ``(ii) the original medicare fee-for-service + program under parts A and B. + ``(B) Applicable + individuals. <<NOTE: Definition.>> --For purposes of + clause (i), the term `applicable individual' means an + individual who-- + ``(i) is enrolled under a specialized MA plan + for special needs individuals (as defined in + subsection (b)(6)); and + ``(ii) is not within the 1 or more of the + classes of special needs individuals to which + enrollment under the plan is restricted to. + ``(C) Exception.--The Secretary shall provide for an + exception to the transition described in subparagraph + (A) + +[[Page 124 STAT. 458]] + + for a limited period of time for individuals enrolled + under a specialized MA plan for special needs + individuals described in subsection (b)(6)(B)(ii) who + are no longer eligible for medical assistance under + title XIX. + ``(D) Timeline for initial + transition. <<NOTE: Deadline.>> --The Secretary shall + ensure that applicable individuals enrolled in a + specialized MA plan for special needs individuals (as + defined in subsection (b)(6)) prior to January 1, 2010, + are transitioned to a plan or the program described in + subparagraph (A) by not later than January 1, 2013.''. + + (d) Temporary Extension of Authority To Operate but No Service Area +Expansion for Dual Special Needs Plans That Do Not Meet Certain +Requirements.--Section 164(c)(2) of the Medicare Improvements for +Patients and Providers Act of 2008 (Public Law 110-275) <<NOTE: 42 +USC 1395w-28 note.>> is amended by striking ``December 31, 2010'' and +inserting ``December 31, 2012''. + + (e) Authority To Require Special Needs Plans Be NCQA Approved.-- +Section 1859(f) of the Social Security Act (42 U.S.C. 1395w-28(f)), as +amended by subsections (a) and (c), is amended-- + (1) in paragraph (2), by adding at the end the following new + subparagraph: + ``(C) If applicable, the plan meets the requirement + described in paragraph (7).''; + (2) in paragraph (3), by adding at the end the following new + subparagraph: + ``(E) If applicable, the plan meets the requirement + described in paragraph (7).''; + (3) in paragraph (4), by adding at the end the following new + subparagraph: + ``(C) If applicable, the plan meets the requirement + described in paragraph (7).''; and + (4) by adding at the end the following new paragraph: + ``(7) Authority to require special needs plans be ncqa + approved. <<NOTE: Standards.>> --For 2012 and subsequent years, + the Secretary shall require that a Medicare Advantage + organization offering a specialized MA plan for special needs + individuals be approved by the National Committee for Quality + Assurance (based on standards established by the Secretary).''. + + (f) Risk Adjustment.--Section 1853(a)(1)(C) of the Social Security +Act <<NOTE: 42 USC 1395w-23.>> (42 U.S.C. 1395i-23(a)(1)(C)) is amended +by adding at the end the following new clause: + ``(iii) Improvements to risk adjustment for + special needs individuals with chronic health + conditions.-- + ``(I) In general.--For 2011 and + subsequent years, for purposes of the + adjustment under clause (i) with respect + to individuals described in subclause + (II), the Secretary shall use a risk + score that reflects the known underlying + risk profile and chronic health status + of similar individuals. Such risk score + shall be used instead of the default + risk score for new enrollees in Medicare + Advantage plans that are not specialized + MA plans for special needs individuals + (as defined in section 1859(b)(6)). + ``(II) Individuals described.--An + individual described in this subclause + is a special needs individual described + in subsection (b)(6)(B)(iii) who + +[[Page 124 STAT. 459]] + + enrolls in a specialized MA plan for + special needs individuals on or after + January 1, 2011. + ``(III) Evaluation.--For 2011 and + periodically thereafter, the Secretary + shall evaluate and revise the risk + adjustment system under this + subparagraph in order to, as accurately + as possible, account for higher medical + and care coordination costs associated + with frailty, individuals with multiple, + comorbid chronic conditions, and + individuals with a diagnosis of mental + illness, and also to account for costs + that may be associated with higher + concentrations of beneficiaries with + those conditions. + ``(IV) Publication of evaluation and + revisions.--The Secretary shall publish, + as part of an announcement under + subsection (b), a description of any + evaluation conducted under subclause + (III) during the preceding year and any + revisions made under such subclause as a + result of such evaluation.''. + + (g) Technical Correction.--Section 1859(f)(5) of the Social Security +Act (42 U.S.C. 1395w-28(f)(5)) is amended, in the matter preceding +subparagraph (A), by striking ``described in subsection (b)(6)(B)(i)''. + +SEC. 3206. EXTENSION OF REASONABLE COST CONTRACTS. + + Section 1876(h)(5)(C)(ii) of the Social Security Act (42 U.S.C. +1395mm(h)(5)(C)(ii)) is amended, in the matter preceding subclause (I), +by striking ``January 1, 2010'' and inserting ``January 1, 2013''. + +SEC. 3207. <<NOTE: 42 USC 1395w-27 note.>> TECHNICAL CORRECTION TO MA + PRIVATE FEE-FOR-SERVICE PLANS. + + <<NOTE: Applicability.>> For plan year 2011 and subsequent plan +years, to the extent that the Secretary of Health and Human Services is +applying the 2008 service area extension waiver policy (as modified in +the April 11, 2008, Centers for Medicare & Medicaid Services' memorandum +with the subject ``2009 Employer Group Waiver-Modification of the 2008 +Service Area Extension Waiver Granted to Certain MA Local Coordinated +Care Plans'') to Medicare Advantage coordinated care plans, the +Secretary shall extend the application of such waiver policy to +employers who contract directly with the Secretary as a Medicare +Advantage private fee-for-service plan under section 1857(i)(2) of the +Social Security Act (42 U.S.C. 1395w-27(i)(2)) and that had enrollment +as of October 1, 2009. + +SEC. 3208. MAKING SENIOR HOUSING FACILITY DEMONSTRATION PERMANENT. + + (a) In General.--Section 1859 of the Social Security Act (42 U.S.C. +1395w-28) is amended by adding at the end the following new subsection: + ``(g) Special Rules for Senior Housing Facility Plans.-- + ``(1) In general.--In the case of a Medicare Advantage + senior housing facility plan described in paragraph (2), + notwithstanding any other provision of this part to the contrary + and in accordance with regulations of the Secretary, the service + area of such plan may be limited to a senior housing facility in + a geographic area. + +[[Page 124 STAT. 460]] + + ``(2) Medicare advantage senior housing facility plan + described.--For purposes of this subsection, a Medicare + Advantage senior housing facility plan is a Medicare Advantage + plan that-- + ``(A) restricts enrollment of individuals under this + part to individuals who reside in a continuing care + retirement community (as defined in section + 1852(l)(4)(B)); + ``(B) provides primary care services onsite and has + a ratio of accessible physicians to beneficiaries that + the Secretary determines is adequate; + ``(C) provides transportation services for + beneficiaries to specialty providers outside of the + facility; and + ``(D) has participated (as of December 31, 2009) in + a demonstration project established by the Secretary + under which such a plan was offered for not less than 1 + year.''. + + (b) Effective Date. <<NOTE: 42 USC 1395w-28 note.>> --The amendment +made by this section shall take effect on January 1, 2010, and shall +apply to plan years beginning on or after such date. + +SEC. 3209. AUTHORITY TO DENY PLAN BIDS. + + (a) In General.--Section 1854(a)(5) of the Social Security Act (42 +U.S.C. 1395w-24(a)(5)) is amended by adding at the end the following new +subparagraph: + ``(C) Rejection of bids.-- + ``(i) In general.--Nothing in this section + shall be construed as requiring the Secretary to + accept any or every bid submitted by an MA + organization under this subsection. + ``(ii) Authority to deny bids that propose + significant increases in cost sharing or decreases + in benefits.--The Secretary may deny a bid + submitted by an MA organization for an MA plan if + it proposes significant increases in cost sharing + or decreases in benefits offered under the + plan.''. + + (b) Application Under Part D.--Section 1860D-11(d) of such Act (42 +U.S.C. 1395w-111(d)) is amended by adding at the end the following new +paragraph: + ``(3) Rejection of bids. <<NOTE: Applicability.>> -- + Paragraph (5)(C) of section 1854(a) shall apply with respect to + bids submitted by a PDP sponsor under subsection (b) in the same + manner as such paragraph applies to bids submitted by an MA + organization under such section 1854(a).''. + + (c) <<NOTE: 42 USC 1395w-24 note.>> Effective Date.--The amendments +made by this section shall apply to bids submitted for contract years +beginning on or after January 1, 2011. + +SEC. 3210. DEVELOPMENT OF NEW STANDARDS FOR CERTAIN MEDIGAP PLANS. + + (a) In General.--Section 1882 of the Social Security Act (42 U.S.C. +1395ss) is amended by adding at the end the following new subsection: + ``(y) Development of New Standards for Certain Medicare Supplemental +Policies.-- + ``(1) In general.--The Secretary shall request the National + Association of Insurance Commissioners to review and revise the + standards for benefit packages described in paragraph (2) under + subsection (p)(1), to otherwise update standards to include + requirements for nominal cost sharing to encourage + +[[Page 124 STAT. 461]] + + the use of appropriate physicians' services under part B. Such + revisions shall be based on evidence published in peer-reviewed + journals or current examples used by integrated delivery systems + and made consistent with the rules applicable under subsection + (p)(1)(E) with the reference to the `1991 NAIC Model Regulation' + deemed a reference to the NAIC Model Regulation as published in + the Federal Register on December 4, 1998, and as subsequently + updated by the National Association of Insurance Commissioners + to reflect previous changes in law and the reference to `date of + enactment of this subsection' deemed a reference to the date of + enactment of the Patient Protection and Affordable Care + Act. <<NOTE: Effective date.>> To the extent practicable, such + revision shall provide for the implementation of revised + standards for benefit packages as of January 1, 2015. + ``(2) Benefit packages described.--The benefit packages + described in this paragraph are benefit packages classified as + `C' and `F'.''. + + (b) Conforming Amendment.--Section 1882(o)(1) of the Social Security +Act (42 U.S.C. 1395ss(o)(1)) is amended by striking ``, and (w)'' and +inserting ``(w), and (y)''. + +Subtitle D--Medicare Part D Improvements for Prescription Drug Plans and + MA-PD Plans + +SEC. 3301. MEDICARE COVERAGE GAP DISCOUNT PROGRAM. + + (a) Condition for Coverage of Drugs Under Part D.--Part D of Title +XVIII of the Social Security Act (42 U.S.C. 1395w-101 et seq.), is +amended by adding at the end the following new section: + + + ``condition for coverage of drugs under this part + + + ``Sec. 1860D-43. <<NOTE: Contracts. 42 USC 1395w-153.>> (a) In +General.--In order for coverage to be available under this part for +covered part D drugs (as defined in section 1860D-2(e)) of a +manufacturer, the manufacturer must-- + ``(1) participate in the Medicare coverage gap discount + program under section 1860D-14A; + ``(2) have entered into and have in effect an agreement + described in subsection (b) of such section with the Secretary; + and + ``(3) have entered into and have in effect, under terms and + conditions specified by the Secretary, a contract with a third + party that the Secretary has entered into a contract with under + subsection (d)(3) of such section. + + ``(b) Effective Date.--Subsection (a) shall apply to covered part D +drugs dispensed under this part on or after July 1, 2010. + ``(c) Authorizing Coverage for Drugs Not Covered Under Agreements.-- +Subsection (a) shall not apply to the dispensing of a covered part D +drug if-- + ``(1) <<NOTE: Determination.>> the Secretary has made a + determination that the availability of the drug is essential to + the health of beneficiaries under this part; or + +[[Page 124 STAT. 462]] + + ``(2) <<NOTE: Determination. Time period.>> the Secretary + determines that in the period beginning on July 1, 2010, and + ending on December 31, 2010, there were extenuating + circumstances. + + ``(d) Definition of Manufacturer.--In this section, the term +`manufacturer' has the meaning given such term in section 1860D- +14A(g)(5).''. + (b) Medicare Coverage Gap Discount Program.--Part D of title XVIII +of the Social Security Act (42 U.S.C. 1395w-101) is amended by inserting +after section 1860D-14 the following new section: + + + ``medicare coverage gap discount program + + + ``Sec. 1860D-14A. <<NOTE: Deadlines. 42 USC 1395w-114a.>> (a) +Establishment.--The Secretary shall establish a Medicare coverage gap +discount program (in this section referred to as the `program') by not +later than July 1, 2010. <<NOTE: Contracts.>> Under the program, the +Secretary shall enter into agreements described in subsection (b) with +manufacturers and provide for the performance of the duties described in +subsection (c)(1). The Secretary shall establish a model agreement for +use under the program by not later than April 1, 2010, in consultation +with manufacturers, and allow for comment on such model agreement. + + ``(b) Terms of Agreement.-- + ``(1) In general.-- + ``(A) Agreement.--An agreement under this section + shall require the manufacturer to provide applicable + beneficiaries access to discounted prices for applicable + drugs of the manufacturer. + ``(B) Provision of discounted prices at the point- + of-sale.--Except as provided in subsection + (c)(1)(A)(iii), such discounted prices shall be provided + to the applicable beneficiary at the pharmacy or by the + mail order service at the point-of-sale of an applicable + drug. + ``(C) <<NOTE: Deadlines.>> Timing of agreement.-- + ``(i) Special rule for 2010 and 2011.--In + order for an agreement with a manufacturer to be + in effect under this section with respect to the + period beginning on July 1, 2010, and ending on + December 31, 2011, the manufacturer shall enter + into such agreement not later than May 1, 2010. + ``(ii) 2012 and subsequent years.--In order + for an agreement with a manufacturer to be in + effect under this section with respect to plan + year 2012 or a subsequent plan year, the + manufacturer shall enter into such agreement (or + such agreement shall be renewed under paragraph + (4)(A)) not later than January 30 of the preceding + year. + ``(2) Provision of appropriate + data. <<NOTE: Determination.>> --Each manufacturer with an + agreement in effect under this section shall collect and have + available appropriate data, as determined by the Secretary, to + ensure that it can demonstrate to the Secretary compliance with + the requirements under the program. + ``(3) Compliance with requirements for administration of + program.--Each manufacturer with an agreement in effect under + this section shall comply with requirements imposed by the + Secretary or a third party with a contract under subsection + (d)(3), as applicable, for purposes of administering the + +[[Page 124 STAT. 463]] + + program, including any determination under clause (i) of + subsection (c)(1)(A) or procedures established under such + subsection (c)(1)(A). + ``(4) Length of agreement.-- + ``(A) In general. <<NOTE: Time period.>> --An + agreement under this section shall be effective for an + initial period of not less than 18 months and shall be + automatically renewed for a period of not less than 1 + year unless terminated under subparagraph (B). + ``(B) Termination.-- + ``(i) By the secretary.--The Secretary may + provide for termination of an agreement under this + section for a knowing and willful violation of the + requirements of the agreement or other good cause + shown. <<NOTE: Notice.>> Such termination shall + not be effective earlier than 30 days after the + date of notice to the manufacturer of such + termination. The Secretary shall provide, upon + request, a manufacturer with a hearing concerning + such a termination, and such hearing shall take + place prior to the effective date of the + termination with sufficient time for such + effective date to be repealed if the Secretary + determines appropriate. + ``(ii) By a manufacturer.--A manufacturer may + terminate an agreement under this section for any + reason. Any such termination shall be effective, + with respect to a plan year-- + ``(I) if the termination occurs + before January 30 of a plan year, as of + the day after the end of the plan year; + and + ``(II) if the termination occurs on + or after January 30 of a plan year, as + of the day after the end of the + succeeding plan year. + ``(iii) Effectiveness of termination.--Any + termination under this subparagraph shall not + affect discounts for applicable drugs of the + manufacturer that are due under the agreement + before the effective date of its termination. + ``(iv) Notice to third + party. <<NOTE: Deadline.>> --The Secretary shall + provide notice of such termination to a third + party with a contract under subsection (d)(3) + within not less than 30 days before the effective + date of such termination. + + ``(c) Duties Described and Special Rule for Supplemental Benefits.-- + ``(1) Duties described.--The duties described in this + subsection are the following: + ``(A) Administration of + program. <<NOTE: Procedures.>> --Administering the + program, including-- + ``(i) <<NOTE: Determination.>> the + determination of the amount of the discounted + price of an applicable drug of a manufacturer; + ``(ii) except as provided in clause (iii), the + establishment of procedures under which discounted + prices are provided to applicable beneficiaries at + pharmacies or by mail order service at the point- + of-sale of an applicable drug; + ``(iii) in the case where, during the period + beginning on July 1, 2010, and ending on December + 31, 2011, + +[[Page 124 STAT. 464]] + + it is not practicable to provide such discounted + prices at the point-of-sale (as described in + clause (ii)), the establishment of procedures to + provide such discounted prices as soon as + practicable after the point-of-sale; + ``(iv) the establishment of procedures to + ensure that, not later than the applicable number + of calendar days after the dispensing of an + applicable drug by a pharmacy or mail order + service, the pharmacy or mail order service is + reimbursed for an amount equal to the difference + between-- + ``(I) the negotiated price of the + applicable drug; and + ``(II) the discounted price of the + applicable drug; + ``(v) the establishment of procedures to + ensure that the discounted price for an applicable + drug under this section is applied before any + coverage or financial assistance under other + health benefit plans or programs that provide + coverage or financial assistance for the purchase + or provision of prescription drug coverage on + behalf of applicable beneficiaries as the + Secretary may specify; + ``(vi) the establishment of procedures to + implement the special rule for supplemental + benefits under paragraph (2); and + ``(vii) providing a reasonable dispute + resolution mechanism to resolve disagreements + between manufacturers, applicable beneficiaries, + and the third party with a contract under + subsection (d)(3). + ``(B) Monitoring compliance.-- + ``(i) In general.--The Secretary shall monitor + compliance by a manufacturer with the terms of an + agreement under this section. + ``(ii) Notification.--If a third party with a + contract under subsection (d)(3) determines that + the manufacturer is not in compliance with such + agreement, the third party shall notify the + Secretary of such noncompliance for appropriate + enforcement under subsection (e). + ``(C) Collection of data from prescription drug + plans and ma-pd plans.--The Secretary may collect + appropriate data from prescription drug plans and MA-PD + plans in a timeframe that allows for discounted prices + to be provided for applicable drugs under this section. + ``(2) Special rule for supplemental benefits.--For plan year + 2010 and each subsequent plan year, in the case where an + applicable beneficiary has supplemental benefits with respect to + applicable drugs under the prescription drug plan or MA-PD plan + that the applicable beneficiary is enrolled in, the applicable + beneficiary shall not be provided a discounted price for an + applicable drug under this section until after such supplemental + benefits have been applied with respect to the applicable drug. + + ``(d) Administration.-- + ``(1) In general.--Subject to paragraph (2), the Secretary + shall provide for the implementation of this section, including + the performance of the duties described in subsection (c)(1). + +[[Page 124 STAT. 465]] + + ``(2) Limitation.-- + ``(A) In general.--Subject to subparagraph (B), in + providing for such implementation, the Secretary shall + not receive or distribute any funds of a manufacturer + under the program. + ``(B) Exception. <<NOTE: Time + period. Determination.>> --The limitation under + subparagraph (A) shall not apply to the Secretary with + respect to drugs dispensed during the period beginning + on July 1, 2010, and ending on December 31, 2010, but + only if the Secretary determines that the exception to + such limitation under this subparagraph is necessary in + order for the Secretary to begin implementation of this + section and provide applicable beneficiaries timely + access to discounted prices during such period. + ``(3) Contract with third parties.--The Secretary shall + enter into a contract with 1 or more third parties to administer + the requirements established by the Secretary in order to carry + out this section. At a minimum, the contract with a third party + under the preceding sentence shall require that the third + party-- + ``(A) receive and transmit information between the + Secretary, manufacturers, and other individuals or + entities the Secretary determines appropriate; + ``(B) receive, distribute, or facilitate the + distribution of funds of manufacturers to appropriate + individuals or entities in order to meet the obligations + of manufacturers under agreements under this section; + ``(C) provide adequate and timely information to + manufacturers, consistent with the agreement with the + manufacturer under this section, as necessary for the + manufacturer to fulfill its obligations under this + section; and + ``(D) permit manufacturers to conduct periodic + audits, directly or through contracts, of the data and + information used by the third party to determine + discounts for applicable drugs of the manufacturer under + the program. + ``(4) Performance requirements.--The Secretary shall + establish performance requirements for a third party with a + contract under paragraph (3) and safeguards to protect the + independence and integrity of the activities carried out by the + third party under the program under this section. + ``(5) Implementation.--The Secretary may implement the + program under this section by program instruction or otherwise. + ``(6) Administration.--Chapter 35 of title 44, United States + Code, shall not apply to the program under this section. + + ``(e) Enforcement.-- + ``(1) Audits.--Each manufacturer with an agreement in effect + under this section shall be subject to periodic audit by the + Secretary. + ``(2) Civil money penalty.-- + ``(A) In general. <<NOTE: Determination.>> --The + Secretary shall impose a civil money penalty on a + manufacturer that fails to provide applicable + beneficiaries discounts for applicable drugs of the + manufacturer in accordance with such agreement for each + such failure in an amount the Secretary determines is + commensurate with the sum of-- + +[[Page 124 STAT. 466]] + + ``(i) the amount that the manufacturer would + have paid with respect to such discounts under the + agreement, which will then be used to pay the + discounts which the manufacturer had failed to + provide; and + ``(ii) 25 percent of such amount. + ``(B) Application.--The provisions of section 1128A + (other than subsections (a) and (b)) shall apply to a + civil money penalty under this paragraph in the same + manner as such provisions apply to a penalty or + proceeding under section 1128A(a). + + ``(f) Clarification Regarding Availability of Other Covered Part D +Drugs.--Nothing in this section shall prevent an applicable beneficiary +from purchasing a covered part D drug that is not an applicable drug +(including a generic drug or a drug that is not on the formulary of the +prescription drug plan or MA-PD plan that the applicable beneficiary is +enrolled in). + ``(g) Definitions.--In this section: + ``(1) Applicable beneficiary.--The term `applicable + beneficiary' means an individual who, on the date of dispensing + an applicable drug-- + ``(A) is enrolled in a prescription drug plan or an + MA-PD plan; + ``(B) is not enrolled in a qualified retiree + prescription drug plan; + ``(C) is not entitled to an income-related subsidy + under section 1860D-14(a); + ``(D) is not subject to a reduction in premium + subsidy under section 1839(i); and + ``(E) who-- + ``(i) has reached or exceeded the initial + coverage limit under section 1860D-2(b)(3) during + the year; and + ``(ii) has not incurred costs for covered part + D drugs in the year equal to the annual out-of- + pocket threshold specified in section 1860D- + 2(b)(4)(B). + ``(2) Applicable drug.--The term `applicable drug' means, + with respect to an applicable beneficiary, a covered part D + drug-- + ``(A) approved under a new drug application under + section 505(b) of the Federal Food, Drug, and Cosmetic + Act or, in the case of a biologic product, licensed + under section 351 of the Public Health Service Act + (other than a product licensed under subsection (k) of + such section 351); and + ``(B)(i) if the PDP sponsor of the prescription drug + plan or the MA organization offering the MA-PD plan uses + a formulary, which is on the formulary of the + prescription drug plan or MA-PD plan that the applicable + beneficiary is enrolled in; + ``(ii) if the PDP sponsor of the prescription drug + plan or the MA organization offering the MA-PD plan does + not use a formulary, for which benefits are available + under the prescription drug plan or MA-PD plan that the + applicable beneficiary is enrolled in; or + ``(iii) is provided through an exception or appeal. + ``(3) Applicable number of calendar days.--The term + `applicable number of calendar days' means-- + +[[Page 124 STAT. 467]] + + ``(A) with respect to claims for reimbursement + submitted electronically, 14 days; and + ``(B) with respect to claims for reimbursement + submitted otherwise, 30 days. + ``(4) Discounted price.-- + ``(A) In general.--The term `discounted price' means + 50 percent of the negotiated price of the applicable + drug of a manufacturer. + ``(B) Clarification.--Nothing in this section shall + be construed as affecting the responsibility of an + applicable beneficiary for payment of a dispensing fee + for an applicable drug. + ``(C) Special case for certain claims.--In the case + where the entire amount of the negotiated price of an + individual claim for an applicable drug with respect to + an applicable beneficiary does not fall at or above the + initial coverage limit under section 1860D-2(b)(3) and + below the annual out-of-pocket threshold specified in + section 1860D-2(b)(4)(B) for the year, the manufacturer + of the applicable drug shall provide the discounted + price under this section on only the portion of the + negotiated price of the applicable drug that falls at or + above such initial coverage limit and below such annual + out-of-pocket threshold. + ``(5) Manufacturer.--The term `manufacturer' means any + entity which is engaged in the production, preparation, + propagation, compounding, conversion, or processing of + prescription drug products, either directly or indirectly by + extraction from substances of natural origin, or independently + by means of chemical synthesis, or by a combination of + extraction and chemical synthesis. Such term does not include a + wholesale distributor of drugs or a retail pharmacy licensed + under State law. + ``(6) Negotiated price.--The term `negotiated price' has the + meaning given such term in section 423.100 of title 42, Code of + Federal Regulations (as in effect on the date of enactment of + this section), except that such negotiated price shall not + include any dispensing fee for the applicable drug. + ``(7) Qualified retiree prescription drug plan.--The term + `qualified retiree prescription drug plan' has the meaning given + such term in section 1860D-22(a)(2).''. + + (c) Inclusion in Incurred Costs.-- + (1) In general.--Section 1860D-2(b)(4) of the Social + Security Act (42 U.S.C. 1395w-102(b)(4)) is amended-- + (A) in subparagraph (C), in the matter preceding + clause (i), by striking ``In applying'' and inserting + ``Except as provided in subparagraph (E), in applying''; + and + (B) by adding at the end the following new + subparagraph: + ``(E) Inclusion of costs of applicable drugs under + medicare coverage gap discount program.--In applying + subparagraph (A), incurred costs shall include the + negotiated price (as defined in paragraph (6) of section + 1860D-14A(g)) of an applicable drug (as defined in + paragraph (2) of such section) of a manufacturer that is + furnished to an applicable beneficiary (as defined in + paragraph (1) of such section) under the Medicare + coverage gap discount + +[[Page 124 STAT. 468]] + + program under section 1860D-14A, regardless of whether + part of such costs were paid by a manufacturer under + such program.''. + (2) Effective date. <<NOTE: 42 USC 1395w-102 note.>> --The + amendments made by this subsection shall apply to costs incurred + on or after July 1, 2010. + + (d) Conforming Amendment Permitting Prescription Drug Discounts.-- + (1) In general.--Section 1128B(b)(3) of the Social Security + Act (42 U.S.C. 1320a-7b(b)(3)) is amended-- + (A) by striking ``and'' at the end of subparagraph + (G); + (B) in the subparagraph (H) added by section 237(d) + of the Medicare Prescription Drug, Improvement, and + Modernization Act of 2003 (Public Law 108-173; 117 Stat. + 2213)-- + (i) by moving such subparagraph 2 ems to the + left; and + (ii) by striking the period at the end and + inserting a semicolon; + (C) in the subparagraph (H) added by section 431(a) + of such Act (117 Stat. 2287)-- + (i) by redesignating such subparagraph as + subparagraph (I); + (ii) by moving such subparagraph 2 ems to the + left; and + (iii) by striking the period at the end and + inserting ``; and''; and + (D) by adding at the end the following new + subparagraph: + ``(J) a discount in the price of an applicable drug + (as defined in paragraph (2) of section 1860D-14A(g)) of + a manufacturer that is furnished to an applicable + beneficiary (as defined in paragraph (1) of such + section) under the Medicare coverage gap discount + program under section 1860D-14A.''. + (2) Conforming amendment to definition of best price under + medicaid.--Section 1927(c)(1)(C)(i)(VI) of the Social Security + Act (42 U.S.C. 1396r-8(c)(1)(C)(i)(VI)) is amended by inserting + ``, or any discounts provided by manufacturers under the + Medicare coverage gap discount program under section 1860D-14A'' + before the period at the end. + (3) <<NOTE: 42 USC 1320a-76 note.>> Effective date.--The + amendments made by this subsection shall apply to drugs + dispensed on or after July 1, 2010. + +SEC. 3302. IMPROVEMENT IN DETERMINATION OF MEDICARE PART D LOW-INCOME + BENCHMARK PREMIUM. + + (a) In General.--Section 1860D-14(b)(2)(B)(iii) of the Social +Security Act (42 U.S.C. 1395w-114(b)(2)(B)(iii)) is amended by inserting +``, determined without regard to any reduction in such premium as a +result of any beneficiary rebate under section 1854(b)(1)(C) or bonus +payment under section 1853(n)'' before the period at the end. + (b) <<NOTE: 42 USC 1395w-114 note.>> Effective Date.--The amendment +made by subsection (a) shall apply to premiums for months beginning on +or after January 1, 2011. + +[[Page 124 STAT. 469]] + +SEC. 3303. VOLUNTARY DE MINIMIS POLICY FOR SUBSIDY ELIGIBLE INDIVIDUALS + UNDER PRESCRIPTION DRUG PLANS AND MA-PD PLANS. + + (a) In General.--Section 1860D-14(a) of the Social Security Act (42 +U.S.C. 1395w-114(a)) is amended by adding at the end the following new +paragraph: + ``(5) Waiver of de minimis + premiums. <<NOTE: Procedures.>> --The Secretary shall, under + procedures established by the Secretary, permit a prescription + drug plan or an MA-PD plan to waive the monthly beneficiary + premium for a subsidy eligible individual if the amount of such + premium is de minimis. If such premium is waived under the plan, + the Secretary shall not reassign subsidy eligible individuals + enrolled in the plan to other plans based on the fact that the + monthly beneficiary premium under the plan was greater than the + low-income benchmark premium amount.''. + + (b) Authorizing the Secretary To Auto-enroll Subsidy Eligible +Individuals in Plans That Waive De Minimis Premiums.--Section 1860D- +1(b)(1) of the Social Security Act (42 U.S.C. 1395w-101(b)(1)) is +amended-- + (1) in subparagraph (C), by inserting ``except as provided + in subparagraph (D),'' after ``shall include,'' + (2) by adding at the end the following new subparagraph: + ``(D) Special rule for plans that waive de minimis + premiums.--The process established under subparagraph + (A) may include, in the case of a part D eligible + individual who is a subsidy eligible individual (as + defined in section 1860D-14(a)(3)) who has failed to + enroll in a prescription drug plan or an MA-PD plan, for + the enrollment in a prescription drug plan or MA-PD plan + that has waived the monthly beneficiary premium for such + subsidy eligible individual under section 1860D- + 14(a)(5). If there is more than one such plan available, + the Secretary shall enroll such an individual under the + preceding sentence on a random basis among all such + plans in the PDP region. Nothing in the previous + sentence shall prevent such an individual from declining + or changing such enrollment.''. + + (c) <<NOTE: 42 USC 1395w-101 note.>> Effective Date.--The amendments +made by this subsection shall apply to premiums for months, and +enrollments for plan years, beginning on or after January 1, 2011. + +SEC. 3304. SPECIAL RULE FOR WIDOWS AND WIDOWERS REGARDING ELIGIBILITY + FOR LOW-INCOME ASSISTANCE. + + (a) In General.--Section 1860D-14(a)(3)(B) of the Social Security +Act (42 U.S.C. 1395w-114(a)(3)(B)) is amended by adding at the end the +following new clause: + ``(vi) Special rule for widows and widowers.-- + Notwithstanding the preceding provisions of this + subparagraph, in the case of an individual whose + spouse dies during the effective period for a + determination or redetermination that has been + made under this subparagraph, such effective + period shall be extended through the date that is + 1 year after the date on which the determination + or redetermination would (but for the application + of this clause) otherwise cease to be + effective.''. + +[[Page 124 STAT. 470]] + + (b) <<NOTE: 42 USC 1395w-114 note.>> Effective Date.--The amendment +made by subsection (a) shall take effect on January 1, 2011. + +SEC. 3305. IMPROVED INFORMATION FOR SUBSIDY ELIGIBLE INDIVIDUALS + REASSIGNED TO PRESCRIPTION DRUG PLANS AND MA-PD PLANS. + + Section 1860D-14 of the Social Security Act (42 U.S.C. 1395w-114) is +amended-- + (1) by redesignating subsection (d) as subsection (e); and + (2) by inserting after subsection (c) the following new + subsection: + + ``(d) Facilitation of Reassignments. <<NOTE: Deadlines.>> -- +Beginning not later than January 1, 2011, the Secretary shall, in the +case of a subsidy eligible individual who is enrolled in one +prescription drug plan and is subsequently reassigned by the Secretary +to a new prescription drug plan, provide the individual, within 30 days +of such reassignment, with-- + ``(1) information on formulary differences between the + individual's former plan and the plan to which the individual is + reassigned with respect to the individual's drug regimens; and + ``(2) a description of the individual's right to request a + coverage determination, exception, or reconsideration under + section 1860D-4(g), bring an appeal under section 1860D-4(h), or + resolve a grievance under section 1860D-4(f).''. + +SEC. 3306. FUNDING OUTREACH AND ASSISTANCE FOR LOW-INCOME PROGRAMS. + + (a) Additional Funding for State Health Insurance Programs.-- +Subsection (a)(1)(B) of section 119 of the Medicare Improvements for +Patients and Providers Act of 2008 (42 U.S.C. 1395b-3 note) is amended +by striking ``(42 U.S.C. 1395w-23(f))'' and all that follows through the +period at the end and inserting ``(42 U.S.C. 1395w-23(f)), to the +Centers for Medicare & Medicaid Services Program Management Account-- + ``(i) for fiscal year 2009, of $7,500,000; and + ``(ii) for the period of fiscal years 2010 + through 2012, of $15,000,000. + Amounts appropriated under this subparagraph shall + remain available until expended.''. + + (b) Additional Funding for Area Agencies on Aging.--Subsection +(b)(1)(B) of such section 119 is amended by striking ``(42 U.S.C. 1395w- +23(f))'' and all that follows through the period at the end and +inserting ``(42 U.S.C. 1395w-23(f)), to the Administration on Aging-- + ``(i) for fiscal year 2009, of $7,500,000; and + ``(ii) for the period of fiscal years 2010 + through 2012, of $15,000,000. + Amounts appropriated under this subparagraph shall + remain available until expended.''. + + (c) Additional Funding for Aging and Disability Resource Centers.-- +Subsection (c)(1)(B) of such section 119 is amended by striking ``(42 +U.S.C. 1395w-23(f))'' and all that follows through the period at the end +and inserting ``(42 U.S.C. 1395w-23(f)), to the Administration on +Aging-- + ``(i) for fiscal year 2009, of $5,000,000; and + ``(ii) for the period of fiscal years 2010 + through 2012, of $10,000,000. + +[[Page 124 STAT. 471]] + + Amounts appropriated under this subparagraph shall + remain available until expended.''. + + (d) Additional Funding for Contract With the National Center for +Benefits and Outreach Enrollment.--Subsection (d)(2) of such section 119 +is amended by striking ``(42 U.S.C. 1395w-23(f))'' and all that follows +through the period at the end and inserting ``(42 U.S.C. 1395w-23(f)), +to the Administration on Aging-- + ``(i) for fiscal year 2009, of $5,000,000; and + ``(ii) for the period of fiscal years 2010 + through 2012, of $5,000,000. + Amounts appropriated under this subparagraph shall + remain available until expended.''. + + (e) Secretarial Authority To Enlist Support in Conducting Certain +Outreach Activities.--Such section 119 is amended by adding at the end +the following new subsection: + ``(g) Secretarial Authority To Enlist Support in Conducting Certain +Outreach Activities.--The Secretary may request that an entity awarded a +grant under this section support the conduct of outreach activities +aimed at preventing disease and promoting wellness. Notwithstanding any +other provision of this section, an entity may use a grant awarded under +this subsection to support the conduct of activities described in the +preceding sentence.''. + +SEC. 3307. IMPROVING FORMULARY REQUIREMENTS FOR PRESCRIPTION DRUG PLANS + AND MA-PD PLANS WITH RESPECT TO CERTAIN CATEGORIES OR + CLASSES OF DRUGS. + + (a) Improving Formulary Requirements.--Section 1860D- +4(b)(3)(G) <<NOTE: 42 USC 1395w-104.>> of the Social Security Act is +amended to read as follows: + ``(G) Required inclusion of drugs in certain + categories and classes.-- + ``(i) Formulary requirements.-- + ``(I) In general.--Subject to + subclause (II), a PDP sponsor offering a + prescription drug plan shall be required + to include all covered part D drugs in + the categories and classes identified by + the Secretary under clause (ii)(I). + ``(II) Exceptions.--The Secretary + may establish exceptions that permit a + PDP sponsor offering a prescription drug + plan to exclude from its formulary a + particular covered part D drug in a + category or class that is otherwise + required to be included in the formulary + under subclause (I) (or to otherwise + limit access to such a drug, including + through prior authorization or + utilization management). + ``(ii) Identification of drugs in certain + categories and classes.-- + ``(I) In general.--Subject to clause + (iv), the Secretary shall identify, as + appropriate, categories and classes of + drugs for which the Secretary determines + are of clinical concern. + ``(II) Criteria.--The Secretary + shall use criteria established by the + Secretary in making any determination + under subclause (I). + +[[Page 124 STAT. 472]] + + ``(iii) <<NOTE: Regulations. Public + information.>> Implementation.--The Secretary + shall establish the criteria under clause (ii)(II) + and any exceptions under clause (i)(II) through + the promulgation of a regulation which includes a + public notice and comment period. + ``(iv) Requirement for certain categories and + classes until criteria established.--Until such + time as the Secretary establishes the criteria + under clause (ii)(II) the following categories and + classes of drugs shall be identified under clause + (ii)(I): + ``(I) Anticonvulsants. + ``(II) Antidepressants. + ``(III) Antineoplastics. + ``(IV) Antipsychotics. + ``(V) Antiretrovirals. + ``(VI) Immunosuppressants for the + treatment of transplant rejection.''. + + (b) <<NOTE: 42 USC 1395w-104 note.>> Effective Date.--The amendments +made by this section shall apply to plan year 2011 and subsequent plan +years. + +SEC. 3308. REDUCING PART D PREMIUM SUBSIDY FOR HIGH-INCOME + BENEFICIARIES. + + (a) Income-Related Increase in Part D Premium.-- + (1) In general.--Section 1860D-13(a) of the Social Security + Act (42 U.S.C. 1395w-113(a)) is amended by adding at the end the + following new paragraph: + ``(7) Increase in base beneficiary premium based on + income.-- + ``(A) In general.--In the case of an individual + whose modified adjusted gross income exceeds the + threshold amount applicable under paragraph (2) of + section 1839(i) (including application of paragraph (5) + of such section) for the calendar year, the monthly + amount of the beneficiary premium applicable under this + section for a month after December 2010 shall be + increased by the monthly adjustment amount specified in + subparagraph (B). + ``(B) Monthly adjustment amount.--The monthly + adjustment amount specified in this subparagraph for an + individual for a month in a year is equal to the product + of-- + ``(i) the quotient obtained by dividing-- + ``(I) the applicable percentage + determined under paragraph (3)(C) of + section 1839(i) (including application + of paragraph (5) of such section) for + the individual for the calendar year + reduced by 25.5 percent; by + ``(II) 25.5 percent; and + ``(ii) the base beneficiary premium (as + computed under paragraph (2)). + ``(C) Modified adjusted gross income.--For purposes + of this paragraph, the term `modified adjusted gross + income' has the meaning given such term in subparagraph + (A) of section 1839(i)(4), determined for the taxable + year applicable under subparagraphs (B) and (C) of such + section. + ``(D) Determination by commissioner of social + security.--The Commissioner of Social Security shall + make any determination necessary to carry out the + income- + +[[Page 124 STAT. 473]] + + related increase in the base beneficiary premium under + this paragraph. + ``(E) <<NOTE: Deadlines.>> Procedures to assure + correct income-related increase in base beneficiary + premium.-- + ``(i) Disclosure of base beneficiary + premium.--Not later than September 15 of each year + beginning with 2010, the Secretary shall disclose + to the Commissioner of Social Security the amount + of the base beneficiary premium (as computed under + paragraph (2)) for the purpose of carrying out the + income-related increase in the base beneficiary + premium under this paragraph with respect to the + following year. + ``(ii) Additional disclosure.--Not later than + October 15 of each year beginning with 2010, the + Secretary shall disclose to the Commissioner of + Social Security the following information for the + purpose of carrying out the income-related + increase in the base beneficiary premium under + this paragraph with respect to the following year: + ``(I) The modified adjusted gross + income threshold applicable under + paragraph (2) of section 1839(i) + (including application of paragraph (5) + of such section). + ``(II) The applicable percentage + determined under paragraph (3)(C) of + section 1839(i) (including application + of paragraph (5) of such section). + ``(III) The monthly adjustment + amount specified in subparagraph (B). + ``(IV) Any other information the + Commissioner of Social Security + determines necessary to carry out the + income-related increase in the base + beneficiary premium under this + paragraph. + ``(F) Rule of construction.--The formula used to + determine the monthly adjustment amount specified under + subparagraph (B) shall only be used for the purpose of + determining such monthly adjustment amount under such + subparagraph.''. + (2) Collection of monthly adjustment amount.--Section 1860D- + 13(c) of the Social Security Act (42 U.S.C. 1395w-113(c)) is + amended-- + (A) in paragraph (1), by striking ``(2) and (3)'' + and inserting ``(2), (3), and (4)''; and + (B) by adding at the end the following new + paragraph: + ``(4) Collection of monthly adjustment amount.-- + ``(A) In general.--Notwithstanding any provision of + this subsection or section 1854(d)(2), subject to + subparagraph (B), the amount of the income-related + increase in the base beneficiary premium for an + individual for a month (as determined under subsection + (a)(7)) shall be paid through withholding from benefit + payments in the manner provided under section 1840. + ``(B) Agreements.--In the case where the monthly + benefit payments of an individual that are withheld + under subparagraph (A) are insufficient to pay the + amount described in such subparagraph, the Commissioner + of Social Security shall enter into agreements with the + Secretary, the Director of the Office of Personnel + Management, + +[[Page 124 STAT. 474]] + + and the Railroad Retirement Board as necessary in order + to allow other agencies to collect the amount described + in subparagraph (A) that was not withheld under such + subparagraph.''. + + (b) Conforming Amendments.-- + (1) Medicare.--Section 1860D-13(a)(1) of the Social Security + Act (42 U.S.C. 1395w-113(a)(1)) is amended-- + (A) by redesignating subparagraph (F) as + subparagraph (G); + (B) in subparagraph (G), as redesignated by + subparagraph (A), by striking ``(D) and (E)'' and + inserting ``(D), (E), and (F)''; and + (C) by inserting after subparagraph (E) the + following new subparagraph: + ``(F) Increase based on income.--The monthly + beneficiary premium shall be increased pursuant to + paragraph (7).''. + (2) <<NOTE: 26 USC 6103.>> Internal revenue code.--Section + 6103(l)(20) of the Internal Revenue Code of 1986 (relating to + disclosure of return information to carry out Medicare part B + premium subsidy adjustment) is amended-- + (A) in the heading, by inserting ``and part d base + beneficiary premium increase'' after ``part b premium + subsidy adjustment''; + (B) in subparagraph (A)-- + (i) in the matter preceding clause (i), by + inserting ``or increase under section 1860D- + 13(a)(7)'' after ``1839(i)''; and + (ii) in clause (vii), by inserting after + ``subsection (i) of such section'' the following: + ``or increase under section 1860D-13(a)(7) of such + Act''; and + (C) in subparagraph (B)-- + (i) by striking ``Return information'' and + inserting the following: + ``(i) In general.--Return information''; + (ii) by inserting ``or increase under such + section 1860D-13(a)(7)'' before the period at the + end; + (iii) as amended by clause (i), by inserting + ``or for the purpose of resolving taxpayer appeals + with respect to any such premium adjustment or + increase'' before the period at the end; and + (iv) by adding at the end the following new + clause: + ``(ii) Disclosure to other agencies.-- + Officers, employees, and contractors of the Social + Security Administration may disclose-- + ``(I) the taxpayer identity + information and the amount of the + premium subsidy adjustment or premium + increase with respect to a taxpayer + described in subparagraph (A) to + officers, employees, and contractors of + the Centers for Medicare and Medicaid + Services, to the extent that such + disclosure is necessary for the + collection of the premium subsidy amount + or the increased premium amount, + ``(II) the taxpayer identity + information and the amount of the + premium subsidy adjustment or the + increased premium amount with respect to + +[[Page 124 STAT. 475]] + + a taxpayer described in subparagraph (A) + to officers and employees of the Office + of Personnel Management and the Railroad + Retirement Board, to the extent that + such disclosure is necessary for the + collection of the premium subsidy amount + or the increased premium amount, + ``(III) return information with + respect to a taxpayer described in + subparagraph (A) to officers and + employees of the Department of Health + and Human Services to the extent + necessary to resolve administrative + appeals of such premium subsidy + adjustment or increased premium, and + ``(IV) return information with + respect to a taxpayer described in + subparagraph (A) to officers and + employees of the Department of Justice + for use in judicial proceedings to the + extent necessary to carry out the + purposes described in clause (i).''. + +SEC. 3309. ELIMINATION OF COST SHARING FOR CERTAIN DUAL ELIGIBLE + INDIVIDUALS. + + Section 1860D-14(a)(1)(D)(i) of the Social Security Act (42 U.S.C. +1395w-114(a)(1)(D)(i)) is amended by inserting ``or, effective on a date +specified by the Secretary (but in no case earlier than January 1, +2012), who would be such an institutionalized individual or couple, if +the full-benefit dual eligible individual were not receiving services +under a home and community-based waiver authorized for a State under +section 1115 or subsection (c) or (d) of section 1915 or under a State +plan amendment under subsection (i) of such section or services provided +through enrollment in a medicaid managed care organization with a +contract under section 1903(m) or under section 1932'' after +``1902(q)(1)(B))''. + +SEC. 3310. REDUCING WASTEFUL DISPENSING OF OUTPATIENT PRESCRIPTION DRUGS + IN LONG-TERM CARE FACILITIES UNDER PRESCRIPTION DRUG PLANS + AND MA-PD PLANS. + + (a) In General.--Section 1860D-4(c) of the Social Security Act (42 +U.S.C. 1395w-104(c)) is amended by adding at the end the following new +paragraph: + ``(3) Reducing wasteful dispensing of outpatient + prescription drugs in long-term care facilities.--The Secretary + shall require PDP sponsors of prescription drug plans to utilize + specific, uniform dispensing techniques, as determined by the + Secretary, in consultation with relevant stakeholders (including + representatives of nursing facilities, residents of nursing + facilities, pharmacists, the pharmacy industry (including retail + and long-term care pharmacy), prescription drug plans, MA-PD + plans, and any other stakeholders the Secretary determines + appropriate), such as weekly, daily, or automated dose + dispensing, when dispensing covered part D drugs to enrollees + who reside in a long-term care facility in order to reduce waste + associated with 30-day fills.''. + + (b) <<NOTE: 42 USC 1395w-104 note.>> Effective Date.--The amendment +made by subsection (a) shall apply to plan years beginning on or after +January 1, 2012. + +SEC. 3311. <<NOTE: 42 USC 1395w-154.>> IMPROVED MEDICARE PRESCRIPTION + DRUG PLAN AND MA-PD PLAN COMPLAINT SYSTEM. + + (a) In General.--The Secretary shall develop and maintain a +complaint system, that is widely known and easy to use, to + +[[Page 124 STAT. 476]] + +collect and maintain information on MA-PD plan and prescription drug +plan complaints that are received (including by telephone, letter, e- +mail, or any other means) by the Secretary (including by a regional +office of the Department of Health and Human Services, the Medicare +Beneficiary Ombudsman, a subcontractor, a carrier, a fiscal +intermediary, and a Medicare administrative contractor under section +1874A of the Social Security Act (42 U.S.C. 1395kk)) through the date on +which the complaint is resolved. The system shall be able to report and +initiate appropriate interventions and monitoring based on substantial +complaints and to guide quality improvement. + (b) Model Electronic Complaint Form.--The Secretary shall develop a +model electronic complaint form to be used for reporting plan complaints +under the system. Such form shall be prominently displayed on the front +page of the Medicare.gov Internet website and on the Internet website of +the Medicare Beneficiary Ombudsman. + (c) Annual Reports by the Secretary.--The Secretary shall submit to +Congress annual reports on the system. Such reports shall include an +analysis of the number and types of complaints reported in the system, +geographic variations in such complaints, the timeliness of agency or +plan responses to such complaints, and the resolution of such +complaints. + (d) Definitions.--In this section: + (1) MA-PD plan.--The term ``MA-PD plan'' has the meaning + given such term in section 1860D-41(a)(9) of such Act (42 U.S.C. + 1395w-151(a)(9)). + (2) Prescription drug plan.--The term ``prescription drug + plan'' has the meaning given such term in section 1860D- + 41(a)(14) of such Act (42 U.S.C. 1395w-151(a)(14)). + (3) Secretary.--The term ``Secretary'' means the Secretary + of Health and Human Services. + (4) System.--The term ``system'' means the plan complaint + system developed and maintained under subsection (a). + +SEC. 3312. UNIFORM EXCEPTIONS AND APPEALS PROCESS FOR PRESCRIPTION DRUG + PLANS AND MA-PD PLANS. + + (a) In General.--Section 1860D-4(b)(3) of the Social Security Act +(42 U.S.C. 1395w-104(b)(3)) is amended by adding at the end the +following new subparagraph: + ``(H) Use of single, uniform exceptions and appeals + process.--Notwithstanding any other provision of this + part, each PDP sponsor of a prescription drug plan + shall-- + ``(i) use a single, uniform exceptions and + appeals process (including, to the extent the + Secretary determines feasible, a single, uniform + model form for use under such process) with + respect to the determination of prescription drug + coverage for an enrollee under the plan; and + ``(ii) provide instant access to such process + by enrollees through a toll-free telephone number + and an Internet website.''. + + (b) <<NOTE: 42 USC 1395w-104 note.>> Effective Date.--The amendment +made by subsection (a) shall apply to exceptions and appeals on or after +January 1, 2012. + +[[Page 124 STAT. 477]] + +SEC. 3313. <<NOTE: 42 USC 1395w-101 note.>> OFFICE OF THE INSPECTOR + GENERAL STUDIES AND REPORTS. + + (a) Study and Annual Report on Part D Formularies' Inclusion of +Drugs Commonly Used by Dual Eligibles.-- + (1) Study.--The Inspector General of the Department of + Health and Human Services shall conduct a study of the extent to + which formularies used by prescription drug plans and MA-PD + plans under part D include drugs commonly used by full-benefit + dual eligible individuals (as defined in section 1935(c)(6) of + the Social Security Act (42 U.S.C. 1396u-5(c)(6))). + (2) Annual reports.--Not later than July 1 of each year + (beginning with 2011), the Inspector General shall submit to + Congress a report on the study conducted under paragraph (1), + together with such recommendations as the Inspector General + determines appropriate. + + (b) Study and Report on Prescription Drug Prices Under Medicare Part +D and Medicaid.-- + (1) Study.-- + (A) In general.--The Inspector General of the + Department of Health and Human Services shall conduct a + study on prices for covered part D drugs under the + Medicare prescription drug program under part D of title + XVIII of the Social Security Act and for covered + outpatient drugs under title XIX. Such study shall + include the following: + (i) A comparison, with respect to the 200 most + frequently dispensed covered part D drugs under + such program and covered outpatient drugs under + such title (as determined by the Inspector General + based on volume and expenditures), of-- + (I) the prices paid for covered part + D drugs by PDP sponsors of prescription + drug plans and Medicare Advantage + organizations offering MA-PD plans; and + (II) the prices paid for covered + outpatient drugs by a State plan under + title XIX. + (ii) An assessment of-- + (I) the financial impact of any + discrepancies in such prices on the + Federal Government; and + (II) the financial impact of any + such discrepancies on enrollees under + part D or individuals eligible for + medical assistance under a State plan + under title XIX. + (B) Price.--For purposes of subparagraph (A), the + price of a covered part D drug or a covered outpatient + drug shall include any rebate or discount under such + program or such title, respectively, including any + negotiated price concession described in section 1860D- + 2(d)(1)(B) of the Social Security Act (42 U.S.C. 1395w- + 102(d)(1)(B)) or rebate under an agreement under section + 1927 of the Social Security Act (42 U.S.C. 1396r-8). + (C) Authority to collect any necessary + information.--Notwithstanding any other provision of + law, the Inspector General of the Department of Health + and Human Services shall be able to collect any + information related to the prices of covered part D + drugs under such program + +[[Page 124 STAT. 478]] + + and covered outpatient drugs under such title XIX + necessary to carry out the comparison under subparagraph + (A). + (2) Report.-- + (A) In general.--Not later than October 1, 2011, + subject to subparagraph (B), the Inspector General shall + submit to Congress a report containing the results of + the study conducted under paragraph (1), together with + recommendations for such legislation and administrative + action as the Inspector General determines appropriate. + (B) Limitation on information contained in report.-- + The report submitted under subparagraph (A) shall not + include any information that the Inspector General + determines is proprietary or is likely to negatively + impact the ability of a PDP sponsor or a State plan + under title XIX to negotiate prices for covered part D + drugs or covered outpatient drugs, respectively. + (3) Definitions.--In this section: + (A) Covered part d drug.--The term ``covered part D + drug'' has the meaning given such term in section 1860D- + 2(e) of the Social Security Act (42 U.S.C. 1395w- + 102(e)). + (B) Covered outpatient drug.--The term ``covered + outpatient drug'' has the meaning given such term in + section 1927(k) of such Act (42 U.S.C. 1396r(k)). + (C) MA-PD plan.--The term ``MA-PD plan'' has the + meaning given such term in section 1860D-41(a)(9) of + such Act (42 U.S.C. 1395w-151(a)(9)). + (D) Medicare advantage organization.--The term + ``Medicare Advantage organization'' has the meaning + given such term in section 1859(a)(1) of such Act (42 + U.S.C. 1395w-28)(a)(1)). + (E) PDP sponsor.--The term ``PDP sponsor'' has the + meaning given such term in section 1860D-41(a)(13) of + such Act (42 U.S.C. 1395w-151(a)(13)). + (F) Prescription drug plan.--The term ``prescription + drug plan'' has the meaning given such term in section + 1860D-41(a)(14) of such Act (42 U.S.C. 1395w- + 151(a)(14)). + +SEC. 3314. INCLUDING COSTS INCURRED BY AIDS DRUG ASSISTANCE PROGRAMS AND + INDIAN HEALTH SERVICE IN PROVIDING PRESCRIPTION DRUGS TOWARD + THE ANNUAL OUT-OF-POCKET THRESHOLD UNDER PART D. + + (a) In General.--Section 1860D-2(b)(4)(C) of the Social Security Act +(42 U.S.C. 1395w-102(b)(4)(C)) is amended-- + (1) in clause (i), by striking ``and'' at the end; + (2) in clause (ii)-- + (A) by striking ``such costs shall be treated as + incurred only if'' and inserting ``subject to clause + (iii), such costs shall be treated as incurred only + if''; + (B) by striking ``, under section 1860D-14, or under + a State Pharmaceutical Assistance Program''; and + (C) by striking the period at the end and inserting + ``; and''; and + (3) by inserting after clause (ii) the following new clause: + ``(iii) such costs shall be treated as + incurred and shall not be considered to be + reimbursed under clause (ii) if such costs are + borne or paid-- + +[[Page 124 STAT. 479]] + + ``(I) under section 1860D-14; + ``(II) under a State Pharmaceutical + Assistance Program; + ``(III) by the Indian Health + Service, an Indian tribe or tribal + organization, or an urban Indian + organization (as defined in section 4 of + the Indian Health Care Improvement Act); + or + ``(IV) under an AIDS Drug Assistance + Program under part B of title XXVI of + the Public Health Service Act.''. + + (b) <<NOTE: 42 USC 1395w-102 note.>> Effective Date.--The amendments +made by subsection (a) shall apply to costs incurred on or after January +1, 2011. + +SEC. 3315. IMMEDIATE REDUCTION IN COVERAGE GAP IN 2010. + + Section 1860D-2(b) of the Social Security Act (42 U.S.C. 1395w- +102(b)) is amended-- + (1) in paragraph (3)(A), by striking ``paragraph (4)'' and + inserting ``paragraphs (4) and (7)''; and + (2) by adding at the end the following new paragraph: + ``(7) Increase in initial coverage limit in 2010.-- + ``(A) <<NOTE: Effective date.>> In general.--For + the plan year beginning on January 1, 2010, the initial + coverage limit described in paragraph (3)(B) otherwise + applicable shall be increased by $500. + ``(B) Application.--In applying subparagraph (A)-- + ``(i) except as otherwise provided in this + subparagraph, there shall be no change in the + premiums, bids, or any other parameters under this + part or part C; + ``(ii) costs that would be treated as incurred + costs for purposes of applying paragraph (4) but + for the application of subparagraph (A) shall + continue to be treated as incurred costs; + ``(iii) <<NOTE: Procedures.>> the Secretary + shall establish procedures, which may include a + reconciliation process, to fully reimburse PDP + sponsors with respect to prescription drug plans + and MA organizations with respect to MA-PD plans + for the reduction in beneficiary cost sharing + associated with the application of subparagraph + (A); + ``(iv) the Secretary shall develop an estimate + of the additional increased costs attributable to + the application of this paragraph for increased + drug utilization and financing and administrative + costs and shall use such estimate to adjust + payments to PDP sponsors with respect to + prescription drug plans under this part and MA + organizations with respect to MA-PD plans under + part C; and + ``(v) <<NOTE: Procedures.>> the Secretary + shall establish procedures for retroactive + reimbursement of part D eligible individuals who + are covered under such a plan for costs which are + incurred before the date of initial implementation + of subparagraph (A) and which would be reimbursed + under such a plan if such implementation occurred + as of January 1, 2010. + ``(C) <<NOTE: Applicability. Time periods.>> No + effect on subsequent years.--The increase under + subparagraph (A) shall only apply with respect to the + plan year beginning on January 1, 2010, and the initial + coverage limit for plan years beginning on or after + January + +[[Page 124 STAT. 480]] + + 1, 2011, shall be determined as if subparagraph (A) had + never applied.''. + + Subtitle E--Ensuring Medicare Sustainability + +SEC. 3401. REVISION OF CERTAIN MARKET BASKET UPDATES AND INCORPORATION + OF PRODUCTIVITY IMPROVEMENTS INTO MARKET BASKET UPDATES THAT + DO NOT ALREADY INCORPORATE SUCH IMPROVEMENTS. + + (a) Inpatient Acute Hospitals.--Section 1886(b)(3)(B) of the Social +Security Act (42 U.S.C. 1395ww(b)(3)(B)), as amended by section +3001(a)(3), is further amended-- + (1) in clause (i)(XX), by striking ``clause (viii)'' and + inserting ``clauses (viii), (ix), (xi), and (xii)''; + (2) in the first sentence of clause (viii), by inserting + ``of such applicable percentage increase (determined without + regard to clause (ix), (xi), or (xii))'' after ``one-quarter''; + (3) in the first sentence of clause (ix)(I), by inserting + ``(determined without regard to clause (viii), (xi), or (xii))'' + after ``clause (i)'' the second time it appears; and + (4) by adding at the end the following new clauses: + + ``(xi)(I) For 2012 and each subsequent fiscal year, after +determining the applicable percentage increase described in clause (i) +and after application of clauses (viii) and (ix), such percentage +increase shall be reduced by the productivity adjustment described in +subclause (II). + ``(II) The productivity adjustment described in this subclause, with +respect to a percentage, factor, or update for a fiscal year, year, cost +reporting period, or other annual period, is a productivity adjustment +equal to the 10-year moving average of changes in annual economy-wide +private nonfarm business multi-factor productivity (as projected by the +Secretary for the 10-year period ending with the applicable fiscal year, +year, cost reporting period, or other annual period). + ``(III) The application of subclause (I) may result in the +applicable percentage increase described in clause (i) being less than +0.0 for a fiscal year, and may result in payment rates under this +section for a fiscal year being less than such payment rates for the +preceding fiscal year. + ``(xii) After determining the applicable percentage increase +described in clause (i), and after application of clauses (viii), (ix), +and (xi), the Secretary shall reduce such applicable percentage +increase-- + ``(I) for each of fiscal years 2010 and 2011, by 0.25 + percentage point; and + ``(II) subject to clause (xiii), for each of fiscal years + 2012 through 2019, by 0.2 percentage point. + +The application of this clause may result in the applicable percentage +increase described in clause (i) being less than 0.0 for a fiscal year, +and may result in payment rates under this section for a fiscal year +being less than such payment rates for the preceding fiscal year. + ``(xiii) <<NOTE: Applicability.>> Clause (xii) shall be applied with +respect to any of fiscal years 2014 through 2019 by substituting `0.0 +percentage points' for `0.2 percentage point', if for such fiscal year-- + +[[Page 124 STAT. 481]] + + ``(I) the excess (if any) of-- + ``(aa) the total percentage of the non-elderly + insured population for the preceding fiscal year (based + on the most recent estimates available from the Director + of the Congressional Budget Office before a vote in + either House on the Patient Protection and Affordable + Care Act that, if determined in the affirmative, would + clear such Act for enrollment); over + ``(bb) the total percentage of the non-elderly + insured population for such preceding fiscal year (as + estimated by the Secretary); exceeds + ``(II) 5 percentage points.''. + + (b) Skilled Nursing Facilities.--Section 1888(e)(5)(B) of the Social +Security Act (42 U.S.C. 1395yy(e)(5)(B)) is amended-- + (1) by striking ``percentage.--The term'' and inserting + ``percentage.-- + ``(i) In general.--Subject to clause (ii), the + term''; and + (2) by adding at the end the following new clause: + ``(ii) Adjustment.--For fiscal year 2012 and + each subsequent fiscal year, after determining the + percentage described in clause (i), the Secretary + shall reduce such percentage by the productivity + adjustment described in section + 1886(b)(3)(B)(xi)(II). The application of the + preceding sentence may result in such percentage + being less than 0.0 for a fiscal year, and may + result in payment rates under this subsection for + a fiscal year being less than such payment rates + for the preceding fiscal year.''. + + (c) Long-term Care Hospitals.--Section 1886(m) of the Social +Security Act (42 U.S.C. 1395ww(m)) is amended by adding at the end the +following new paragraphs: + ``(3) Implementation for rate year 2010 and subsequent + years.-- + ``(A) In general.--In implementing the system + described in paragraph (1) for rate year 2010 and each + subsequent rate year, any annual update to a standard + Federal rate for discharges for the hospital during the + rate year, shall be reduced-- + ``(i) for rate year 2012 and each subsequent + rate year, by the productivity adjustment + described in section 1886(b)(3)(B)(xi)(II); and + ``(ii) for each of rate years 2010 through + 2019, by the other adjustment described in + paragraph (4). + ``(B) Special rule.--The application of this + paragraph may result in such annual update being less + than 0.0 for a rate year, and may result in payment + rates under the system described in paragraph (1) for a + rate year being less than such payment rates for the + preceding rate year. + ``(4) Other adjustment.-- + ``(A) In general.--For purposes of paragraph + (3)(A)(ii), the other adjustment described in this + paragraph is-- + ``(i) for each of rate years 2010 and 2011, + 0.25 percentage point; and + ``(ii) subject to subparagraph (B), for each + of rate years 2012 through 2019, 0.2 percentage + point. + +[[Page 124 STAT. 482]] + + ``(B) Reduction of other adjustment.--Subparagraph + (A)(ii) shall be applied with respect to any of rate + years 2014 through 2019 by substituting `0.0 percentage + points' for `0.2 percentage point', if for such rate + year-- + ``(i) the excess (if any) of-- + ``(I) the total percentage of the + non-elderly insured population for the + preceding rate year (based on the most + recent estimates available from the + Director of the Congressional Budget + Office before a vote in either House on + the Patient Protection and Affordable + Care Act that, if determined in the + affirmative, would clear such Act for + enrollment); over + ``(II) the total percentage of the + non-elderly insured population for such + preceding rate year (as estimated by the + Secretary); exceeds + ``(ii) 5 percentage points.''. + + (d) Inpatient Rehabilitation Facilities.--Section 1886(j)(3) of the +Social Security Act (42 U.S.C. 1395ww(j)(3)) is amended-- + (1) in subparagraph (C)-- + (A) by striking ``factor.--For purposes'' and + inserting ``factor.-- + ``(i) In general.--For purposes''; + (B) by inserting ``subject to clause (ii)'' before + the period at the end of the first sentence of clause + (i), as added by paragraph (1); and + (C) by adding at the end the following new clause: + ``(ii) Productivity and other adjustment.-- + After establishing the increase factor described + in clause (i) for a fiscal year, the Secretary + shall reduce such increase factor-- + ``(I) for fiscal year 2012 and each + subsequent fiscal year, by the + productivity adjustment described in + section 1886(b)(3)(B)(xi)(II); and + ``(II) for each of fiscal years 2010 + through 2019, by the other adjustment + described in subparagraph (D). + The application of this clause may result in the + increase factor under this subparagraph being less + than 0.0 for a fiscal year, and may result in + payment rates under this subsection for a fiscal + year being less than such payment rates for the + preceding fiscal year.''; and + (2) by adding at the end the following new subparagraph: + ``(D) Other adjustment.-- + ``(i) In general.--For purposes of + subparagraph (C)(ii)(II), the other adjustment + described in this subparagraph is-- + ``(I) for each of fiscal years 2010 + and 2011, 0.25 percentage point; and + ``(II) subject to clause (ii), for + each of fiscal years 2012 through 2019, + 0.2 percentage point. + ``(ii) <<NOTE: Applicability.>> Reduction of + other adjustment.--Clause (i)(II) shall be applied + with respect to any of fiscal years 2014 through + 2019 by substituting `0.0 percentage points' for + `0.2 percentage point', if for such fiscal year-- + +[[Page 124 STAT. 483]] + + ``(I) the excess (if any) of-- + ``(aa) the total percentage + of the non-elderly insured + population for the preceding + fiscal year (based on the most + recent estimates available from + the Director of the + Congressional Budget Office + before a vote in either House on + the Patient Protection and + Affordable Care Act that, if + determined in the affirmative, + would clear such Act for + enrollment); over + ``(bb) the total percentage + of the non-elderly insured + population for such preceding + fiscal year (as estimated by the + Secretary); exceeds + ``(II) 5 percentage points.''. + + (e) Home Health Agencies.--Section 1895(b)(3)(B) of the Social +Security Act (42 U.S.C. 1395fff(b)(3)(B)) is amended-- + (1) in clause (ii)(V), by striking ``clause (v)'' and + inserting ``clauses (v) and (vi)''; and + (2) by adding at the end the following new clause: + ``(vi) Adjustments.--After determining the + home health market basket percentage increase + under clause (iii), and after application of + clause (v), the Secretary shall reduce such + percentage-- + ``(I) for 2015 and each subsequent + year, by the productivity adjustment + described in section + 1886(b)(3)(B)(xi)(II); and + ``(II) for each of 2011 and 2012, by + 1 percentage point. + The application of this clause may result in the + home health market basket percentage increase + under clause (iii) being less than 0.0 for a year, + and may result in payment rates under the system + under this subsection for a year being less than + such payment rates for the preceding year.''. + + (f) Psychiatric Hospitals.--Section 1886 of the Social Security +Act, <<NOTE: 42 USC 1395ww.>> as amended by sections 3001, 3008, 3025, +and 3133, is amended by adding at the end the following new subsection: + + ``(s) Prospective Payment for Psychiatric Hospitals.-- + ``(1) Reference to establishment and implementation of + system.--For provisions related to the establishment and + implementation of a prospective payment system for payments + under this title for inpatient hospital services furnished by + psychiatric hospitals (as described in clause (i) of subsection + (d)(1)(B)) and psychiatric units (as described in the matter + following clause (v) of such subsection), see section 124 of the + Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of + 1999. + ``(2) Implementation for rate year beginning in 2010 and + subsequent rate years.-- + ``(A) In general.--In implementing the system + described in paragraph (1) for the rate year beginning + in 2010 and any subsequent rate year, any update to a + base rate for days during the rate year for a + psychiatric hospital or unit, respectively, shall be + reduced-- + +[[Page 124 STAT. 484]] + + ``(i) for the rate year beginning in 2012 and + each subsequent rate year, by the productivity + adjustment described in section + 1886(b)(3)(B)(xi)(II); and + ``(ii) for each of the rate years beginning in + 2010 through 2019, by the other adjustment + described in paragraph (3). + ``(B) Special rule.--The application of this + paragraph may result in such update being less than 0.0 + for a rate year, and may result in payment rates under + the system described in paragraph (1) for a rate year + being less than such payment rates for the preceding + rate year. + ``(3) Other adjustment.-- + ``(A) In general.--For purposes of paragraph + (2)(A)(ii), the other adjustment described in this + paragraph is-- + ``(i) for each of the rate years beginning in + 2010 and 2011, 0.25 percentage point; and + ``(ii) subject to subparagraph (B), for each + of the rate years beginning in 2012 through 2019, + 0.2 percentage point. + ``(B) Reduction of other adjustment.--Subparagraph + (A)(ii) shall be applied with respect to any of rate + years 2014 through 2019 by substituting `0.0 percentage + points' for `0.2 percentage point', if for such rate + year-- + ``(i) the excess (if any) of-- + ``(I) the total percentage of the + non-elderly insured population for the + preceding rate year (based on the most + recent estimates available from the + Director of the Congressional Budget + Office before a vote in either House on + the Patient Protection and Affordable + Care Act that, if determined in the + affirmative, would clear such Act for + enrollment); over + ``(II) the total percentage of the + non-elderly insured population for such + preceding rate year (as estimated by the + Secretary); exceeds + ``(ii) 5 percentage points.''. + + (g) Hospice Care.--Section 1814(i)(1)(C) of the Social Security Act +(42 U.S.C. 1395f(i)(1)(C)), as amended by section 3132, is amended by +adding at the end the following new clauses: + ``(iv) After determining the market basket percentage increase under +clause (ii)(VII) or (iii), as applicable, with respect to fiscal year +2013 and each subsequent fiscal year, the Secretary shall reduce such +percentage-- + ``(I) for 2013 and each subsequent fiscal year, by the + productivity adjustment described in section + 1886(b)(3)(B)(xi)(II); and + ``(II) subject to clause (v), for each of fiscal years 2013 + through 2019, by 0.5 percentage point. + +The application of this clause may result in the market basket +percentage increase under clause (ii)(VII) or (iii), as applicable, +being less than 0.0 for a fiscal year, and may result in payment rates +under this subsection for a fiscal year being less than such payment +rates for the preceding fiscal year. + ``(v) <<NOTE: Applicability.>> Clause (iv)(II) shall be applied with +respect to any of fiscal years 2014 through 2019 by substituting `0.0 +percentage points' for `0.5 percentage point', if for such fiscal year-- + ``(I) the excess (if any) of-- + +[[Page 124 STAT. 485]] + + ``(aa) the total percentage of the non-elderly + insured population for the preceding fiscal year (based + on the most recent estimates available from the Director + of the Congressional Budget Office before a vote in + either House on the Patient Protection and Affordable + Care Act that, if determined in the affirmative, would + clear such Act for enrollment); over + ``(bb) the total percentage of the non-elderly + insured population for such preceding fiscal year (as + estimated by the Secretary); exceeds + ``(II) 5 percentage points.''. + + (h) Dialysis.--Section 1881(b)(14)(F) of the Social Security Act (42 +U.S.C. 1395rr(b)(14)(F)) is amended-- + (1) in clause (i)-- + (A) by inserting ``(I)'' after ``(F)(i)'' + (B) in subclause (I), as inserted by subparagraph + (A)-- + (i) by striking ``clause (ii)'' and inserting + ``subclause (II) and clause (ii)''; and + (ii) by striking ``minus 1.0 percentage + point''; and + (C) by adding at the end the following new + subclause: + + ``(II) For 2012 and each subsequent year, after determining the +increase factor described in subclause (I), the Secretary shall reduce +such increase factor by the productivity adjustment described in section +1886(b)(3)(B)(xi)(II). The application of the preceding sentence may +result in such increase factor being less than 0.0 for a year, and may +result in payment rates under the payment system under this paragraph +for a year being less than such payment rates for the preceding year.''; +and + (2) in clause (ii)(II)-- + (A) by striking ``The'' and inserting ``Subject to + clause (i)(II), the''; and + (B) by striking ``clause (i) minus 1.0 percentage + point'' and inserting ``clause (i)(I)''. + + (i) Outpatient Hospitals.--Section 1833(t)(3) of the Social Security +Act (42 U.S.C. 1395l(t)(3)) is amended-- + (1) in subparagraph (C)(iv), by inserting ``and subparagraph + (F) of this paragraph'' after ``(17)''; and + (2) by adding at the end the following new subparagraphs: + ``(F) Productivity and other adjustment.--After + determining the OPD fee schedule increase factor under + subparagraph (C)(iv), the Secretary shall reduce such + increase factor-- + ``(i) for 2012 and subsequent years, by the + productivity adjustment described in section + 1886(b)(3)(B)(xi)(II); and + ``(ii) for each of 2010 through 2019, by the + adjustment described in subparagraph (G). + The application of this subparagraph may result in the + increase factor under subparagraph (C)(iv) being less + than 0.0 for a year, and may result in payment rates + under the payment system under this subsection for a + year being less than such payment rates for the + preceding year. + ``(G) Other adjustment.-- + ``(i) Adjustment.--For purposes of + subparagraph (F)(ii), the adjustment described in + this subparagraph is-- + +[[Page 124 STAT. 486]] + + ``(I) for each of 2010 and 2011, + 0.25 percentage point; and + ``(II) subject to clause (ii), for + each of 2012 through 2019, 0.2 + percentage point. + ``(ii) Reduction of other adjustment.--Clause + (i)(II) shall be applied with respect to any of + 2014 through 2019 by substituting `0.0 percentage + points' for `0.2 percentage point', if for such + year-- + ``(I) the excess (if any) of-- + ``(aa) the total percentage + of the non-elderly insured + population for the preceding + year (based on the most recent + estimates available from the + Director of the Congressional + Budget Office before a vote in + either House on the Patient + Protection and Affordable Care + Act that, if determined in the + affirmative, would clear such + Act for enrollment); over + ``(bb) the total percentage + of the non-elderly insured + population for such preceding + year (as estimated by the + Secretary); exceeds + ``(II) 5 percentage points.''. + + (j) Ambulance Services.--Section 1834(l)(3) of the Social Security +Act (42 U.S.C. 1395m(l)(3)) is amended-- + (1) in subparagraph (A), by striking ``and'' at the end; + (2) in subparagraph (B)-- + (A) by inserting ``, subject to subparagraph (C) and + the succeeding sentence of this paragraph,'' after + ``increased''; and + (B) by striking the period at the end and inserting + ``; and''; + (3) by adding at the end the following new subparagraph: + ``(C) for 2011 and each subsequent year, after + determining the percentage increase under subparagraph + (B) for the year, reduce such percentage increase by the + productivity adjustment described in section + 1886(b)(3)(B)(xi)(II).''; and + (4) by adding at the end the following flush sentence: + ``The application of subparagraph (C) may result in the + percentage increase under subparagraph (B) being less than 0.0 + for a year, and may result in payment rates under the fee + schedule under this subsection for a year being less than such + payment rates for the preceding year.''. + + (k) Ambulatory Surgical Center Services.--Section 1833(i)(2)(D) of +the Social Security Act (42 U.S.C. 1395l(i)(2)(D)) is amended-- + (1) by redesignating clause (v) as clause (vi); and + (2) by inserting after clause (iv) the following new clause: + ``(v) In implementing the system described in + clause (i) for 2011 and each subsequent year, any + annual update under such system for the year, + after application of clause (iv), shall be reduced + by the productivity adjustment described in + section 1886(b)(3)(B)(xi)(II). The application of + the preceding sentence may result in such update + being less than 0.0 for a year, and may result in + payment rates under the system described in clause + (i) for a year being less than such payment rates + for the preceding year.''. + +[[Page 124 STAT. 487]] + + (l) Laboratory Services.--Section 1833(h)(2)(A) of the Social +Security Act (42 U.S.C. 1395l(h)(2)(A)) is amended-- + (1) in clause (i)-- + (A) by inserting ``, subject to clause (iv),'' after + ``year) by''; and + (B) by striking ``through 2013'' and inserting ``and + 2010''; and + (2) by adding at the end the following new clause: + ``(iv) After determining the adjustment to the + fee schedules under clause (i), the Secretary + shall reduce such adjustment-- + ``(I) for 2011 and each subsequent + year, by the productivity adjustment + described in section + 1886(b)(3)(B)(xi)(II); and + ``(II) for each of 2011 through + 2015, by 1.75 percentage points. + Subclause (I) shall not apply in a year where the + adjustment to the fee schedules determined under + clause (i) is 0.0 or a percentage decrease for a + year. The application of the productivity + adjustment under subclause (I) shall not result in + an adjustment to the fee schedules under clause + (i) being less than 0.0 for a year. The + application of subclause (II) may result in an + adjustment to the fee schedules under clause (i) + being less than 0.0 for a year, and may result in + payment rates for a year being less than such + payment rates for the preceding year.''. + + (m) Certain Durable Medical Equipment.--Section 1834(a)(14) of the +Social Security Act (42 U.S.C. 1395m(a)(14)) is amended-- + (1) in subparagraph (K)-- + (A) by striking ``2011, 2012, and 2013,''; and + (B) by inserting ``and'' after the semicolon at the + end; + (2) by striking subparagraphs (L) and (M) and inserting the + following new subparagraph: + ``(L) for 2011 and each subsequent year-- + ``(i) the percentage increase in the consumer + price index for all urban consumers (United States + city average) for the 12-month period ending with + June of the previous year, reduced by-- + ``(ii) the productivity adjustment described + in section 1886(b)(3)(B)(xi)(II).''; and + (3) by adding at the end the following flush sentence: + ``The application of subparagraph (L)(ii) may result in the + covered item update under this paragraph being less than 0.0 for + a year, and may result in payment rates under this subsection + for a year being less than such payment rates for the preceding + year.''. + + (n) Prosthetic Devices, Orthotics, and Prosthetics.--Section +1834(h)(4) of the Social Security Act (42 U.S.C. 1395m(h)(4)) is +amended-- + (1) in subparagraph (A)-- + (A) in clause (ix), by striking ``and'' at the end; + (B) in clause (x)-- + (i) by striking ``a subsequent year'' and + inserting ``for each of 2007 through 2010''; and + +[[Page 124 STAT. 488]] + + (ii) by inserting ``and'' after the semicolon + at the end; + (C) by adding at the end the following new clause: + ``(xi) for 2011 and each subsequent year-- + ``(I) the percentage increase in the + consumer price index for all urban + consumers (United States city average) + for the 12-month period ending with June + of the previous year, reduced by-- + ``(II) the productivity adjustment + described in section + 1886(b)(3)(B)(xi)(II).''; and + (D) by adding at the end the following flush + sentence: + ``The application of subparagraph (A)(xi)(II) may result in the + applicable percentage increase under subparagraph (A) being less + than 0.0 for a year, and may result in payment rates under this + subsection for a year being less than such payment rates for the + preceding year.''. + + (o) Other Items.--Section 1842(s)(1) of the Social Security Act (42 +U.S.C. 1395u(s)(1)) is amended-- + (1) in the first sentence, by striking ``Subject to'' and + inserting ``(A) Subject to''; + (2) by striking the second sentence and inserting the + following new subparagraph: + ``(B) Any fee schedule established under this + paragraph for such item or service shall be updated-- + ``(i) for years before 2011-- + ``(I) subject to subclause (II), by + the percentage increase in the consumer + price index for all urban consumers + (United States city average) for the 12- + month period ending with June of the + preceding year; and + ``(II) for items and services + described in paragraph (2)(D) for 2009, + section 1834(a)(14)(J) shall apply under + this paragraph instead of the percentage + increase otherwise applicable; and + ``(ii) for 2011 and subsequent years-- + ``(I) the percentage increase in the + consumer price index for all urban + consumers (United States city average) + for the 12-month period ending with June + of the previous year, reduced by-- + ``(II) the productivity adjustment + described in section + 1886(b)(3)(B)(xi)(II).''; and + (3) by adding at the end the following flush sentence: + ``The application of subparagraph (B)(ii)(II) may result in the + update under this paragraph being less than 0.0 for a year, and + may result in payment rates under any fee schedule established + under this paragraph for a year being less than such payment + rates for the preceding year.''. + + (p) <<NOTE: 42 USC 1395ww note.>> No Application Prior to April 1, +2010.--Notwithstanding the preceding provisions of this section, the +amendments made by subsections (a), (c), and (d) shall not apply to +discharges occurring before April 1, 2010. + +SEC. 3402. TEMPORARY ADJUSTMENT TO THE CALCULATION OF PART B PREMIUMS. + + Section 1839(i) of the Social Security Act (42 U.S.C. 1395r(i)) is +amended-- + +[[Page 124 STAT. 489]] + + (1) in paragraph (2), in the matter preceding subparagraph + (A), by inserting ``subject to paragraph (6),'' after + ``subsection,''; + (2) in paragraph (3)(A)(i), by striking ``The applicable'' + and inserting ``Subject to paragraph (6), the applicable''; + (3) by redesignating paragraph (6) as paragraph (7); and + (4) by inserting after paragraph (5) the following new + paragraph: + ``(6) <<NOTE: Time period.>> Temporary adjustment to income + thresholds.--Notwithstanding any other provision of this + subsection, during the period beginning on January 1, 2011, and + ending on December 31, 2019-- + ``(A) the threshold amount otherwise applicable + under paragraph (2) shall be equal to such amount for + 2010; and + ``(B) the dollar amounts otherwise applicable under + paragraph (3)(C)(i) shall be equal to such dollar + amounts for 2010.''. + +SEC. 3403. INDEPENDENT MEDICARE ADVISORY BOARD. + + (a) Board.-- + (1) In general.--Title XVIII of the Social Security Act (42 + U.S.C. 1395 et seq.), as amended by section 3022, is amended by + adding at the end the following new section: + + + ``independent medicare advisory board + + + ``Sec. 1899A. <<NOTE: 42 USC 1395kkk.>> (a) Establishment.--There +is established an independent board to be known as the `Independent +Medicare Advisory Board'. + + ``(b) Purpose.--It is the purpose of this section to, in accordance +with the following provisions of this section, reduce the per capita +rate of growth in Medicare spending-- + ``(1) by requiring the Chief Actuary of the Centers for + Medicare & Medicaid Services to determine in each year to which + this section applies (in this section referred to as `a + determination year') the projected per capita growth rate under + Medicare for the second year following the determination year + (in this section referred to as `an implementation year'); + ``(2) if the projection for the implementation year exceeds + the target growth rate for that year, by requiring the Board to + develop and submit during the first year following the + determination year (in this section referred to as `a proposal + year') a proposal containing recommendations to reduce the + Medicare per capita growth rate to the extent required by this + section; and + ``(3) by requiring the Secretary to implement such proposals + unless Congress enacts legislation pursuant to this section. + + ``(c) Board Proposals.-- + ``(1) Development.-- + ``(A) In general.--The Board shall develop detailed + and specific proposals related to the Medicare program + in accordance with the succeeding provisions of this + section. + ``(B) Advisory reports.--Beginning January 15, 2014, + the Board may develop and submit to Congress advisory + reports on matters related to the Medicare program, + regardless of whether or not the Board submitted a + proposal for such year. Such a report may, for years + prior to 2020, + +[[Page 124 STAT. 490]] + + include recommendations regarding improvements to + payment systems for providers of services and suppliers + who are not otherwise subject to the scope of the + Board's recommendations in a proposal under this + section. Any advisory report submitted under this + subparagraph shall not be subject to the rules for + congressional consideration under subsection (d). + ``(2) Proposals.-- + ``(A) Requirements.--Each proposal submitted under + this section in a proposal year shall meet each of the + following requirements: + ``(i) If the Chief Actuary of the Centers for + Medicare & Medicaid Services has made a + determination under paragraph (7)(A) in the + determination year, the proposal shall include + recommendations so that the proposal as a whole + (after taking into account recommendations under + clause (v)) will result in a net reduction in + total Medicare program spending in the + implementation year that is at least equal to the + applicable savings target established under + paragraph (7)(B) for such implementation year. In + determining whether a proposal meets the + requirement of the preceding sentence, reductions + in Medicare program spending during the 3-month + period immediately preceding the implementation + year shall be counted to the extent that such + reductions are a result of the implementation of + recommendations contained in the proposal for a + change in the payment rate for an item or service + that was effective during such period pursuant to + subsection (e)(2)(A). + ``(ii) The proposal shall not include any + recommendation to ration health care, raise + revenues or Medicare beneficiary premiums under + section 1818, 1818A, or 1839, increase Medicare + beneficiary cost-sharing (including deductibles, + coinsurance, and copayments), or otherwise + restrict benefits or modify eligibility criteria. + ``(iii) In the case of proposals submitted + prior to December 31, 2018, the proposal shall not + include any recommendation that would reduce + payment rates for items and services furnished, + prior to December 31, 2019, by providers of + services (as defined in section 1861(u)) and + suppliers (as defined in section 1861(d)) + scheduled, pursuant to the amendments made by + section 3401 of the Patient Protection and + Affordable Care Act, to receive a reduction to the + inflationary payment updates of such providers of + services and suppliers in excess of a reduction + due to productivity in a year in which such + recommendations would take effect. + ``(iv) As appropriate, the proposal shall + include recommendations to reduce Medicare + payments under parts C and D, such as reductions + in direct subsidy payments to Medicare Advantage + and prescription drug plans specified under + paragraph (1) and (2) of section 1860D-15(a) that + are related to administrative expenses (including + profits) for basic coverage, denying high bids or + removing high bids for prescription drug + +[[Page 124 STAT. 491]] + + coverage from the calculation of the national + average monthly bid amount under section 1860D- + 13(a)(4), and reductions in payments to Medicare + Advantage plans under clauses (i) and (ii) of + section 1853(a)(1)(B) that are related to + administrative expenses (including profits) and + performance bonuses for Medicare Advantage plans + under section 1853(n). Any such recommendation + shall not affect the base beneficiary premium + percentage specified under 1860D-13(a). + ``(v) The proposal shall include + recommendations with respect to administrative + funding for the Secretary to carry out the + recommendations contained in the proposal. + ``(vi) The proposal shall only include + recommendations related to the Medicare program. + ``(B) Additional considerations.--In developing and + submitting each proposal under this section in a + proposal year, the Board shall, to the extent feasible-- + ``(i) give priority to recommendations that + extend Medicare solvency; + ``(ii) include recommendations that-- + ``(I) improve the health care + delivery system and health outcomes, + including by promoting integrated care, + care coordination, prevention and + wellness, and quality and efficiency + improvement; and + ``(II) protect and improve Medicare + beneficiaries' access to necessary and + evidence-based items and services, + including in rural and frontier areas; + ``(iii) include recommendations that target + reductions in Medicare program spending to sources + of excess cost growth; + ``(iv) consider the effects on Medicare + beneficiaries of changes in payments to providers + of services (as defined in section 1861(u)) and + suppliers (as defined in section 1861(d)); + ``(v) consider the effects of the + recommendations on providers of services and + suppliers with actual or projected negative cost + margins or payment updates; and + ``(vi) consider the unique needs of Medicare + beneficiaries who are dually eligible for Medicare + and the Medicaid program under title XIX. + ``(C) No increase in total medicare program + spending.--Each proposal submitted under this section + shall be designed in such a manner that implementation + of the recommendations contained in the proposal would + not be expected to result, over the 10-year period + starting with the implementation year, in any increase + in the total amount of net Medicare program spending + relative to the total amount of net Medicare program + spending that would have occurred absent such + implementation. + ``(D) Consultation with + medpac. <<NOTE: Submission.>> --The Board shall submit a + draft copy of each proposal to be submitted under this + section to the Medicare Payment Advisory Commission + established under section 1805 for its + review. <<NOTE: Deadline.>> The Board + +[[Page 124 STAT. 492]] + + shall submit such draft copy by not later than September + 1 of the determination year. + ``(E) Review and comment by the + secretary. <<NOTE: Submission. Deadlines.>> --The Board + shall submit a draft copy of each proposal to be + submitted to Congress under this section to the + Secretary for the Secretary's review and comment. The + Board shall submit such draft copy by not later than + September 1 of the determination + year. <<NOTE: Reports.>> Not later than March 1 of the + submission year, the Secretary shall submit a report to + Congress on the results of such review, unless the + Secretary submits a proposal under paragraph (5)(A) in + that year. + ``(F) Consultations.--In carrying out its duties + under this section, the Board shall engage in regular + consultations with the Medicaid and CHIP Payment and + Access Commission under section 1900. + ``(3) Transmission of board proposal to president.-- + ``(A) In general.-- + ``(i) In general. <<NOTE: Deadline.>> --Except + as provided in clause (ii) and subsection + (f)(3)(B), the Board shall transmit a proposal + under this section to the President on January 15 + of each year (beginning with 2014). + ``(ii) Exception.--The Board shall not submit + a proposal under clause (i) in a proposal year if + the year is-- + ``(I) a year for which the Chief + Actuary of the Centers for Medicare & + Medicaid Services makes a determination + in the determination year under + paragraph (6)(A) that the growth rate + described in clause (i) of such + paragraph does not exceed the growth + rate described in clause (ii) of such + paragraph; + ``(II) a year in which the Chief + Actuary of the Centers for Medicare & + Medicaid Services makes a determination + in the determination year that the + projected percentage increase (if any) + for the medical care expenditure + category of the Consumer Price Index for + All Urban Consumers (United States city + average) for the implementation year is + less than the projected percentage + increase (if any) in the Consumer Price + Index for All Urban Consumers (all + items; United States city average) for + such implementation year; or + ``(III) for proposal year 2019 and + subsequent proposal years, a year in + which the Chief Actuary of the Centers + for Medicare & Medicaid Services makes a + determination in the determination year + that the growth rate described in + paragraph (8) exceeds the growth rate + described in paragraph (6)(A)(i). + ``(iii) Start-up period.--The Board may not + submit a proposal under clause (i) prior to + January 15, 2014. + ``(B) Required information.--Each proposal submitted + by the Board under subparagraph (A)(i) shall include-- + ``(i) the recommendations described in + paragraph (2)(A)(i); + +[[Page 124 STAT. 493]] + + ``(ii) an explanation of each recommendation + contained in the proposal and the reasons for + including such recommendation; + ``(iii) an actuarial opinion by the Chief + Actuary of the Centers for Medicare & Medicaid + Services certifying that the proposal meets the + requirements of subparagraphs (A)(i) and (C) of + paragraph (2); + ``(iv) a legislative proposal that implements + the recommendations; and + ``(v) other information determined appropriate + by the Board. + ``(4) Presidential submission to congress.--Upon receiving a + proposal from the Board under paragraph (3)(A)(i) or the + Secretary under paragraph (5), the President shall immediately + submit such proposal to Congress. + ``(5) Contingent secretarial development of proposal.--If, + with respect to a proposal year, the Board is required, to but + fails, to submit a proposal to the President by the deadline + applicable under paragraph (3)(A)(i), the Secretary shall + develop a detailed and specific proposal that satisfies the + requirements of subparagraphs (A) and (C) (and, to the extent + feasible, subparagraph (B)) of paragraph (2) and contains the + information required paragraph + (3)(B)). <<NOTE: Deadline. Transmission.>> By not later than + January 25 of the year, the Secretary shall transmit-- + ``(A) such proposal to the President; and + ``(B) a copy of such proposal to the Medicare + Payment Advisory Commission for its review. + ``(6) Per capita growth rate projections by chief actuary.-- + ``(A) In + general. <<NOTE: Deadlines. Determination.>> --Subject + to subsection (f)(3)(A), not later than April 30, 2013, + and annually thereafter, the Chief Actuary of the + Centers for Medicare & Medicaid Services shall determine + in each such year whether-- + ``(i) the projected Medicare per capita growth + rate for the implementation year (as determined + under subparagraph (B)); exceeds + ``(ii) the projected Medicare per capita + target growth rate for the implementation year (as + determined under subparagraph (C)). + ``(B) Medicare per capita growth rate.-- + ``(i) In general.--For purposes of this + section, the Medicare per capita growth rate for + an implementation year shall be calculated as the + projected 5-year average (ending with such year) + of the growth in Medicare program spending per + unduplicated enrollee. + ``(ii) Requirement.--The projection under + clause (i) shall-- + ``(I) to the extent that there is + projected to be a negative update to the + single conversion factor applicable to + payments for physicians' services under + section 1848(d) furnished in the + proposal year or the implementation + year, assume that such update for such + services is 0 percent rather than the + negative percent that would otherwise + apply; and + +[[Page 124 STAT. 494]] + + ``(II) take into account any + delivery system reforms or other payment + changes that have been enacted or + published in final rules but not yet + implemented as of the making of such + calculation. + ``(C) Medicare per capita target growth rate.--For + purposes of this section, the Medicare per capita target + growth rate for an implementation year shall be + calculated as the projected 5-year average (ending with + such year) percentage increase in-- + ``(i) with respect to a determination year + that is prior to 2018, the average of the + projected percentage increase (if any) in-- + ``(I) the Consumer Price Index for + All Urban Consumers (all items; United + States city average); and + ``(II) the medical care expenditure + category of the Consumer Price Index for + All Urban Consumers (United States city + average); and + ``(ii) with respect to a determination year + that is after 2017, the nominal gross domestic + product per capita plus 1.0 percentage point. + ``(7) Savings requirement.-- + ``(A) In general.--If, with respect to a + determination year, the Chief Actuary of the Centers for + Medicare & Medicaid Services makes a determination under + paragraph (6)(A) that the growth rate described in + clause (i) of such paragraph exceeds the growth rate + described in clause (ii) of such paragraph, the Chief + Actuary shall establish an applicable savings target for + the implementation year. + ``(B) Applicable savings target.--For purposes of + this section, the applicable savings target for an + implementation year shall be an amount equal to the + product of-- + ``(i) the total amount of projected Medicare + program spending for the proposal year; and + ``(ii) the applicable percent for the + implementation year. + ``(C) Applicable percent.--For purposes of + subparagraph (B), the applicable percent for an + implementation year is the lesser of-- + ``(i) in the case of-- + ``(I) implementation year 2015, 0.5 + percent; + ``(II) implementation year 2016, 1.0 + percent; + ``(III) implementation year 2017, + 1.25 percent; and + ``(IV) implementation year 2018 or + any subsequent implementation year, 1.5 + percent; and + ``(ii) the projected excess for the + implementation year (expressed as a percent) + determined under subparagraph (A). + ``(8) Per capita rate of growth in national health + expenditures. <<NOTE: Effective date.>> --In each determination + year (beginning in 2018), the Chief Actuary of the Centers for + Medicare & Medicaid Services shall project the per capita rate + of growth in national health expenditures for the implementation + year. Such rate of growth for an implementation year shall be + calculated as the projected 5-year average (ending with such + year) percentage increase in national health care expenditures. + +[[Page 124 STAT. 495]] + + ``(d) Congressional Consideration.-- + ``(1) <<NOTE: Proposal.>> Introduction.-- + ``(A) In general.--On the day on which a proposal is + submitted by the President to the House of + Representatives and the Senate under subsection (c)(4), + the legislative proposal (described in subsection + (c)(3)(B)(iv)) contained in the proposal shall be + introduced (by request) in the Senate by the majority + leader of the Senate or by Members of the Senate + designated by the majority leader of the Senate and + shall be introduced (by request) in the House by the + majority leader of the House or by Members of the House + designated by the majority leader of the House. + ``(B) Not in session.--If either House is not in + session on the day on which such legislative proposal is + submitted, the legislative proposal shall be introduced + in that House, as provided in subparagraph (A), on the + first day thereafter on which that House is in session. + ``(C) <<NOTE: Deadline.>> Any member.--If the + legislative proposal is not introduced in either House + within 5 days on which that House is in session after + the day on which the legislative proposal is submitted, + then any Member of that House may introduce the + legislative proposal. + ``(D) Referral.--The legislation introduced under + this paragraph shall be referred by the Presiding + Officers of the respective Houses to the Committee on + Finance in the Senate and to the Committee on Energy and + Commerce and the Committee on Ways and Means in the + House of Representatives. + ``(2) Committee consideration of proposal.-- + ``(A) Reporting bill.--Not later than April 1 of any + proposal year in which a proposal is submitted by the + President to Congress under this section, the Committee + on Ways and Means and the Committee on Energy and + Commerce of the House of Representatives and the + Committee on Finance of the Senate may report the bill + referred to the Committee under paragraph (1)(D) with + committee amendments related to the Medicare program. + ``(B) Calculations.--In determining whether a + committee amendment meets the requirement of + subparagraph (A), the reductions in Medicare program + spending during the 3-month period immediately preceding + the implementation year shall be counted to the extent + that such reductions are a result of the implementation + provisions in the committee amendment for a change in + the payment rate for an item or service that was + effective during such period pursuant to such amendment. + ``(C) Committee jurisdiction.--Notwithstanding rule + XV of the Standing Rules of the Senate, a committee + amendment described in subparagraph (A) may include + matter not within the jurisdiction of the Committee on + Finance if that matter is relevant to a proposal + contained in the bill submitted under subsection (c)(3). + ``(D) Discharge.--If, with respect to the House + involved, the committee has not reported the bill by the + date required by subparagraph (A), the committee shall + be discharged from further consideration of the + proposal. + +[[Page 124 STAT. 496]] + + ``(3) Limitation on changes to the board recommendations.-- + ``(A) In general.--It shall not be in order in the + Senate or the House of Representatives to consider any + bill, resolution, or amendment, pursuant to this + subsection or conference report thereon, that fails to + satisfy the requirements of subparagraphs (A)(i) and (C) + of subsection (c)(2). + ``(B) Limitation on changes to the board + recommendations in other legislation.--It shall not be + in order in the Senate or the House of Representatives + to consider any bill, resolution, amendment, or + conference report (other than pursuant to this section) + that would repeal or otherwise change the + recommendations of the Board if that change would fail + to satisfy the requirements of subparagraphs (A)(i) and + (C) of subsection (c)(2). + ``(C) Limitation on changes to this subsection.--It + shall not be in order in the Senate or the House of + Representatives to consider any bill, resolution, + amendment, or conference report that would repeal or + otherwise change this subsection. + ``(D) Waiver.--This paragraph may be waived or + suspended in the Senate only by the affirmative vote of + three-fifths of the Members, duly chosen and sworn. + ``(E) Appeals.--An affirmative vote of three-fifths + of the Members of the Senate, duly chosen and sworn, + shall be required in the Senate to sustain an appeal of + the ruling of the Chair on a point of order raised under + this paragraph. + ``(4) Expedited procedure.-- + ``(A) Consideration.--A motion to proceed to the + consideration of the bill in the Senate is not + debatable. + ``(B) Amendment.-- + ``(i) Time limitation.--Debate in the Senate + on any amendment to a bill under this section + shall be limited to 1 hour, to be equally divided + between, and controlled by, the mover and the + manager of the bill, and debate on any amendment + to an amendment, debatable motion, or appeal shall + be limited to 30 minutes, to be equally divided + between, and controlled by, the mover and the + manager of the bill, except that in the event the + manager of the bill is in favor of any such + amendment, motion, or appeal, the time in + opposition thereto shall be controlled by the + minority leader or such leader's designee. + ``(ii) Germane.--No amendment that is not + germane to the provisions of such bill shall be + received. + ``(iii) Additional time.--The leaders, or + either of them, may, from the time under their + control on the passage of the bill, allot + additional time to any Senator during the + consideration of any amendment, debatable motion, + or appeal. + ``(iv) Amendment not in order.--It shall not + be in order to consider an amendment that would + cause the bill to result in a net reduction in + total Medicare program spending in the + implementation year that is less than the + applicable savings target established + +[[Page 124 STAT. 497]] + + under subsection (c)(7)(B) for such implementation + year. + ``(v) Waiver and appeals.--This paragraph may + be waived or suspended in the Senate only by the + affirmative vote of three-fifths of the Members, + duly chosen and sworn. An affirmative vote of + three-fifths of the Members of the Senate, duly + chosen and sworn, shall be required in the Senate + to sustain an appeal of the ruling of the Chair on + a point of order raised under this section. + ``(C) Consideration by the other house.-- + ``(i) In general.--The expedited procedures + provided in this subsection for the consideration + of a bill introduced pursuant to paragraph (1) + shall not apply to such a bill that is received by + one House from the other House if such a bill was + not introduced in the receiving House. + ``(ii) Before + passage. <<NOTE: Applicability.>> --If a bill that + is introduced pursuant to paragraph (1) is + received by one House from the other House, after + introduction but before disposition of such a bill + in the receiving House, then the following shall + apply: + ``(I) The receiving House shall + consider the bill introduced in that + House through all stages of + consideration up to, but not including, + passage. + ``(II) The question on passage shall + be put on the bill of the other House as + amended by the language of the receiving + House. + ``(iii) After passage.--If a bill introduced + pursuant to paragraph (1) is received by one House + from the other House, after such a bill is passed + by the receiving House, then the vote on passage + of the bill that originates in the receiving House + shall be considered to be the vote on passage of + the bill received from the other House as amended + by the language of the receiving House. + ``(iv) Disposition.--Upon disposition of a + bill introduced pursuant to paragraph (1) that is + received by one House from the other House, it + shall no longer be in order to consider the bill + that originates in the receiving House. + ``(v) Limitation. <<NOTE: Applicability.>> -- + Clauses (ii), (iii), and (iv) shall apply only to + a bill received by one House from the other House + if the bill-- + ``(I) is related only to the program + under this title; and + ``(II) satisfies the requirements of + subparagraphs (A)(i) and (C) of + subsection (c)(2). + ``(D) Senate limits on debate.-- + ``(i) In general.--In the Senate, + consideration of the bill and on all debatable + motions and appeals in connection therewith shall + not exceed a total of 30 hours, which shall be + divided equally between the majority and minority + leaders or their designees. + ``(ii) Motion to further limit debate.--A + motion to further limit debate on the bill is in + order and is not debatable. + +[[Page 124 STAT. 498]] + + ``(iii) Motion or appeal.--Any debatable + motion or appeal is debatable for not to exceed 1 + hour, to be divided equally between those favoring + and those opposing the motion or appeal. + ``(iv) Final disposition.--After 30 hours of + consideration, the Senate shall proceed, without + any further debate on any question, to vote on the + final disposition thereof to the exclusion of all + amendments not then pending before the Senate at + that time and to the exclusion of all motions, + except a motion to table, or to reconsider and one + quorum call on demand to establish the presence of + a quorum (and motions required to establish a + quorum) immediately before the final vote begins. + ``(E) Consideration in conference.-- + ``(i) In general.--Consideration in the Senate + and the House of Representatives on the conference + report or any messages between Houses shall be + limited to 10 hours, equally divided and + controlled by the majority and minority leaders of + the Senate or their designees and the Speaker of + the House of Representatives and the minority + leader of the House of Representatives or their + designees. + ``(ii) Time limitation.--Debate in the Senate + on any amendment under this subparagraph shall be + limited to 1 hour, to be equally divided between, + and controlled by, the mover and the manager of + the bill, and debate on any amendment to an + amendment, debatable motion, or appeal shall be + limited to 30 minutes, to be equally divided + between, and controlled by, the mover and the + manager of the bill, except that in the event the + manager of the bill is in favor of any such + amendment, motion, or appeal, the time in + opposition thereto shall be controlled by the + minority leader or such leader's designee. + ``(iii) Final disposition.--After 10 hours of + consideration, the Senate shall proceed, without + any further debate on any question, to vote on the + final disposition thereof to the exclusion of all + motions not then pending before the Senate at that + time or necessary to resolve the differences + between the Houses and to the exclusion of all + other motions, except a motion to table, or to + reconsider and one quorum call on demand to + establish the presence of a quorum (and motions + required to establish a quorum) immediately before + the final vote begins. + ``(iv) Limitation. <<NOTE: Applicability.>> -- + Clauses (i) through (iii) shall only apply to a + conference report, message or the amendments + thereto if the conference report, message, or an + amendment thereto-- + ``(I) is related only to the program + under this title; and + ``(II) satisfies the requirements of + subparagraphs (A)(i) and (C) of + subsection (c)(2). + ``(F) Veto.--If the President vetoes the bill debate + on a veto message in the Senate under this subsection + shall + +[[Page 124 STAT. 499]] + + be 1 hour equally divided between the majority and + minority leaders or their designees. + ``(5) Rules of the senate and house of representatives.-- + This subsection and subsection (f)(2) are enacted by Congress-- + ``(A) as an exercise of the rulemaking power of the + Senate and the House of Representatives, respectively, + and is deemed to be part of the rules of each House, + respectively, but applicable only with respect to the + procedure to be followed in that House in the case of + bill under this section, and it supersedes other rules + only to the extent that it is inconsistent with such + rules; and + ``(B) with full recognition of the constitutional + right of either House to change the rules (so far as + they relate to the procedure of that House) at any time, + in the same manner, and to the same extent as in the + case of any other rule of that House. + + ``(e) Implementation of Proposal.-- + ``(1) In general.--Notwithstanding any other provision of + law, the Secretary shall, except as provided in paragraph (3), + implement the recommendations contained in a proposal submitted + by the President to Congress pursuant to this section on August + 15 of the year in which the proposal is so submitted. + ``(2) Application.-- + ``(A) In general.--A recommendation described in + paragraph (1) shall apply as follows: + ``(i) In the case of a recommendation that is + a change in the payment rate for an item or + service under Medicare in which payment rates + change on a fiscal year basis (or a cost reporting + period basis that relates to a fiscal year), on a + calendar year basis (or a cost reporting period + basis that relates to a calendar year), or on a + rate year basis (or a cost reporting period basis + that relates to a rate year), such recommendation + shall apply to items and services furnished on the + first day of the first fiscal year, calendar year, + or rate year (as the case may be) that begins + after such August 15. + ``(ii) In the case of a recommendation + relating to payments to plans under parts C and D, + such recommendation shall apply to plan years + beginning on the first day of the first calendar + year that begins after such August 15. + ``(iii) In the case of any other + recommendation, such recommendation shall be + addressed in the regular regulatory process + timeframe and shall apply as soon as practicable. + ``(B) Interim final rulemaking.--The Secretary may + use interim final rulemaking to implement any + recommendation described in paragraph (1). + ``(3) Exception.--The Secretary shall not be required to + implement the recommendations contained in a proposal submitted + in a proposal year by the President to Congress pursuant to this + section if-- + ``(A) prior to August 15 of the proposal year, + Federal legislation is enacted that includes the + following provision: `This Act supercedes the + recommendations of the Board + +[[Page 124 STAT. 500]] + + contained in the proposal submitted, in the year which + includes the date of enactment of this Act, to Congress + under section 1899A of the Social Security Act.'; and + ``(B) <<NOTE: Deadline.>> in the case of + implementation year 2020 and subsequent implementation + years, a joint resolution described in subsection (f)(1) + is enacted not later than August 15, 2017. + ``(4) No affect on authority to implement certain + provisions.--Nothing in paragraph (3) shall be construed to + affect the authority of the Secretary to implement any + recommendation contained in a proposal or advisory report under + this section to the extent that the Secretary otherwise has the + authority to implement such recommendation administratively. + ``(5) Limitation on review.--There shall be no + administrative or judicial review under section 1869, section + 1878, or otherwise of the implementation by the Secretary under + this subsection of the recommendations contained in a proposal. + + ``(f) Joint Resolution Required To Discontinue the Board.-- + ``(1) In general. <<NOTE: Definition.>> --For purposes of + subsection (e)(3)(B), a joint resolution described in this + paragraph means only a joint resolution-- + ``(A) that is introduced in 2017 by not later than + February 1 of such year; + ``(B) which does not have a preamble; + ``(C) the title of which is as follows: `Joint + resolution approving the discontinuation of the process + for consideration and automatic implementation of the + annual proposal of the Independent Medicare Advisory + Board under section 1899A of the Social Security Act'; + and + ``(D) the matter after the resolving clause of which + is as follows: `That Congress approves the + discontinuation of the process for consideration and + automatic implementation of the annual proposal of the + Independent Medicare Advisory Board under section 1899A + of the Social Security Act.'. + ``(2) Procedure.-- + ``(A) Referral.--A joint resolution described in + paragraph (1) shall be referred to the Committee on Ways + and Means and the Committee on Energy and Commerce of + the House of Representatives and the Committee on + Finance of the Senate. + ``(B) Discharge. <<NOTE: Deadline. Petition.>> --In + the Senate, if the committee to which is referred a + joint resolution described in paragraph (1) has not + reported such joint resolution (or an identical joint + resolution) at the end of 20 days after the joint + resolution described in paragraph (1) is introduced, + such committee may be discharged from further + consideration of such joint resolution upon a petition + supported in writing by 30 Members of the Senate, and + such joint resolution shall be placed on the calendar. + ``(C) Consideration.-- + ``(i) In general.--In the Senate, when the + committee to which a joint resolution is referred + has reported, or when a committee is discharged + (under subparagraph (C)) from further + consideration of a joint + +[[Page 124 STAT. 501]] + + resolution described in paragraph (1), it is at + any time thereafter in order (even though a + previous motion to the same effect has been + disagreed to) for a motion to proceed to the + consideration of the joint resolution to be made, + and all points of order against the joint + resolution (and against consideration of the joint + resolution) are waived, except for points of order + under the Congressional Budget act of 1974 or + under budget resolutions pursuant to that Act. The + motion is not debatable. A motion to reconsider + the vote by which the motion is agreed to or + disagreed to shall not be in order. If a motion to + proceed to the consideration of the joint + resolution is agreed to, the joint resolution + shall remain the unfinished business of the Senate + until disposed of. + ``(ii) Debate limitation.--In the Senate, + consideration of the joint resolution, and on all + debatable motions and appeals in connection + therewith, shall be limited to not more than 10 + hours, which shall be divided equally between the + majority leader and the minority leader, or their + designees. A motion further to limit debate is in + order and not debatable. An amendment to, or a + motion to postpone, or a motion to proceed to the + consideration of other business, or a motion to + recommit the joint resolution is not in order. + ``(iii) Passage.--In the Senate, immediately + following the conclusion of the debate on a joint + resolution described in paragraph (1), and a + single quorum call at the conclusion of the debate + if requested in accordance with the rules of the + Senate, the vote on passage of the joint + resolution shall occur. + ``(iv) Appeals.--Appeals from the decisions of + the Chair relating to the application of the rules + of the Senate to the procedure relating to a joint + resolution described in paragraph (1) shall be + decided without debate. + ``(D) Other house acts + first. <<NOTE: Applicability.>> --If, before the passage + by 1 House of a joint resolution of that House described + in paragraph (1), that House receives from the other + House a joint resolution described in paragraph (1), + then the following procedures shall apply: + ``(i) The joint resolution of the other House + shall not be referred to a committee. + ``(ii) With respect to a joint resolution + described in paragraph (1) of the House receiving + the joint resolution-- + ``(I) the procedure in that House + shall be the same as if no joint + resolution had been received from the + other House; but + ``(II) the vote on final passage + shall be on the joint resolution of the + other House. + ``(E) Excluded days.--For purposes of determining + the period specified in subparagraph (B), there shall be + excluded any days either House of Congress is adjourned + for more than 3 days during a session of Congress. + +[[Page 124 STAT. 502]] + + ``(F) Majority required for adoption.--A joint + resolution considered under this subsection shall + require an affirmative vote of three-fifths of the + Members, duly chosen and sworn, for adoption. + ``(3) <<NOTE: Deadlines.>> Termination.--If a joint + resolution described in paragraph (1) is enacted not later than + August 15, 2017-- + ``(A) the Chief Actuary of the Medicare & Medicaid + Services shall not-- + ``(i) make any determinations under subsection + (c)(6) after May 1, 2017; or + ``(ii) provide any opinion pursuant to + subsection (c)(3)(B)(iii) after January 16, 2018; + ``(B) the Board shall not submit any proposals or + advisory reports to Congress under this section after + January 16, 2018; and + ``(C) the Board and the consumer advisory council + under subsection (k) shall terminate on August 16, 2018. + + ``(g) Board Membership; Terms of Office; Chairperson; Removal.-- + ``(1) Membership.-- + ``(A) <<NOTE: President. Appointments.>> In + general.--The Board shall be composed of-- + ``(i) 15 members appointed by the President, + by and with the advice and consent of the Senate; + and + ``(ii) the Secretary, the Administrator of the + Center for Medicare & Medicaid Services, and the + Administrator of the Health Resources and Services + Administration, all of whom shall serve ex officio + as nonvoting members of the Board. + ``(B) Qualifications.-- + ``(i) In general.--The appointed membership of + the Board shall include individuals with national + recognition for their expertise in health finance + and economics, actuarial science, health facility + management, health plans and integrated delivery + systems, reimbursement of health facilities, + allopathic and osteopathic physicians, and other + providers of health services, and other related + fields, who provide a mix of different + professionals, broad geographic representation, + and a balance between urban and rural + representatives. + ``(ii) Inclusion.--The appointed membership of + the Board shall include (but not be limited to) + physicians and other health professionals, experts + in the area of pharmaco-economics or prescription + drug benefit programs, employers, third-party + payers, individuals skilled in the conduct and + interpretation of biomedical, health services, and + health economics research and expertise in + outcomes and effectiveness research and technology + assessment. Such membership shall also include + representatives of consumers and the elderly. + ``(iii) Majority nonproviders.--Individuals + who are directly involved in the provision or + management of the delivery of items and services + covered under this title shall not constitute a + majority of the appointed membership of the Board. + ``(C) Ethical disclosure. <<NOTE: President. Public + information.>> --The President shall establish a system + for public disclosure by appointed members + +[[Page 124 STAT. 503]] + + of the Board of financial and other potential conflicts + of interest relating to such members. Appointed members + of the Board shall be treated as officers in the + executive branch for purposes of applying title I of the + Ethics in Government Act of 1978 (Public Law 95-521). + ``(D) Conflicts of interest.--No individual may + serve as an appointed member if that individual engages + in any other business, vocation, or employment. + ``(E) Consultation with + congress. <<NOTE: President.>> --In selecting + individuals for nominations for appointments to the + Board, the President shall consult with-- + ``(i) the majority leader of the Senate + concerning the appointment of 3 members; + ``(ii) the Speaker of the House of + Representatives concerning the appointment of 3 + members; + ``(iii) the minority leader of the Senate + concerning the appointment of 3 members; and + ``(iv) the minority leader of the House of + Representatives concerning the appointment of 3 + members. + ``(2) Term of office.--Each appointed member shall hold + office for a term of 6 years except that-- + ``(A) a member may not serve more than 2 full + consecutive terms (but may be reappointed to 2 full + consecutive terms after being appointed to fill a + vacancy on the Board); + ``(B) a member appointed to fill a vacancy occurring + prior to the expiration of the term for which that + member's predecessor was appointed shall be appointed + for the remainder of such term; + ``(C) a member may continue to serve after the + expiration of the member's term until a successor has + taken office; and + ``(D) of the members first appointed under this + section, 5 shall be appointed for a term of 1 year, 5 + shall be appointed for a term of 3 years, and 5 shall be + appointed for a term of 6 years, the term of each to be + designated by the President at the time of nomination. + ``(3) Chairperson.-- + ``(A) In + general. <<NOTE: Appointment. President.>> --The + Chairperson shall be appointed by the President, by and + with the advice and consent of the Senate, from among + the members of the Board. + ``(B) Duties.--The Chairperson shall be the + principal executive officer of the Board, and shall + exercise all of the executive and administrative + functions of the Board, including functions of the Board + with respect to-- + ``(i) the appointment and supervision of + personnel employed by the Board; + ``(ii) the distribution of business among + personnel appointed and supervised by the + Chairperson and among administrative units of the + Board; and + ``(iii) the use and expenditure of funds. + ``(C) Governance.--In carrying out any of the + functions under subparagraph (B), the Chairperson shall + be governed by the general policies established by the + Board and by the decisions, findings, and determinations + the Board shall by law be authorized to make. + +[[Page 124 STAT. 504]] + + ``(D) Requests for appropriations.--Requests or + estimates for regular, supplemental, or deficiency + appropriations on behalf of the Board may not be + submitted by the Chairperson without the prior approval + of a majority vote of the Board. + ``(4) Removal.--Any appointed member may be removed by the + President for neglect of duty or malfeasance in office, but for + no other cause. + + ``(h) Vacancies; Quorum; Seal; Vice Chairperson; Voting on +Reports.-- + ``(1) Vacancies.--No vacancy on the Board shall impair the + right of the remaining members to exercise all the powers of the + Board. + ``(2) Quorum.--A majority of the appointed members of the + Board shall constitute a quorum for the transaction of business, + but a lesser number of members may hold hearings. + ``(3) Seal.--The Board shall have an official seal, of which + judicial notice shall be taken. + ``(4) Vice chairperson. <<NOTE: Deadline.>> --The Board + shall annually elect a Vice Chairperson to act in the absence or + disability of the Chairperson or in case of a vacancy in the + office of the Chairperson. + ``(5) Voting on proposals.--Any proposal of the Board must + be approved by the majority of appointed members present. + + ``(i) Powers of the Board.-- + ``(1) Hearings.--The Board may hold such hearings, sit and + act at such times and places, take such testimony, and receive + such evidence as the Board considers advisable to carry out this + section. + ``(2) Authority to inform research priorities for data + collection.--The Board may advise the Secretary on priorities + for health services research, particularly as such priorities + pertain to necessary changes and issues regarding payment + reforms under Medicare. + ``(3) Obtaining official data.--The Board may secure + directly from any department or agency of the United States + information necessary to enable it to carry out this section. + Upon request of the Chairperson, the head of that department or + agency shall furnish that information to the Board on an agreed + upon schedule. + ``(4) Postal services.--The Board may use the United States + mails in the same manner and under the same conditions as other + departments and agencies of the Federal Government. + ``(5) Gifts.--The Board may accept, use, and dispose of + gifts or donations of services or property. + ``(6) Offices.--The Board shall maintain a principal office + and such field offices as it determines necessary, and may meet + and exercise any of its powers at any other place. + + ``(j) Personnel Matters.-- + ``(1) Compensation of members and chairperson.--Each + appointed member, other than the Chairperson, shall be + compensated at a rate equal to the annual rate of basic pay + prescribed for level III of the Executive Schedule under section + 5315 of title 5, United States Code. The Chairperson shall be + compensated at a rate equal to the daily equivalent of the + annual rate of basic pay prescribed for level II of the + +[[Page 124 STAT. 505]] + + Executive Schedule under section 5315 of title 5, United States + Code. + ``(2) Travel expenses.--The appointed members shall be + allowed travel expenses, including per diem in lieu of + subsistence, at rates authorized for employees of agencies under + subchapter I of chapter 57 of title 5, United States Code, while + away from their homes or regular places of business in the + performance of services for the Board. + ``(3) Staff.-- + ``(A) In general.--The Chairperson may, without + regard to the civil service laws and regulations, + appoint and terminate an executive director and such + other additional personnel as may be necessary to enable + the Board to perform its duties. The employment of an + executive director shall be subject to confirmation by + the Board. + ``(B) Compensation.--The Chairperson may fix the + compensation of the executive director and other + personnel without regard to chapter 51 and subchapter + III of chapter 53 of title 5, United States Code, + relating to classification of positions and General + Schedule pay rates, except that the rate of pay for the + executive director and other personnel may not exceed + the rate payable for level V of the Executive Schedule + under section 5316 of such title. + ``(4) Detail of government employees.--Any Federal + Government employee may be detailed to the Board without + reimbursement, and such detail shall be without interruption or + loss of civil service status or privilege. + ``(5) Procurement of temporary and intermittent services.-- + The Chairperson may procure temporary and intermittent services + under section 3109(b) of title 5, United States Code, at rates + for individuals which do not exceed the daily equivalent of the + annual rate of basic pay prescribed for level V of the Executive + Schedule under section 5316 of such title. + + ``(k) Consumer Advisory Council.-- + ``(1) In general. <<NOTE: Establishment.>> --There is + established a consumer advisory council to advise the Board on + the impact of payment policies under this title on consumers. + ``(2) Membership.-- + ``(A) Number and appointment.--The consumer advisory + council shall be composed of 10 consumer representatives + appointed by the Comptroller General of the United + States, 1 from among each of the 10 regions established + by the Secretary as of the date of enactment of this + section. + ``(B) Qualifications.--The membership of the council + shall represent the interests of consumers and + particular communities. + ``(3) Duties. <<NOTE: Deadlines.>> --The consumer advisory + council shall, subject to the call of the Board, meet not less + frequently than 2 times each year in the District of Columbia. + ``(4) Open meetings.--Meetings of the consumer advisory + council shall be open to the public. + ``(5) Election of officers.--Members of the consumer + advisory council shall elect their own officers. + ``(6) Application of faca.--The Federal Advisory Committee + Act (5 U.S.C. App.) shall apply to the consumer advisory council + except that section 14 of such Act shall not apply. + +[[Page 124 STAT. 506]] + + ``(l) Definitions.--In this section: + ``(1) Board; chairperson; member.--The terms `Board', + `Chairperson', and `Member' mean the Independent Medicare + Advisory Board established under subsection (a) and the + Chairperson and any Member thereof, respectively. + ``(2) Medicare.--The term `Medicare' means the program + established under this title, including parts A, B, C, and D. + ``(3) Medicare beneficiary.--The term `Medicare beneficiary' + means an individual who is entitled to, or enrolled for, + benefits under part A or enrolled for benefits under part B. + ``(4) Medicare program spending.--The term `Medicare program + spending' means program spending under parts A, B, and D net of + premiums. + + ``(m) Funding.-- + ``(1) In general.--There are appropriated to the Board to + carry out its duties and functions-- + ``(A) for fiscal year 2012, $15,000,000; and + ``(B) for each subsequent fiscal year, the amount + appropriated under this paragraph for the previous + fiscal year increased by the annual percentage increase + in the Consumer Price Index for All Urban Consumers (all + items; United States city average) as of June of the + previous fiscal year. + ``(2) From trust funds.--Sixty percent of amounts + appropriated under paragraph (1) shall be derived by transfer + from the Federal Hospital Insurance Trust Fund under section + 1817 and 40 percent of amounts appropriated under such paragraph + shall be derived by transfer from the Federal Supplementary + Medical Insurance Trust Fund under section 1841.''. + (2) Lobbying cooling-off period for members of the + independent medicare advisory board.--Section 207(c) of title + 18, United States Code, is amended by inserting at the end the + following: + ``(3) Members of the independent medicare advisory board.-- + ``(A) In general. <<NOTE: Applicability.>> -- + Paragraph (1) shall apply to a member of the Independent + Medicare Advisory Board under section 1899A. + ``(B) Agencies and congress.--For purposes of + paragraph (1), the agency in which the individual + described in subparagraph (A) served shall be considered + to be the Independent Medicare Advisory Board, the + Department of Health and Human Services, and the + relevant committees of jurisdiction of Congress, + including the Committee on Ways and Means and the + Committee on Energy and Commerce of the House of + Representatives and the Committee on Finance of the + Senate.''. + + (b) <<NOTE: 42 USC 1395kkk-1.>> GAO Study and Report on +Determination and Implementation of Payment and Coverage Policies Under +the Medicare Program.-- + (1) Initial study and report.-- + (A) Study.--The Comptroller General of the United + States (in this section referred to as the ``Comptroller + General'') shall conduct a study on changes to payment + policies, methodologies, and rates and coverage policies + and methodologies under the Medicare program under title + XVIII + +[[Page 124 STAT. 507]] + + of the Social Security Act as a result of the + recommendations contained in the proposals made by the + Independent Medicare Advisory Board under section 1899A + of such Act (as added by subsection (a)), including an + analysis of the effect of such recommendations on-- + (i) Medicare beneficiary access to providers + and items and services; + (ii) the affordability of Medicare premiums + and cost-sharing (including deductibles, + coinsurance, and copayments); + (iii) the potential impact of changes on other + government or private-sector purchasers and payers + of care; and + (iv) quality of patient care, including + patient experience, outcomes, and other measures + of care. + (B) Report.--Not later than July 1, 2015, the + Comptroller General shall submit to Congress a report + containing the results of the study conducted under + subparagraph (A), together with recommendations for such + legislation and administrative action as the Comptroller + General determines appropriate. + (2) Subsequent studies and reports.--The Comptroller General + shall periodically conduct such additional studies and submit + reports to Congress on changes to Medicare payments policies, + methodologies, and rates and coverage policies and methodologies + as the Comptroller General determines appropriate, in + consultation with the Committee on Ways and Means and the + Committee on Energy and Commerce of the House of Representatives + and the Committee on Finance of the Senate. + + (c) Conforming Amendments.--Section 1805(b) of the Social Security +Act (42 U.S.C. 1395b-6(b)) is amended-- + (1) by redesignating paragraphs (4) through (8) as + paragraphs (5) through (9), respectively; and + (2) by inserting after paragraph (3) the following: + ``(4) Review and comment on the independent medicare + advisory board or secretarial proposal. <<NOTE: Deadline.>> --If + the Independent Medicare Advisory Board (as established under + subsection (a) of section 1899A) or the Secretary submits a + proposal to the Commission under such section in a year, the + Commission shall review the proposal and, not later than March 1 + of that year, submit to the Committee on Ways and Means and the + Committee on Energy and Commerce of the House of Representatives + and the Committee on Finance of the Senate written comments on + such proposal. Such comments may include such recommendations as + the Commission deems appropriate.''. + + Subtitle F--Health Care Quality Improvements + +SEC. 3501. HEALTH CARE DELIVERY SYSTEM RESEARCH; QUALITY IMPROVEMENT + TECHNICAL ASSISTANCE. + + Part D of title IX of the Public Health Service Act, as amended by +section 3013, is further amended by adding at the end the following: + +[[Page 124 STAT. 508]] + + ``Subpart II--Health Care Quality Improvement Programs + +``SEC. 933. <<NOTE: 42 USC 299b-33.>> HEALTH CARE DELIVERY SYSTEM + RESEARCH. + + ``(a) Purpose.--The purposes of this section are to-- + ``(1) enable the Director to identify, develop, evaluate, + disseminate, and provide training in innovative methodologies + and strategies for quality improvement practices in the delivery + of health care services that represent best practices (referred + to as `best practices') in health care quality, safety, and + value; and + ``(2) ensure that the Director is accountable for + implementing a model to pursue such research in a collaborative + manner with other related Federal agencies. + + ``(b) General Functions of the Center.--The Center for Quality +Improvement and Patient Safety of the Agency for Healthcare Research and +Quality (referred to in this section as the `Center'), or any other +relevant agency or department designated by the Director, shall-- + ``(1) carry out its functions using research from a variety + of disciplines, which may include epidemiology, health services, + sociology, psychology, human factors engineering, biostatistics, + health economics, clinical research, and health informatics; + ``(2) conduct or support activities consistent with the + purposes described in subsection (a), and for-- + ``(A) best practices for quality improvement + practices in the delivery of health care services; and + ``(B) that include changes in processes of care and + the redesign of systems used by providers that will + reliably result in intended health outcomes, improve + patient safety, and reduce medical errors (such as skill + development for health care providers in team-based + health care delivery and rapid cycle process + improvement) and facilitate adoption of improved + workflow; + ``(3) identify health care providers, including health care + systems, single institutions, and individual providers, that-- + ``(A) deliver consistently high-quality, efficient + health care services (as determined by the Secretary); + and + ``(B) employ best practices that are adaptable and + scalable to diverse health care settings or effective in + improving care across diverse settings; + ``(4) assess research, evidence, and knowledge about what + strategies and methodologies are most effective in improving + health care delivery; + ``(5) find ways to translate such information rapidly and + effectively into practice, and document the sustainability of + those improvements; + ``(6) create strategies for quality improvement through the + development of tools, methodologies, and interventions that can + successfully reduce variations in the delivery of health care; + ``(7) identify, measure, and improve organizational, human, + or other causative factors, including those related to the + culture and system design of a health care organization, that + contribute to the success and sustainability of specific quality + improvement and patient safety strategies; + +[[Page 124 STAT. 509]] + + ``(8) provide for the development of best practices in the + delivery of health care services that-- + ``(A) have a high likelihood of success, based on + structured review of empirical evidence; + ``(B) are specified with sufficient detail of the + individual processes, steps, training, skills, and + knowledge required for implementation and incorporation + into workflow of health care practitioners in a variety + of settings; + ``(C) are designed to be readily adapted by health + care providers in a variety of settings; and + ``(D) where applicable, assist health care providers + in working with other health care providers across the + continuum of care and in engaging patients and their + families in improving the care and patient health + outcomes; + ``(9) provide for the funding of the activities of + organizations with recognized expertise and excellence in + improving the delivery of health care services, including + children's health care, by involving multiple disciplines, + managers of health care entities, broad development and + training, patients, caregivers and families, and frontline + health care workers, including activities for the examination of + strategies to share best quality improvement practices and to + promote excellence in the delivery of health care services; and + ``(10) build capacity at the State and community level to + lead quality and safety efforts through education, training, and + mentoring programs to carry out the activities under paragraphs + (1) through (9). + + ``(c) Research Functions of Center.-- + ``(1) In general.--The Center shall support, such as through + a contract or other mechanism, research on health care delivery + system improvement and the development of tools to facilitate + adoption of best practices that improve the quality, safety, and + efficiency of health care delivery services. Such support may + include establishing a Quality Improvement Network Research + Program for the purpose of testing, scaling, and disseminating + of interventions to improve quality and efficiency in health + care. Recipients of funding under the Program may include + national, State, multi-State, or multi-site quality improvement + networks. + ``(2) Research requirements.--The research conducted + pursuant to paragraph (1) shall-- + ``(A) address the priorities identified by the + Secretary in the national strategic plan established + under section 399HH; + ``(B) identify areas in which evidence is + insufficient to identify strategies and methodologies, + taking into consideration areas of insufficient evidence + identified by the entity with a contract under section + 1890(a) of the Social Security Act in the report + required under section 399JJ; + ``(C) address concerns identified by health care + institutions and providers and communicated through the + Center pursuant to subsection (d); + ``(D) reduce preventable morbidity, mortality, and + associated costs of morbidity and mortality by building + capacity for patient safety research; + ``(E) support the discovery of processes for the + reliable, safe, efficient, and responsive delivery of + health care, taking + +[[Page 124 STAT. 510]] + + into account discoveries from clinical research and + comparative effectiveness research; + ``(F) allow communication of research findings and + translate evidence into practice recommendations that + are adaptable to a variety of settings, and which, as + soon as practicable after the establishment of the + Center, shall include-- + ``(i) the implementation of a national + application of Intensive Care Unit improvement + projects relating to the adult (including + geriatric), pediatric, and neonatal patient + populations; + ``(ii) practical methods for addressing health + care associated infections, including Methicillin- + Resistant Staphylococcus Aureus and Vancomycin- + Resistant Entercoccus infections and other + emerging infections; and + ``(iii) practical methods for reducing + preventable hospital admissions and readmissions; + ``(G) expand demonstration projects for improving + the quality of children's health care and the use of + health information technology, such as through Pediatric + Quality Improvement Collaboratives and Learning + Networks, consistent with provisions of section 1139A of + the Social Security Act for assessing and improving + quality, where applicable; + ``(H) identify and mitigate hazards by-- + ``(i) analyzing events reported to patient + safety reporting systems and patient safety + organizations; and + ``(ii) using the results of such analyses to + develop scientific methods of response to such + events; + ``(I) include the conduct of systematic reviews of + existing practices that improve the quality, safety, and + efficiency of health care delivery, as well as new + research on improving such practices; and + ``(J) include the examination of how to measure and + evaluate the progress of quality and patient safety + activities. + + ``(d) Dissemination of Research Findings.-- + ``(1) Public availability.--The Director shall make the + research findings of the Center available to the public through + multiple media and appropriate formats to reflect the varying + needs of health care providers and consumers and diverse levels + of health literacy. + ``(2) Linkage to health information technology.--The + Secretary shall ensure that research findings and results + generated by the Center are shared with the Office of the + National Coordinator of Health Information Technology and used + to inform the activities of the health information technology + extension program under section 3012, as well as any relevant + standards, certification criteria, or implementation + specifications. + + ``(e) Prioritization. <<NOTE: List.>> --The Director shall identify +and regularly update a list of processes or systems on which to focus +research and dissemination activities of the Center, taking into +account-- + ``(1) the cost to Federal health programs; + ``(2) consumer assessment of health care experience; + +[[Page 124 STAT. 511]] + + ``(3) provider assessment of such processes or systems and + opportunities to minimize distress and injury to the health care + workforce; + ``(4) the potential impact of such processes or systems on + health status and function of patients, including vulnerable + populations including children; + ``(5) the areas of insufficient evidence identified under + subsection (c)(2)(B); and + ``(6) the evolution of meaningful use of health information + technology, as defined in section 3000. + + ``(f) Coordination.--The Center shall coordinate its activities with +activities conducted by the Center for Medicare and Medicaid Innovation +established under section 1115A of the Social Security Act. + ``(g) Funding.--There is authorized to be appropriated to carry out +this section $20,000,000 for fiscal years 2010 through 2014. + +``SEC. 934. <<NOTE: Grants. Contracts. 42 USC 299b-34.>> QUALITY + IMPROVEMENT TECHNICAL ASSISTANCE AND IMPLEMENTATION. + + ``(a) In General.--The Director, through the Center for Quality +Improvement and Patient Safety of the Agency for Healthcare Research and +Quality (referred to in this section as the `Center'), shall award-- + ``(1) technical assistance grants or contracts to eligible + entities to provide technical support to institutions that + deliver health care and health care providers (including rural + and urban providers of services and suppliers with limited + infrastructure and financial resources to implement and support + quality improvement activities, providers of services and + suppliers with poor performance scores, and providers of + services and suppliers for which there are disparities in care + among subgroups of patients) so that such institutions and + providers understand, adapt, and implement the models and + practices identified in the research conducted by the Center, + including the Quality Improvement Networks Research Program; and + ``(2) implementation grants or contracts to eligible + entities to implement the models and practices described under + paragraph (1). + + ``(b) Eligible Entities.-- + ``(1) Technical assistance award.--To be eligible to receive + a technical assistance grant or contract under subsection + (a)(1), an entity-- + ``(A) may be a health care provider, health care + provider association, professional society, health care + worker organization, Indian health organization, quality + improvement organization, patient safety organization, + local quality improvement collaborative, the Joint + Commission, academic health center, university, + physician-based research network, primary care extension + program established under section 399W, a Federal Indian + Health Service program or a health program operated by + an Indian tribe (as defined in section 4 of the Indian + Health Care Improvement Act), or any other entity + identified by the Secretary; and + ``(B) shall have demonstrated expertise in providing + information and technical support and assistance to + health care providers regarding quality improvement. + +[[Page 124 STAT. 512]] + + ``(2) Implementation award.--To be eligible to receive an + implementation grant or contract under subsection (a)(2), an + entity-- + ``(A) may be a hospital or other health care + provider or consortium or providers, as determined by + the Secretary; and + ``(B) shall have demonstrated expertise in providing + information and technical support and assistance to + health care providers regarding quality improvement. + + ``(c) Application.-- + ``(1) Technical assistance award.--To receive a technical + assistance grant or contract under subsection (a)(1), an + eligible entity shall submit an application to the Secretary at + such time, in such manner, and containing-- + ``(A) a plan for a sustainable business model that + may include a system of-- + ``(i) charging fees to institutions and + providers that receive technical support from the + entity; and + ``(ii) reducing or eliminating such fees for + such institutions and providers that serve low- + income populations; and + ``(B) such other information as the Director may + require. + ``(2) Implementation award.--To receive a grant or contract + under subsection (a)(2), an eligible entity shall submit an + application to the Secretary at such time, in such manner, and + containing-- + ``(A) a plan for implementation of a model or + practice identified in the research conducted by the + Center including-- + ``(i) financial cost, staffing requirements, + and timeline for implementation; and + ``(ii) pre- and projected post-implementation + quality measure performance data in targeted + improvement areas identified by the Secretary; and + ``(B) such other information as the Director may + require. + + ``(d) Matching Funds.--The Director may not award a grant or +contract under this section to an entity unless the entity agrees that +it will make available (directly or through contributions from other +public or private entities) non-Federal contributions toward the +activities to be carried out under the grant or contract in an amount +equal to $1 for each $5 of Federal funds provided under the grant or +contract. Such non-Federal matching funds may be provided directly or +through donations from public or private entities and may be in cash or +in-kind, fairly evaluated, including plant, equipment, or services. + ``(e) Evaluation.-- + ``(1) In general.--The Director shall evaluate the + performance of each entity that receives a grant or contract + under this section. The evaluation of an entity shall include a + study of-- + ``(A) the success of such entity in achieving the + implementation, by the health care institutions and + providers assisted by such entity, of the models and + practices identified in the research conducted by the + Center under section 933; + +[[Page 124 STAT. 513]] + + ``(B) the perception of the health care institutions + and providers assisted by such entity regarding the + value of the entity; and + ``(C) where practicable, better patient health + outcomes and lower cost resulting from the assistance + provided by such entity. + ``(2) Effect of evaluation. <<NOTE: Determination.>> --Based + on the outcome of the evaluation of the entity under paragraph + (1), the Director shall determine whether to renew a grant or + contract with such entity under this section. + + ``(f) Coordination.--The entities that receive a grant or contract +under this section shall coordinate with health information technology +regional extension centers under section 3012(c) and the primary care +extension program established under section 399W regarding the +dissemination of quality improvement, system delivery reform, and best +practices information.''. + +SEC. 3502. <<NOTE: Grants. Contracts. 42 USC 256a-1.>> ESTABLISHING + COMMUNITY HEALTH TEAMS TO SUPPORT THE PATIENT-CENTERED + MEDICAL HOME. + + (a) In General.--The Secretary of Health and Human Services +(referred to in this section as the ``Secretary'') shall establish a +program to provide grants to or enter into contracts with eligible +entities to establish community-based interdisciplinary, +interprofessional teams (referred to in this section as ``health +teams'') to support primary care practices, including obstetrics and +gynecology practices, within the hospital service areas served by the +eligible entities. Grants or contracts shall be used to-- + (1) establish health teams to provide support services to + primary care providers; and + (2) provide capitated payments to primary care providers as + determined by the Secretary. + + (b) Eligible Entities.--To be eligible to receive a grant or +contract under subsection (a), an entity shall-- + (1)(A) be a State or State-designated entity; or + (B) be an Indian tribe or tribal organization, as defined in + section 4 of the Indian Health Care Improvement Act; + (2) <<NOTE: Plans. Deadline.>> submit a plan for achieving + long-term financial sustainability within 3 years; + (3) <<NOTE: Plans.>> submit a plan for incorporating + prevention initiatives and patient education and care management + resources into the delivery of health care that is integrated + with community-based prevention and treatment resources, where + available; + (4) ensure that the health team established by the entity + includes an interdisciplinary, interprofessional team of health + care providers, as determined by the Secretary; such team may + include medical specialists, nurses, pharmacists, nutritionists, + dieticians, social workers, behavioral and mental health + providers (including substance use disorder prevention and + treatment providers), doctors of chiropractic, licensed + complementary and alternative medicine practitioners, and + physicians' assistants; + (5) agree to provide services to eligible individuals with + chronic conditions, as described in section 1945 of the Social + Security Act (as added by section 2703), in accordance with the + payment methodology established under subsection (c) of such + section; and + +[[Page 124 STAT. 514]] + + (6) submit to the Secretary an application at such time, in + such manner, and containing such information as the Secretary + may require. + + (c) Requirements for Health Teams.--A health team established +pursuant to a grant or contract under subsection (a) shall-- + (1) establish contractual agreements with primary care + providers to provide support services; + (2) support patient-centered medical homes, defined as a + mode of care that includes-- + (A) personal physicians; + (B) whole person orientation; + (C) coordinated and integrated care; + (D) safe and high-quality care through evidence- + informed medicine, appropriate use of health information + technology, and continuous quality improvements; + (E) expanded access to care; and + (F) payment that recognizes added value from + additional components of patient-centered care; + (3) collaborate with local primary care providers and + existing State and community based resources to coordinate + disease prevention, chronic disease management, transitioning + between health care providers and settings and case management + for patients, including children, with priority given to those + amenable to prevention and with chronic diseases or conditions + identified by the Secretary; + (4) <<NOTE: Plans.>> in collaboration with local health care + providers, develop and implement interdisciplinary, + interprofessional care plans that integrate clinical and + community preventive and health promotion services for patients, + including children, with a priority given to those amenable to + prevention and with chronic diseases or conditions identified by + the Secretary; + (5) incorporate health care providers, patients, caregivers, + and authorized representatives in program design and oversight; + (6) provide support necessary for local primary care + providers to-- + (A) coordinate and provide access to high-quality + health care services; + (B) coordinate and provide access to preventive and + health promotion services; + (C) provide access to appropriate specialty care and + inpatient services; + (D) provide quality-driven, cost-effective, + culturally appropriate, and patient- and family-centered + health care; + (E) provide access to pharmacist-delivered + medication management services, including medication + reconciliation; + (F) provide coordination of the appropriate use of + complementary and alternative (CAM) services to those + who request such services; + (G) promote effective strategies for treatment + planning, monitoring health outcomes and resource use, + sharing information, treatment decision support, and + organizing care to avoid duplication of service and + other medical management approaches intended to improve + quality and value of health care services; + (H) provide local access to the continuum of health + care services in the most appropriate setting, including + +[[Page 124 STAT. 515]] + + access to individuals that implement the care plans of + patients and coordinate care, such as integrative health + care practitioners; + (I) collect and report data that permits evaluation + of the success of the collaborative effort on patient + outcomes, including collection of data on patient + experience of care, and identification of areas for + improvement; and + (J) establish a coordinated system of early + identification and referral for children at risk for + developmental or behavioral problems such as through the + use of infolines, health information technology, or + other means as determined by the Secretary; + (7) provide 24-hour care management and support during + transitions in care settings including-- + (A) a transitional care program that provides onsite + visits from the care coordinator, assists with the + development of discharge plans and medication + reconciliation upon admission to and discharge from the + hospitals, nursing home, or other institution setting; + (B) discharge planning and counseling support to + providers, patients, caregivers, and authorized + representatives; + (C) assuring that post-discharge care plans include + medication management, as appropriate; + (D) referrals for mental and behavioral health + services, which may include the use of infolines; and + (E) transitional health care needs from adolescence + to adulthood; + (8) serve as a liaison to community prevention and treatment + programs; + (9) demonstrate a capacity to implement and maintain health + information technology that meets the requirements of certified + EHR technology (as defined in section 3000 of the Public Health + Service Act (42 U.S.C. 300jj)) to facilitate coordination among + members of the applicable care team and affiliated primary care + practices; and + (10) <<NOTE: Reports.>> where applicable, report to the + Secretary information on quality measures used under section + 399JJ of the Public Health Service Act. + + (d) Requirement for Primary Care Providers.--A provider who +contracts with a care team shall-- + (1) <<NOTE: Plans.>> provide a care plan to the care team + for each patient participant; + (2) <<NOTE: Records.>> provide access to participant health + records; and + (3) meet regularly with the care team to ensure integration + of care. + + (e) Reporting to Secretary.--An entity that receives a grant or +contract under subsection (a) shall submit to the Secretary a report +that describes and evaluates, as requested by the Secretary, the +activities carried out by the entity under subsection (c). + (f) Definition of Primary Care.--In this section, the term ``primary +care'' means the provision of integrated, accessible health care +services by clinicians who are accountable for addressing a large +majority of personal health care needs, developing a sustained +partnership with patients, and practicing in the context of family and +community. + +[[Page 124 STAT. 516]] + +SEC. 3503. MEDICATION MANAGEMENT SERVICES IN TREATMENT OF CHRONIC + DISEASE. + + Title IX of the Public Health Service Act (42 U.S.C. 299 et seq.), +as amended by section 3501, is further amended by inserting after +section 934 the following: + +``SEC. 935. <<NOTE: 42 USC 299b-35.>> GRANTS OR CONTRACTS TO IMPLEMENT + MEDICATION MANAGEMENT SERVICES IN TREATMENT OF CHRONIC + DISEASES. + + ``(a) In General.--The Secretary, acting through the Patient Safety +Research Center established in section 933 (referred to in this section +as the `Center'), shall establish a program to provide grants or +contracts to eligible entities to implement medication management +(referred to in this section as `MTM') services provided by licensed +pharmacists, as a collaborative, multidisciplinary, inter-professional +approach to the treatment of chronic diseases for targeted individuals, +to improve the quality of care and reduce overall cost in the treatment +of such diseases. <<NOTE: Deadline.>> The Secretary shall commence the +program under this section not later than May 1, 2010. + + ``(b) <<NOTE: Plans.>> Eligible Entities.--To be eligible to receive +a grant or contract under subsection (a), an entity shall-- + ``(1) provide a setting appropriate for MTM services, as + recommended by the experts described in subsection (e); + ``(2) submit to the Secretary a plan for achieving long-term + financial sustainability; + ``(3) where applicable, submit a plan for coordinating MTM + services through local community health teams established in + section 3502 of the Patient Protection and Affordable Care Act + or in collaboration with primary care extension programs + established in section 399W; + ``(4) submit a plan for meeting the requirements under + subsection (c); and + ``(5) submit to the Secretary such other information as the + Secretary may require. + + ``(c) MTM Services to Targeted Individuals.--The MTM services +provided with the assistance of a grant or contract awarded under +subsection (a) shall, as allowed by State law including applicable +collaborative pharmacy practice agreements, include-- + ``(1) performing or obtaining necessary assessments of the + health and functional status of each patient receiving such MTM + services; + ``(2) formulating a medication treatment plan according to + therapeutic goals agreed upon by the prescriber and the patient + or caregiver or authorized representative of the patient; + ``(3) selecting, initiating, modifying, recommending changes + to, or administering medication therapy; + ``(4) monitoring, which may include access to, ordering, or + performing laboratory assessments, and evaluating the response + of the patient to therapy, including safety and effectiveness; + ``(5) performing an initial comprehensive medication review + to identify, resolve, and prevent medication-related problems, + including adverse drug events, quarterly targeted medication + reviews for ongoing monitoring, and additional followup + interventions on a schedule developed collaboratively with the + prescriber; + +[[Page 124 STAT. 517]] + + ``(6) documenting the care delivered and communicating + essential information about such care, including a summary of + the medication review, and the recommendations of the pharmacist + to other appropriate health care providers of the patient in a + timely fashion; + ``(7) providing education and training designed to enhance + the understanding and appropriate use of the medications by the + patient, caregiver, and other authorized representative; + ``(8) providing information, support services, and resources + and strategies designed to enhance patient adherence with + therapeutic regimens; + ``(9) coordinating and integrating MTM services within the + broader health care management services provided to the patient; + and + ``(10) such other patient care services allowed under + pharmacist scopes of practice in use in other Federal programs + that have implemented MTM services. + + ``(d) Targeted Individuals.--MTM services provided by licensed +pharmacists under a grant or contract awarded under subsection (a) shall +be offered to targeted individuals who-- + ``(1) take 4 or more prescribed medications (including over- + the-counter medications and dietary supplements); + ``(2) take any `high risk' medications; + ``(3) have 2 or more chronic diseases, as identified by the + Secretary; or + ``(4) have undergone a transition of care, or other factors, + as determined by the Secretary, that are likely to create a high + risk of medication-related problems. + + ``(e) Consultation With Experts.--In designing and implementing MTM +services provided under grants or contracts awarded under subsection +(a), the Secretary shall consult with Federal, State, private, public- +private, and academic entities, pharmacy and pharmacist organizations, +health care organizations, consumer advocates, chronic disease groups, +and other stakeholders involved with the research, dissemination, and +implementation of pharmacist-delivered MTM services, as the Secretary +determines appropriate. <<NOTE: Determination.>> The Secretary, in +collaboration with this group, shall determine whether it is possible to +incorporate rapid cycle process improvement concepts in use in other +Federal programs that have implemented MTM services. + + ``(f) Reporting to the Secretary.--An entity that receives a grant +or contract under subsection (a) shall submit to the Secretary a report +that describes and evaluates, as requested by the Secretary, the +activities carried out under subsection (c), including quality measures +endorsed by the entity with a contract under section 1890 of the Social +Security Act, as determined by the Secretary. + ``(g) Evaluation and Report.--The Secretary shall submit to the +relevant committees of Congress a report which shall-- + ``(1) assess the clinical effectiveness of pharmacist- + provided services under the MTM services program, as compared to + usual care, including an evaluation of whether enrollees + maintained better health with fewer hospitalizations and + emergency room visits than similar patients not enrolled in the + program; + ``(2) assess changes in overall health care resource use by + targeted individuals; + +[[Page 124 STAT. 518]] + + ``(3) assess patient and prescriber satisfaction with MTM + services; + ``(4) assess the impact of patient-cost sharing requirements + on medication adherence and recommendations for modifications; + ``(5) identify and evaluate other factors that may impact + clinical and economic outcomes, including demographic + characteristics, clinical characteristics, and health services + use of the patient, as well as characteristics of the regimen, + pharmacy benefit, and MTM services provided; and + ``(6) evaluate the extent to which participating pharmacists + who maintain a dispensing role have a conflict of interest in + the provision of MTM services, and if such conflict is found, + provide recommendations on how such a conflict might be + appropriately addressed. + + ``(h) Grants or Contracts To Fund Development of Performance +Measures.--The Secretary may, through the quality measure development +program under section 931 of the Public Health Service Act, award grants +or contracts to eligible entities for the purpose of funding the +development of performance measures that assess the use and +effectiveness of medication therapy management services.''. + +SEC. 3504. DESIGN AND IMPLEMENTATION OF REGIONALIZED SYSTEMS FOR + EMERGENCY CARE. + + (a) In General.--Title XII of the Public Health Service Act (42 +U.S.C. 300d et seq.) is amended-- + (1) <<NOTE: 42 USC 300d-5.>> in section 1203-- + (A) in the section heading, by inserting ``for + trauma systems'' after ``grants''; and + (B) in subsection (a), by striking ``Administrator + of the Health Resources and Services Administration'' + and inserting ``Assistant Secretary for Preparedness and + Response''; + (2) by inserting after section 1203 the following: + +``SEC. 1204. <<NOTE: Contracts. 42 USC 300d-6.>> COMPETITIVE GRANTS FOR + REGIONALIZED SYSTEMS FOR EMERGENCY CARE RESPONSE. + + ``(a) In General.--The Secretary, acting through the Assistant +Secretary for Preparedness and Response, shall award not fewer than 4 +multiyear contracts or competitive grants to eligible entities to +support pilot projects that design, implement, and evaluate innovative +models of regionalized, comprehensive, and accountable emergency care +and trauma systems. + ``(b) <<NOTE: Definitions.>> Eligible Entity; Region.--In this +section: + ``(1) Eligible entity.--The term `eligible entity' means-- + ``(A) a State or a partnership of 1 or more States + and 1 or more local governments; or + ``(B) an Indian tribe (as defined in section 4 of + the Indian Health Care Improvement Act) or a partnership + of 1 or more Indian tribes. + ``(2) Region.--The term `region' means an area within a + State, an area that lies within multiple States, or a similar + area (such as a multicounty area), as determined by the + Secretary. + ``(3) Emergency services.--The term `emergency services' + includes acute, prehospital, and trauma care. + +[[Page 124 STAT. 519]] + + ``(c) Pilot Projects.--The Secretary shall award a contract or grant +under subsection (a) to an eligible entity that proposes a pilot project +to design, implement, and evaluate an emergency medical and trauma +system that-- + ``(1) coordinates with public health and safety services, + emergency medical services, medical facilities, trauma centers, + and other entities in a region to develop an approach to + emergency medical and trauma system access throughout the + region, including 9-1-1 Public Safety Answering Points and + emergency medical dispatch; + ``(2) includes a mechanism, such as a regional medical + direction or transport communications system, that operates + throughout the region to ensure that the patient is taken to the + medically appropriate facility (whether an initial facility or a + higher-level facility) in a timely fashion; + ``(3) allows for the tracking of prehospital and hospital + resources, including inpatient bed capacity, emergency + department capacity, trauma center capacity, on-call specialist + coverage, ambulance diversion status, and the coordination of + such tracking with regional communications and hospital + destination decisions; and + ``(4) includes a consistent region-wide prehospital, + hospital, and interfacility data management system that-- + ``(A) submits data to the National EMS Information + System, the National Trauma Data Bank, and others; + ``(B) reports data to appropriate Federal and State + databanks and registries; and + ``(C) contains information sufficient to evaluate + key elements of prehospital care, hospital destination + decisions, including initial hospital and interfacility + decisions, and relevant health outcomes of hospital + care. + + ``(d) Application.-- + ``(1) In general.--An eligible entity that seeks a contract + or grant described in subsection (a) shall submit to the + Secretary an application at such time and in such manner as the + Secretary may require. + ``(2) Application information.--Each application shall + include-- + ``(A) an assurance from the eligible entity that the + proposed system-- + ``(i) has been coordinated with the applicable + State Office of Emergency Medical Services (or + equivalent State office); + ``(ii) includes consistent indirect and direct + medical oversight of prehospital, hospital, and + interfacility transport throughout the region; + ``(iii) coordinates prehospital treatment and + triage, hospital destination, and interfacility + transport throughout the region; + ``(iv) includes a categorization or + designation system for special medical facilities + throughout the region that is integrated with + transport and destination protocols; + ``(v) includes a regional medical direction, + patient tracking, and resource allocation system + that supports day-to-day emergency care and surge + capacity and is + +[[Page 124 STAT. 520]] + + integrated with other components of the national + and State emergency preparedness system; and + ``(vi) addresses pediatric concerns related to + integration, planning, preparedness, and + coordination of emergency medical services for + infants, children and adolescents; and + ``(B) such other information as the Secretary may + require. + + ``(e) Requirement of Matching Funds.-- + ``(1) In general.--The Secretary may not make a grant under + this section unless the State (or consortia of States) involved + agrees, with respect to the costs to be incurred by the State + (or consortia) in carrying out the purpose for which such grant + was made, to make available non-Federal contributions (in cash + or in kind under paragraph (2)) toward such costs in an amount + equal to not less than $1 for each $3 of Federal funds provided + in the grant. Such contributions may be made directly or through + donations from public or private entities. + ``(2) Non-federal contributions.--Non-Federal contributions + required in paragraph (1) may be in cash or in kind, fairly + evaluated, including equipment or services (and excluding + indirect or overhead costs). Amounts provided by the Federal + Government, or services assisted or subsidized to any + significant extent by the Federal Government, may not be + included in determining the amount of such non-Federal + contributions. + + ``(f) Priority.--The Secretary shall give priority for the award of +the contracts or grants described in subsection (a) to any eligible +entity that serves a population in a medically underserved area (as +defined in section 330(b)(3)). + ``(g) Report.--Not later than 90 days after the completion of a +pilot project under subsection (a), the recipient of such contract or +grant described in shall submit to the Secretary a report containing the +results of an evaluation of the program, including an identification +of-- + ``(1) the impact of the regional, accountable emergency care + and trauma system on patient health outcomes for various + critical care categories, such as trauma, stroke, cardiac + emergencies, neurological emergencies, and pediatric + emergencies; + ``(2) the system characteristics that contribute to the + effectiveness and efficiency of the program (or lack thereof); + ``(3) methods of assuring the long-term financial + sustainability of the emergency care and trauma system; + ``(4) the State and local legislation necessary to implement + and to maintain the system; + ``(5) the barriers to developing regionalized, accountable + emergency care and trauma systems, as well as the methods to + overcome such barriers; and + ``(6) recommendations on the utilization of available + funding for future regionalization efforts. + + ``(h) Dissemination of Findings.--The <<NOTE: Public +information.>> Secretary shall, as appropriate, disseminate to the +public and to the appropriate Committees of the Congress, the +information contained in a report made under subsection (g).''; and + (3) in <<NOTE: 42 USC 300d-32.>> section 1232-- + (A) in subsection (a), by striking ``appropriated'' + and all that follows through the period at the end and + inserting + +[[Page 124 STAT. 521]] + + ``appropriated $24,000,000 for each of fiscal years 2010 + through 2014.''; and + (B) by inserting after subsection (c) the following: + + ``(d) Authority.--For <<NOTE: Effective date.>> the purpose of +carrying out parts A through C, beginning on the date of enactment of +the Patient Protection and Affordable Care Act, the Secretary shall +transfer authority in administering grants and related authorities under +such parts from the Administrator of the Health Resources and Services +Administration to the Assistant Secretary for Preparedness and +Response.''. + + (b) Support for Emergency Medicine Research.--Part H of title IV of +the Public Health Service Act (42 U.S.C. 289 et seq.) is amended by +inserting after the section 498C the following: + +``SEC. 498D. <<NOTE: 42 USC 289g-4.>> SUPPORT FOR EMERGENCY MEDICINE + RESEARCH. + + ``(a) Emergency Medical Research.--The Secretary shall support +Federal programs administered by the National Institutes of Health, the +Agency for Healthcare Research and Quality, the Health Resources and +Services Administration, the Centers for Disease Control and Prevention, +and other agencies involved in improving the emergency care system to +expand and accelerate research in emergency medical care systems and +emergency medicine, including-- + ``(1) the basic science of emergency medicine; + ``(2) the model of service delivery and the components of + such models that contribute to enhanced patient health outcomes; + ``(3) the translation of basic scientific research into + improved practice; and + ``(4) the development of timely and efficient delivery of + health services. + + ``(b) Pediatric Emergency Medical Research.--The Secretary shall +support Federal programs administered by the National Institutes of +Health, the Agency for Healthcare Research and Quality, the Health +Resources and Services Administration, the Centers for Disease Control +and Prevention, and other agencies to coordinate and expand research in +pediatric emergency medical care systems and pediatric emergency +medicine, including-- + ``(1) an examination of the gaps and opportunities in + pediatric emergency care research and a strategy for the optimal + organization and funding of such research; + ``(2) the role of pediatric emergency services as an + integrated component of the overall health system; + ``(3) system-wide pediatric emergency care planning, + preparedness, coordination, and funding; + ``(4) pediatric training in professional education; and + ``(5) research in pediatric emergency care, specifically on + the efficacy, safety, and health outcomes of medications used + for infants, children, and adolescents in emergency care + settings in order to improve patient safety. + + ``(c) Impact Research.--The Secretary shall support research to +determine the estimated economic impact of, and savings that result +from, the implementation of coordinated emergency care systems. + ``(d) Authorization of Appropriations.--There are authorized to be +appropriated to carry out this section such sums as may be necessary for +each of fiscal years 2010 through 2014.''. + +[[Page 124 STAT. 522]] + +SEC. 3505. TRAUMA CARE CENTERS AND SERVICE AVAILABILITY. + + (a) Trauma Care Centers.-- + (1) Grants for trauma care centers.--Section 1241 of the + Public Health Service Act (42 U.S.C. 300d-41) is amended by + striking subsections (a) and (b) and inserting the following: + + ``(a) In General.--The Secretary shall establish 3 programs to award +grants to qualified public, nonprofit Indian Health Service, Indian +tribal, and urban Indian trauma centers-- + ``(1) to assist in defraying substantial uncompensated care + costs; + ``(2) to further the core missions of such trauma centers, + including by addressing costs associated with patient + stabilization and transfer, trauma education and outreach, + coordination with local and regional trauma systems, essential + personnel and other fixed costs, and expenses associated with + employee and non-employee physician services; and + ``(3) to provide emergency relief to ensure the continued + and future availability of trauma services. + + ``(b) Minimum Qualifications of Trauma Centers.-- + ``(1) Participation in trauma care system operating under + certain professional guidelines.--Except as provided in + paragraph (2), the Secretary may not award a grant to a trauma + center under subsection (a) unless the trauma center is a + participant in a trauma system that substantially complies with + section 1213. + ``(2) Exemption.--Paragraph (1) shall not apply to trauma + centers that are located in States with no existing trauma care + system. + ``(3) Qualification for substantial uncompensated care + costs.--The Secretary shall award substantial uncompensated care + grants under subsection (a)(1) only to trauma centers meeting at + least 1 of the criteria in 1 of the following 3 categories: + ``(A) Category a.--The criteria for category A are + as follows: + ``(i) At least 40 percent of the visits in the + emergency department of the hospital in which the + trauma center is located were charity or self-pay + patients. + ``(ii) At least 50 percent of the visits in + such emergency department were Medicaid (under + title XIX of the Social Security Act (42 U.S.C. + 1396 et seq.)) and charity and self-pay patients + combined. + ``(B) Category b.--The criteria for category B are + as follows: + ``(i) At least 35 percent of the visits in the + emergency department were charity or self-pay + patients. + ``(ii) At least 50 percent of the visits in + the emergency department were Medicaid and charity + and self-pay patients combined. + ``(C) Category c.--The criteria for category C are + as follows: + ``(i) At least 20 percent of the visits in the + emergency department were charity or self-pay + patients. + ``(ii) At least 30 percent of the visits in + the emergency department were Medicaid and charity + and self-pay patients combined. + +[[Page 124 STAT. 523]] + + ``(4) Trauma centers in 1115 waiver states.--Notwithstanding + paragraph (3), the Secretary may award a substantial + uncompensated care grant to a trauma center under subsection + (a)(1) if the trauma center qualifies for funds under a Low + Income Pool or Safety Net Care Pool established through a waiver + approved under section 1115 of the Social Security Act (42 + U.S.C. 1315). + ``(5) Designation.--The Secretary may not award a grant to a + trauma center unless such trauma center is verified by the + American College of Surgeons or designated by an equivalent + State or local agency. + + ``(c) Additional Requirements.--The Secretary may not award a grant +to a trauma center under subsection (a)(1) unless such trauma center-- + ``(1) submits <<NOTE: Plans.>> to the Secretary a plan + satisfactory to the Secretary that demonstrates a continued + commitment to serving trauma patients regardless of their + ability to pay; and + ``(2) has policies in place to assist patients who cannot + pay for part or all of the care they receive, including a + sliding fee scale, and to ensure fair billing and collection + practices.''. + (2) Considerations in making grants.--Section 1242 of the + Public Health Service Act (42 U.S.C. 300d-42) is amended by + striking subsections (a) and (b) and inserting the following: + + ``(a) Substantial Uncompensated Care Awards.-- + ``(1) In general.--The Secretary shall establish an award + basis for each eligible trauma center for grants under section + 1241(a)(1) according to the percentage described in paragraph + (2), subject to the requirements of section 1241(b)(3). + ``(2) Percentages.--The applicable percentages are as + follows: + ``(A) With respect to a category A trauma center, + 100 percent of the uncompensated care costs. + ``(B) With respect to a category B trauma center, + not more than 75 percent of the uncompensated care + costs. + ``(C) With respect to a category C trauma center, + not more than 50 percent of the uncompensated care + costs. + + ``(b) Core Mission Awards.-- + ``(1) In general.--In awarding grants under section + 1241(a)(2), the Secretary shall-- + ``(A) reserve 25 percent of the amount allocated for + core mission awards for Level III and Level IV trauma + centers; and + ``(B) reserve 25 percent of the amount allocated for + core mission awards for large urban Level I and II + trauma centers-- + ``(i) that have at least 1 graduate medical + education fellowship in trauma or trauma related + specialties for which demand is exceeding supply; + ``(ii) for which-- + ``(I) annual uncompensated care + costs exceed $10,000,000; or + ``(II) at least 20 percent of + emergency department visits are charity + or self-pay or Medicaid patients; and + ``(iii) that are not eligible for substantial + uncompensated care awards under section + 1241(a)(1). + +[[Page 124 STAT. 524]] + + ``(c) Emergency Awards.--In awarding grants under section +1241(a)(3), the Secretary shall-- + ``(1) give preference to any application submitted by a + trauma center that provides trauma care in a geographic area in + which the availability of trauma care has significantly + decreased or will significantly decrease if the center is forced + to close or downgrade service or growth in demand for trauma + services exceeds capacity; and + ``(2) reallocate any emergency awards funds not obligated + due to insufficient, or a lack of qualified, applications to the + significant uncompensated care award program.''. + (3) Certain agreements.--Section 1243 of the Public Health + Service Act (42 U.S.C. 300d-43) is amended by striking + subsections (a), (b), and (c) and inserting the following: + + ``(a) Maintenance of Financial Support.--The Secretary may require a +trauma center receiving a grant under section 1241(a) to maintain access +to trauma services at comparable levels to the prior year during the +grant period. + ``(b) Trauma Care Registry.--The Secretary may require the trauma +center receiving a grant under section 1241(a) to provide data to a +national and centralized registry of trauma cases, in accordance with +guidelines developed by the American College of Surgeons, and as the +Secretary may otherwise require.''. + (4) General provisions.--Section 1244 of the Public Health + Service Act (42 U.S.C. 300d-44) is amended by striking + subsections (a), (b), and (c) and inserting the following: + + ``(a) Application.--The Secretary may not award a grant to a trauma +center under section 1241(a) unless such center submits an application +for the grant to the Secretary and the application is in such form, is +made in such manner, and contains such agreements, assurances, and +information as the Secretary determines to be necessary to carry out +this part. + ``(b) Limitation on Duration of Support.--The period <<NOTE: Waiver +authority.>> during which a trauma center receives payments under a +grant under section 1241(a)(3) shall be for 3 fiscal years, except that +the Secretary may waive such requirement for a center and authorize such +center to receive such payments for 1 additional fiscal year. + + ``(c) Limitation on Amount of Grant.--Notwithstanding section +1242(a), a grant under section 1241 may not be made in an amount +exceeding $2,000,000 for each fiscal year. + ``(d) Eligibility.--Except as provided in section +1242(b)(1)(B)(iii), acquisition of, or eligibility for, a grant under +section 1241(a) shall not preclude a trauma center from being eligible +for other grants described in such section. + ``(e) Funding Distribution.--Of the total amount appropriated for a +fiscal year under section 1245, 70 percent shall be used for substantial +uncompensated care awards under section 1241(a)(1), 20 percent shall be +used for core mission awards under section 1241(a)(2), and 10 percent +shall be used for emergency awards under section 1241(a)(3). + ``(f) Minimum Allowance.--Notwithstanding subsection (e), if the +amount appropriated for a fiscal year under section 1245 is less than +$25,000,000, all available funding for such fiscal year shall be used +for substantial uncompensated care awards under section 1241(a)(1). + ``(g) Substantial Uncompensated Care Award Distribution and +Proportional Share.--Notwithstanding section 1242(a), of + +[[Page 124 STAT. 525]] + +the amount appropriated for substantial uncompensated care grants for a +fiscal year, the Secretary shall-- + ``(1) make available-- + ``(A) 50 percent of such funds for category A trauma + center grantees; + ``(B) 35 percent of such funds for category B trauma + center grantees; and + ``(C) 15 percent of such funds for category C trauma + center grantees; and + ``(2) provide available funds within each category in a + manner proportional to the award basis specified in section + 1242(a)(2) to each eligible trauma center. + + ``(h) Report.--Beginning 2 years after the date of enactment of the +Patient Protection and Affordable Care Act, and every 2 years +thereafter, the Secretary shall biennially report to Congress regarding +the status of the grants made under section 1241 and on the overall +financial stability of trauma centers.''. + (5) Authorization of appropriations.--Section 1245 of the + Public Health Service Act (42 U.S.C. 300d-45) is amended to read + as follows: + +``SEC. 1245. <<NOTE: 42 USC 300d-45.>> AUTHORIZATION OF APPROPRIATIONS. + + ``For the purpose of carrying out this part, there are authorized to +be appropriated $100,000,000 for fiscal year 2009, and such sums as may +be necessary for each of fiscal years 2010 through 2015. Such +authorization of appropriations is in addition to any other +authorization of appropriations or amounts that are available for such +purpose.''. + (6) Definition.--Part D of title XII of the Public Health + Service Act (42 U.S.C. 300d-41 et seq.) is amended by adding at + the end the following: + +``SEC. 1246. <<NOTE: 42 USC 300d-46.>> DEFINITION. + + ``In this part, the term `uncompensated care costs' means +unreimbursed costs from serving self-pay, charity, or Medicaid patients, +without regard to payment under section 1923 of the Social Security Act, +all of which are attributable to emergency care and trauma care, +including costs related to subsequent inpatient admissions to the +hospital.''. + (b) Trauma Service Availability.--Title XII of the Public Health +Service Act (42 U.S.C. 300d et seq.) is amended by adding at the end the +following: + + ``PART H--TRAUMA SERVICE AVAILABILITY + +``SEC. 1281. <<NOTE: 42 USC 300d-81.>> GRANTS TO STATES. + + ``(a) Establishment.--To promote universal access to trauma care +services provided by trauma centers and trauma-related physician +specialties, the Secretary shall provide funding to States to enable +such States to award grants to eligible entities for the purposes +described in this section. + ``(b) Awarding of Grants by States.--Each State may award grants to +eligible entities within the State for the purposes described in +subparagraph (d). + ``(c) Eligibility.-- + ``(1) In general.--To be eligible to receive a grant under + subsection (b) an entity shall-- + ``(A) be-- + +[[Page 124 STAT. 526]] + + ``(i) a public or nonprofit trauma center or + consortium thereof that meets that requirements of + paragraphs (1), (2), and (5) of section 1241(b); + ``(ii) a safety net public or nonprofit trauma + center that meets the requirements of paragraphs + (1) through (5) of section 1241(b); or + ``(iii) a hospital in an underserved area (as + defined by the State) that seeks to establish new + trauma services; and + ``(B) submit to the State an application at such + time, in such manner, and containing such information as + the State may require. + ``(2) Limitation.--A State shall use at least 40 percent of + the amount available to the State under this part for a fiscal + year to award grants to safety net trauma centers described in + paragraph (1)(A)(ii). + + ``(d) Use of Funds.--The recipient of a grant under subsection (b) +shall carry out 1 or more of the following activities consistent with +subsection (b): + ``(1) Providing trauma centers with funding to support + physician compensation in trauma-related physician specialties + where shortages exist in the region involved, with priority + provided to safety net trauma centers described in subsection + (c)(1)(A)(ii). + ``(2) Providing for individual safety net trauma center + fiscal stability and costs related to having service that is + available 24 hours a day, 7 days a week, with priority provided + to safety net trauma centers described in subsection + (c)(1)(A)(ii) located in urban, border, and rural areas. + ``(3) Reducing trauma center overcrowding at specific trauma + centers related to throughput of trauma patients. + ``(4) Establishing new trauma services in underserved areas + as defined by the State. + ``(5) Enhancing collaboration between trauma centers and + other hospitals and emergency medical services personnel related + to trauma service availability. + ``(6) Making capital improvements to enhance access and + expedite trauma care, including providing helipads and + associated safety infrastructure. + ``(7) Enhancing trauma surge capacity at specific trauma + centers. + ``(8) Ensuring expedient receipt of trauma patients + transported by ground or air to the appropriate trauma center. + ``(9) Enhancing interstate trauma center collaboration. + + ``(e) Limitation.-- + ``(1) In general.--A State may use not more than 20 percent + of the amount available to the State under this part for a + fiscal year for administrative costs associated with awarding + grants and related costs. + ``(2) Maintenance of effort.--The Secretary may not provide + funding to a State under this part unless the State agrees that + such funds will be used to supplement and not supplant State + funding otherwise available for the activities and costs + described in this part. + + ``(f) Distribution of Funds.--The <<NOTE: Applicability.>> following +shall apply with respect to grants provided in this part: + +[[Page 124 STAT. 527]] + + ``(1) Less than $10,000,000.--If the amount of + appropriations for this part in a fiscal year is less than + $10,000,000, the Secretary shall divide such funding evenly + among only those States that have 1 or more trauma centers + eligible for funding under section 1241(b)(3)(A). + ``(2) Less than $20,000,000.--If the amount of + appropriations in a fiscal year is less than $20,000,000, the + Secretary shall divide such funding evenly among only those + States that have 1 or more trauma centers eligible for funding + under subparagraphs (A) and (B) of section 1241(b)(3). + ``(3) Less than $30,000,000.--If the amount of + appropriations for this part in a fiscal year is less than + $30,000,000, the Secretary shall divide such funding evenly + among only those States that have 1 or more trauma centers + eligible for funding under section 1241(b)(3). + ``(4) $30,000,000 or more.--If the amount of appropriations + for this part in a fiscal year is $30,000,000 or more, the + Secretary shall divide such funding evenly among all States. + +``SEC. 1282. <<NOTE: 42 USC 300d-82.>> AUTHORIZATION OF APPROPRIATIONS. + + ``For the purpose of carrying out this part, there is authorized to +be appropriated $100,000,000 for each of fiscal years 2010 through +2015.''. + +SEC. 3506. PROGRAM TO FACILITATE SHARED DECISIONMAKING. + + Part D of title IX of the Public Health Service Act, as amended by +section 3503, is further amended by adding at the end the following: + +``SEC. 936. <<NOTE: 42 USC 299b-36.>> PROGRAM TO FACILITATE SHARED + DECISIONMAKING. + + ``(a) Purpose.--The purpose of this section is to facilitate +collaborative processes between patients, caregivers or authorized +representatives, and clinicians that engages the patient, caregiver or +authorized representative in decisionmaking, provides patients, +caregivers or authorized representatives with information about trade- +offs among treatment options, and facilitates the incorporation of +patient preferences and values into the medical plan. + ``(b) Definitions.--In this section: + ``(1) Patient decision aid.--The term `patient decision aid' + means an educational tool that helps patients, caregivers or + authorized representatives understand and communicate their + beliefs and preferences related to their treatment options, and + to decide with their health care provider what treatments are + best for them based on their treatment options, scientific + evidence, circumstances, beliefs, and preferences. + ``(2) Preference sensitive care.--The term `preference + sensitive care' means medical care for which the clinical + evidence does not clearly support one treatment option such that + the appropriate course of treatment depends on the values of the + patient or the preferences of the patient, caregivers or + authorized representatives regarding the benefits, harms and + scientific evidence for each treatment option, the use of such + care should depend on the informed patient choice among + clinically appropriate treatment options. + + ``(c) Establishment of Independent Standards for Patient Decision +Aids for Preference Sensitive Care.-- + ``(1) Contract with entity to establish standards and + certify patient decision aids.-- + +[[Page 124 STAT. 528]] + + ``(A) In general.--For purposes of supporting + consensus-based standards for patient decision aids for + preference sensitive care and a certification process + for patient decision aids for use in the Federal health + programs and by other interested parties, the Secretary + shall have in effect a contract with the entity with a + contract under section 1890 of the Social Security Act. + Such contract shall provide that the entity perform the + duties described in paragraph (2). + ``(B) Timing for first contract.--As soon as + practicable after the date of the enactment of this + section, the Secretary shall enter into the first + contract under subparagraph (A). + ``(C) Period of contract.--A contract under + subparagraph (A) shall be for a period of 18 months + (except such contract may be renewed after a subsequent + bidding process). + ``(2) Duties.--The following duties are described in this + paragraph: + ``(A) Develop and identify standards for patient + decision aids.--The entity shall synthesize evidence and + convene a broad range of experts and key stakeholders to + develop and identify consensus-based standards to + evaluate patient decision aids for preference sensitive + care. + ``(B) Endorse patient decision aids.--The entity + shall review patient decision aids and develop a + certification process whether patient decision aids meet + the standards developed and identified under + subparagraph (A). The entity shall give priority to the + review and certification of patient decision aids for + preference sensitive care. + + ``(d) Program <<NOTE: Grants. Contracts.>> To Develop, Update and +Patient Decision Aids To Assist Health Care Providers and Patients.-- + ``(1) In general.--The Secretary, acting through the + Director, and in coordination with heads of other relevant + agencies, such as the Director of the Centers for Disease + Control and Prevention and the Director of the National + Institutes of Health, shall establish a program to award grants + or contracts-- + ``(A) to develop, update, and produce patient + decision aids for preference sensitive care to assist + health care providers in educating patients, caregivers, + and authorized representatives concerning the relative + safety, relative effectiveness (including possible + health outcomes and impact on functional status), and + relative cost of treatment or, where appropriate, + palliative care options; + ``(B) to test such materials to ensure such + materials are balanced and evidence based in aiding + health care providers and patients, caregivers, and + authorized representatives to make informed decisions + about patient care and can be easily incorporated into a + broad array of practice settings; and + ``(C) to educate providers on the use of such + materials, including through academic curricula. + ``(2) Requirements for patient decision aids.--Patient + decision aids developed and produced pursuant to a grant or + contract under paragraph (1)-- + +[[Page 124 STAT. 529]] + + ``(A) shall be designed to engage patients, + caregivers, and authorized representatives in informed + decisionmaking with health care providers; + ``(B) shall present up-to-date clinical evidence + about the risks and benefits of treatment options in a + form and manner that is age-appropriate and can be + adapted for patients, caregivers, and authorized + representatives from a variety of cultural and + educational backgrounds to reflect the varying needs of + consumers and diverse levels of health literacy; + ``(C) shall, where appropriate, explain why there is + a lack of evidence to support one treatment option over + another; and + ``(D) shall address health care decisions across the + age span, including those affecting vulnerable + populations including children. + ``(3) Distribution.--The Director shall ensure that patient + decision aids produced with grants or contracts under this + section are available to the public. + ``(4) Nonduplication of efforts.--The Director shall ensure + that the activities under this section of the Agency and other + agencies, including the Centers for Disease Control and + Prevention and the National Institutes of Health, are free of + unnecessary duplication of effort. + + ``(e) Grants To Support Shared Decisionmaking Implementation.-- + ``(1) In general.--The Secretary shall establish a program + to provide for the phased-in development, implementation, and + evaluation of shared decisionmaking using patient decision aids + to meet the objective of improving the understanding of patients + of their medical treatment options. + ``(2) Shared decisionmaking resource centers.-- + ``(A) In general.--The Secretary shall provide + grants for the establishment and support of Shared + Decisionmaking Resource Centers (referred to in this + subsection as `Centers') to provide technical assistance + to providers and to develop and disseminate best + practices and other information to support and + accelerate adoption, implementation, and effective use + of patient decision aids and shared decisionmaking by + providers. + ``(B) Objectives.--The objective of a Center is to + enhance and promote the adoption of patient decision + aids and shared decisionmaking through-- + ``(i) providing assistance to eligible + providers with the implementation and effective + use of, and training on, patient decision aids; + and + ``(ii) the dissemination of best practices and + research on the implementation and effective use + of patient decision aids. + ``(3) Shared decisionmaking participation grants.-- + ``(A) In general.--The Secretary shall provide + grants to health care providers for the development and + implementation of shared decisionmaking techniques and + to assess the use of such techniques. + ``(B) Preference.--In order to facilitate the use of + best practices, the Secretary shall provide a preference + in making grants under this subsection to health care + +[[Page 124 STAT. 530]] + + providers who participate in training by Shared + Decisionmaking Resource Centers or comparable training. + ``(C) Limitation.--Funds under this paragraph shall + not be used to purchase or implement use of patient + decision aids other than those certified under the + process identified in subsection (c). + ``(4) Guidance.--The Secretary may issue guidance to + eligible grantees under this subsection on the use of patient + decision aids. + + ``(f) Funding.--For purposes of carrying out this section there are +authorized to be appropriated such sums as may be necessary for fiscal +year 2010 and each subsequent fiscal year.''. + +SEC. 3507. PRESENTATION <<NOTE: 21 USC 352 note.>> OF PRESCRIPTION DRUG + BENEFIT AND RISK INFORMATION. + + (a) In General.--The <<NOTE: Determination.>> Secretary of Health +and Human Services (referred to in this section as the ``Secretary''), +acting through the Commissioner of Food and Drugs, shall determine +whether the addition of quantitative summaries of the benefits and risks +of prescription drugs in a standardized format (such as a table or drug +facts box) to the promotional labeling or print advertising of such +drugs would improve health care decisionmaking by clinicians and +patients and consumers. + + (b) Review and Consultation.--In making the determination under +subsection (a), the Secretary shall review all available scientific +evidence and research on decisionmaking and social and cognitive +psychology and consult with drug manufacturers, clinicians, patients and +consumers, experts in health literacy, representatives of racial and +ethnic minorities, and experts in women's and pediatric health. + (c) Report.--Not later than 1 year after the date of enactment of +this Act, the Secretary shall submit to Congress a report that +provides-- + (1) the determination by the Secretary under subsection (a); + and + (2) the reasoning and analysis underlying that + determination. + + (d) Authority.--If the <<NOTE: Deadline. Regulations.>> Secretary +determines under subsection (a) that the addition of quantitative +summaries of the benefits and risks of prescription drugs in a +standardized format (such as a table or drug facts box) to the +promotional labeling or print advertising of such drugs would improve +health care decisionmaking by clinicians and patients and consumers, +then the Secretary, not later than 3 years after the date of submission +of the report under subsection (c), shall promulgate proposed +regulations as necessary to implement such format. + + (e) Clarification.--Nothing in this section shall be construed to +restrict the existing authorities of the Secretary with respect to +benefit and risk information. + +SEC. 3508. DEMONSTRATION <<NOTE: 42 USC 294j.>> PROGRAM TO INTEGRATE + QUALITY IMPROVEMENT AND PATIENT SAFETY TRAINING INTO + CLINICAL EDUCATION OF HEALTH PROFESSIONALS. + + (a) In General.--The Secretary may award grants to eligible entities +or consortia under this section to carry out demonstration projects to +develop and implement academic curricula that integrates quality +improvement and patient safety in the clinical + +[[Page 124 STAT. 531]] + +education of health professionals. Such awards shall be made on a +competitive basis and pursuant to peer review. + (b) Eligibility.--To be eligible to receive a grant under subsection +(a), an entity or consortium shall-- + (1) submit to the Secretary an application at such time, in + such manner, and containing such information as the Secretary + may require; + (2) be or include-- + (A) a health professions school; + (B) a school of public health; + (C) a school of social work; + (D) a school of nursing; + (E) a school of pharmacy; + (F) an institution with a graduate medical education + program; or + (G) a school of health care administration; + (3) collaborate in the development of curricula described in + subsection (a) with an organization that accredits such school + or institution; + (4) provide for the collection of data regarding the + effectiveness of the demonstration project; and + (5) provide matching funds in accordance with subsection + (c). + + (c) Matching Funds.-- + (1) In general.--The Secretary may award a grant to an + entity or consortium under this section only if the entity or + consortium agrees to make available non-Federal contributions + toward the costs of the program to be funded under the grant in + an amount that is not less than $1 for each $5 of Federal funds + provided under the grant. + (2) Determination of amount contributed.--Non-Federal + contributions under paragraph (1) may be in cash or in-kind, + fairly evaluated, including equipment or services. Amounts + provided by the Federal Government, or services assisted or + subsidized to any significant extent by the Federal Government, + may not be included in determining the amount of such + contributions. + + (d) Evaluation.--The <<NOTE: Publication. Public +information.>> Secretary shall take such action as may be necessary to +evaluate the projects funded under this section and publish, make +publicly available, and disseminate the results of such evaluations on +as wide a basis as is practicable. + + (e) Reports.--Not later than 2 years after the date of enactment of +this section, and annually thereafter, the Secretary shall submit to the +Committee on Health, Education, Labor, and Pensions and the Committee on +Finance of the Senate and the Committee on Energy and Commerce and the +Committee on Ways and Means of the House of Representatives a report +that-- + (1) describes the specific projects supported under this + section; and + (2) contains recommendations for Congress based on the + evaluation conducted under subsection (d). + +SEC. 3509. IMPROVING WOMEN'S HEALTH. + + (a) Health and Human Services Office on Women's Health.-- + +[[Page 124 STAT. 532]] + + (1) Establishment.--Part A of title II of the Public Health + Service Act (42 U.S.C. 202 et seq.) is amended by adding at the + end the following: + +``SEC. 229. HEALTH <<NOTE: 42 USC 237a.>> AND HUMAN SERVICES OFFICE ON + WOMEN'S HEALTH. + + ``(a) Establishment of Office.--There is established within the +Office of the Secretary, an Office on Women's Health (referred to in +this section as the `Office'). The Office shall be headed by a Deputy +Assistant Secretary for Women's Health who may report to the Secretary. + ``(b) Duties.--The Secretary, acting through the Office, with +respect to the health concerns of women, shall-- + ``(1) establish short-range and long-range goals and + objectives within the Department of Health and Human Services + and, as relevant and appropriate, coordinate with other + appropriate offices on activities within the Department that + relate to disease prevention, health promotion, service + delivery, research, and public and health care professional + education, for issues of particular concern to women throughout + their lifespan; + ``(2) provide expert advice and consultation to the + Secretary concerning scientific, legal, ethical, and policy + issues relating to women's health; + ``(3) monitor the Department of Health and Human Services' + offices, agencies, and regional activities regarding women's + health and identify needs regarding the coordination of + activities, including intramural and extramural + multidisciplinary activities; + ``(4) establish a Department of Health and Human Services + Coordinating Committee on Women's Health, which shall be chaired + by the Deputy Assistant Secretary for Women's Health and + composed of senior level representatives from each of the + agencies and offices of the Department of Health and Human + Services; + ``(5) establish <<NOTE: Establishment.>> a National Women's + Health Information Center to-- + ``(A) facilitate the exchange of information + regarding matters relating to health information, health + promotion, preventive health services, research + advances, and education in the appropriate use of health + care; + ``(B) facilitate access to such information; + ``(C) assist in the analysis of issues and problems + relating to the matters described in this paragraph; and + ``(D) provide technical assistance with respect to + the exchange of information (including facilitating the + development of materials for such technical assistance); + ``(6) coordinate efforts to promote women's health programs + and policies with the private sector; and + ``(7) through publications and any other means appropriate, + provide for the exchange of information between the Office and + recipients of grants, contracts, and agreements under subsection + (c), and between the Office and health professionals and the + general public. + + ``(c) Grants and Contracts Regarding Duties.-- + +[[Page 124 STAT. 533]] + + ``(1) Authority.--In carrying out subsection (b), the + Secretary may make grants to, and enter into cooperative + agreements, contracts, and interagency agreements with, public + and private entities, agencies, and organizations. + ``(2) Evaluation and dissemination.--The Secretary shall + directly or through contracts with public and private entities, + agencies, and organizations, provide for evaluations of projects + carried out with financial assistance provided under paragraph + (1) and for the dissemination of information developed as a + result of such projects. + + ``(d) Reports.--Not later than 1 year after the date of enactment of +this section, and every second year thereafter, the Secretary shall +prepare and submit to the appropriate committees of Congress a report +describing the activities carried out under this section during the +period for which the report is being prepared. + ``(e) Authorization of Appropriations.--For the purpose of carrying +out this section, there are authorized to be appropriated such sums as +may be necessary for each of the fiscal years 2010 through 2014.''. + (2) Transfer of functions.--There <<NOTE: 42 USC 237a + note.>> are transferred to the Office on Women's Health + (established under section 229 of the Public Health Service Act, + as added by this section), all functions exercised by the Office + on Women's Health of the Public Health Service prior to the date + of enactment of this section, including all personnel and + compensation authority, all delegation and assignment authority, + and all remaining appropriations. All orders, determinations, + rules, regulations, permits, agreements, grants, contracts, + certificates, licenses, registrations, privileges, and other + administrative actions that-- + (A) have been issued, made, granted, or allowed to + become effective by the President, any Federal agency or + official thereof, or by a court of competent + jurisdiction, in the performance of functions + transferred under this paragraph; and + (B) are in effect at the time this section takes + effect, or were final before the date of enactment of + this section and are to become effective on or after + such date, + shall continue in effect according to their terms until + modified, terminated, superseded, set aside, or revoked in + accordance with law by the President, the Secretary, or other + authorized official, a court of competent jurisdiction, or by + operation of law. + + (b) Centers for Disease Control and Prevention Office of Women's +Health.--Part A of title III of the Public Health Service Act (42 U.S.C. +241 et seq.) is amended by adding at the end the following: + +``SEC. 310A. CENTERS <<NOTE: 42 USC 242s.>> FOR DISEASE CONTROL AND + PREVENTION OFFICE OF WOMEN'S HEALTH. + + ``(a) Establishment.--There is established within the Office of the +Director of the Centers for Disease Control and Prevention, an office to +be known as the Office of Women's Health (referred to in this section as +the `Office'). The Office shall be headed by a director who shall be +appointed by the Director of such Centers. + ``(b) Purpose.--The Director of the Office shall-- + +[[Page 124 STAT. 534]] + + ``(1) report to the Director of the Centers for Disease + Control and Prevention on the current level of the Centers' + activity regarding women's health conditions across, where + appropriate, age, biological, and sociocultural contexts, in all + aspects of the Centers' work, including prevention programs, + public and professional education, services, and treatment; + ``(2) establish short-range and long-range goals and + objectives within the Centers for women's health and, as + relevant and appropriate, coordinate with other appropriate + offices on activities within the Centers that relate to + prevention, research, education and training, service delivery, + and policy development, for issues of particular concern to + women; + ``(3) identify projects in women's health that should be + conducted or supported by the Centers; + ``(4) consult with health professionals, nongovernmental + organizations, consumer organizations, women's health + professionals, and other individuals and groups, as appropriate, + on the policy of the Centers with regard to women; and + ``(5) serve as a member of the Department of Health and + Human Services Coordinating Committee on Women's Health + (established under section 229(b)(4)). + + ``(c) Definition.--As used in this section, the term `women's health +conditions', with respect to women of all age, ethnic, and racial +groups, means diseases, disorders, and conditions-- + ``(1) unique to, significantly more serious for, or + significantly more prevalent in women; and + ``(2) for which the factors of medical risk or type of + medical intervention are different for women, or for which there + is reasonable evidence that indicates that such factors or types + may be different for women. + + ``(d) Authorization of Appropriations.--For the purpose of carrying +out this section, there are authorized to be appropriated such sums as +may be necessary for each of the fiscal years 2010 through 2014.''. + (c) Office of Women's Health Research.--Section 486(a) of the Public +Health Service Act (42 U.S.C. 287d(a)) is amended by inserting ``and who +shall report directly to the Director'' before the period at the end +thereof. + (d) Substance Abuse and Mental Health Services Administration.-- +Section 501(f) of the Public Health Service Act (42 U.S.C. 290aa(f)) is +amended-- + (1) in paragraph (1), by inserting ``who shall report + directly to the Administrator'' before the period; + (2) by redesignating paragraph (4) as paragraph (5); and + (3) by inserting after paragraph (3), the following: + ``(4) Office.--Nothing in this subsection shall be construed + to preclude the Secretary from establishing within the Substance + Abuse and Mental Health Administration an Office of Women's + Health.''. + + (e) Agency for Healthcare Research and Quality Activities Regarding +Women's Health.--Part <<NOTE: 42 USC 299b-25, 299b-26.>> C of title IX +of the Public Health Service Act (42 U.S.C. 299c et seq.) is amended-- + (1) by redesignating sections 925 and 926 as sections 926 + and 927, respectively; and + (2) by inserting after section 924 the following: + +[[Page 124 STAT. 535]] + +``SEC. 925. <<NOTE: 42 USC 299b-24a.>> ACTIVITIES REGARDING WOMEN'S + HEALTH. + + ``(a) Establishment.--There is established within the Office of the +Director, an Office of Women's Health and Gender-Based Research +(referred to in this section as the `Office'). The Office shall be +headed by a director who shall be appointed by the Director of +Healthcare and Research Quality. + ``(b) Purpose.--The official designated under subsection (a) shall-- + ``(1) report to the Director on the current Agency level of + activity regarding women's health, across, where appropriate, + age, biological, and sociocultural contexts, in all aspects of + Agency work, including the development of evidence reports and + clinical practice protocols and the conduct of research into + patient outcomes, delivery of health care services, quality of + care, and access to health care; + ``(2) establish short-range and long-range goals and + objectives within the Agency for research important to women's + health and, as relevant and appropriate, coordinate with other + appropriate offices on activities within the Agency that relate + to health services and medical effectiveness research, for + issues of particular concern to women; + ``(3) identify projects in women's health that should be + conducted or supported by the Agency; + ``(4) consult with health professionals, nongovernmental + organizations, consumer organizations, women's health + professionals, and other individuals and groups, as appropriate, + on Agency policy with regard to women; and + ``(5) serve as a member of the Department of Health and + Human Services Coordinating Committee on Women's Health + (established under section 229(b)(4)).''. + + ``(c) Authorization of Appropriations.--For the purpose of carrying +out this section, there are authorized to be appropriated such sums as +may be necessary for each of the fiscal years 2010 through 2014.''. + (f) Health Resources and Services Administration Office of Women's +Health.--Title VII of the Social Security Act (42 U.S.C. 901 et seq.) is +amended by adding at the end the following: + +``SEC. 713. OFFICE <<NOTE: 42 USC 914.>> OF WOMEN'S HEALTH. + + ``(a) Establishment.--The Secretary shall establish within the +Office of the Administrator of the Health Resources and Services +Administration, an office to be known as the Office of Women's Health. +The Office shall be headed by a director who shall be appointed by the +Administrator. + ``(b) Purpose.--The Director of the Office shall-- + ``(1) report to the Administrator on the current + Administration level of activity regarding women's health + across, where appropriate, age, biological, and sociocultural + contexts; + ``(2) establish short-range and long-range goals and + objectives within the Health Resources and Services + Administration for women's health and, as relevant and + appropriate, coordinate with other appropriate offices on + activities within the Administration that relate to health care + provider training, health service delivery, research, and + demonstration projects, for issues of particular concern to + women; + ``(3) identify projects in women's health that should be + conducted or supported by the bureaus of the Administration; + +[[Page 124 STAT. 536]] + + ``(4) consult with health professionals, nongovernmental + organizations, consumer organizations, women's health + professionals, and other individuals and groups, as appropriate, + on Administration policy with regard to women; and + ``(5) serve as a member of the Department of Health and + Human Services Coordinating Committee on Women's Health + (established under section 229(b)(4) of the Public Health + Service Act). + + ``(c) Continued Administration of Existing Programs.--The Director +of the Office shall assume the authority for the development, +implementation, administration, and evaluation of any projects carried +out through the Health Resources and Services Administration relating to +women's health on the date of enactment of this section. + ``(d) Definitions.--For purposes of this section: + ``(1) Administration.--The term `Administration' means the + Health Resources and Services Administration. + ``(2) Administrator.--The term `Administrator' means the + Administrator of the Health Resources and Services + Administration. + ``(3) Office.--The term `Office' means the Office of Women's + Health established under this section in the Administration. + + ``(e) Authorization of Appropriations.--For the purpose of carrying +out this section, there are authorized to be appropriated such sums as +may be necessary for each of the fiscal years 2010 through 2014.''. + (g) Food and Drug Administration Office of Women's Health.--Chapter +X of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 391 et seq.) is +amended by adding at the end the following: + +``SEC. 1011. OFFICE <<NOTE: 21 USC 399b.>> OF WOMEN'S HEALTH. + + ``(a) Establishment.--There is established within the Office of the +Commissioner, an office to be known as the Office of Women's Health +(referred to in this section as the `Office'). The Office shall be +headed by a director who shall be appointed by the Commissioner of Food +and Drugs. + ``(b) Purpose.--The Director of the Office shall-- + ``(1) report to the Commissioner of Food and Drugs on + current Food and Drug Administration (referred to in this + section as the `Administration') levels of activity regarding + women's participation in clinical trials and the analysis of + data by sex in the testing of drugs, medical devices, and + biological products across, where appropriate, age, biological, + and sociocultural contexts; + ``(2) establish short-range and long-range goals and + objectives within the Administration for issues of particular + concern to women's health within the jurisdiction of the + Administration, including, where relevant and appropriate, + adequate inclusion of women and analysis of data by sex in + Administration protocols and policies; + ``(3) provide information to women and health care providers + on those areas in which differences between men and women exist; + ``(4) consult with pharmaceutical, biologics, and device + manufacturers, health professionals with expertise in women's + +[[Page 124 STAT. 537]] + + issues, consumer organizations, and women's health professionals + on Administration policy with regard to women; + ``(5) make annual estimates of funds needed to monitor + clinical trials and analysis of data by sex in accordance with + needs that are identified; and + ``(6) serve as a member of the Department of Health and + Human Services Coordinating Committee on Women's Health + (established under section 229(b)(4) of the Public Health + Service Act). + + ``(c) Authorization of Appropriations.--For the purpose of carrying +out this section, there are authorized to be appropriated such sums as +may be necessary for each of the fiscal years 2010 through 2014.''. + (h) No New Regulatory <<NOTE: 42 USC 237a note.>> Authority.-- +Nothing in this section and the amendments made by this section may be +construed as establishing regulatory authority or modifying any existing +regulatory authority. + + (i) Limitation on <<NOTE: 42 USC 237a note.>> Termination.-- +Notwithstanding any other provision of law, a Federal office of women's +health (including the Office of Research on Women's Health of the +National Institutes of Health) or Federal appointive position with +primary responsibility over women's health issues (including the +Associate Administrator for Women's Services under the Substance Abuse +and Mental Health Services Administration) that is in existence on the +date of enactment of this section shall not be terminated, reorganized, +or have any of it's powers or duties transferred unless such +termination, reorganization, or transfer is approved by Congress through +the adoption of a concurrent resolution of approval. + + (j) Rule of <<NOTE: 42 USC 237a note.>> Construction.--Nothing in +this section (or the amendments made by this section) shall be construed +to limit the authority of the Secretary of Health and Human Services +with respect to women's health, or with respect to activities carried +out through the Department of Health and Human Services on the date of +enactment of this section. + +SEC. 3510. PATIENT NAVIGATOR PROGRAM. + + Section 340A of the Public Health Service Act (42 U.S.C. 256a) is +amended-- + (1) by striking subsection (d)(3) and inserting the + following: + ``(3) Limitations on grant period.--In carrying out this + section, the Secretary shall ensure that the total period of a + grant does not exceed 4 years.''; + (2) in subsection (e), by adding at the end the following: + ``(3) Minimum core proficiencies.--The Secretary shall not + award a grant to an entity under this section unless such entity + provides assurances that patient navigators recruited, assigned, + trained, or employed using grant funds meet minimum core + proficiencies, as defined by the entity that submits the + application, that are tailored for the main focus or + intervention of the navigator involved.''; and + (3) in subsection (m)-- + (A) in paragraph (1), by striking ``and $3,500,000 + for fiscal year 2010.'' and inserting ``$3,500,000 for + fiscal year 2010, and such sums as may be necessary for + each of fiscal years 2011 through 2015.''; and + (B) in paragraph (2), by striking ``2010'' and + inserting ``2015''. + +[[Page 124 STAT. 538]] + +SEC. 3511. AUTHORIZATION OF APPROPRIATIONS. + + Except where otherwise provided in this subtitle (or an amendment +made by this subtitle), there is authorized to be appropriated such sums +as may be necessary to carry out this subtitle (and such amendments made +by this subtitle). + + Subtitle G--Protecting and Improving Guaranteed Medicare Benefits + +SEC. 3601. PROTECTING <<NOTE: 42 USC 1395 note.>> AND IMPROVING + GUARANTEED MEDICARE BENEFITS. + + (a) Protecting Guaranteed Medicare Benefits.--Nothing in the +provisions of, or amendments made by, this Act shall result in a +reduction of guaranteed benefits under title XVIII of the Social +Security Act. + (b) Ensuring That Medicare Savings Benefit the Medicare Program and +Medicare Beneficiaries.--Savings generated for the Medicare program +under title XVIII of the Social Security Act under the provisions of, +and amendments made by, this Act shall extend the solvency of the +Medicare trust funds, reduce Medicare premiums and other cost-sharing +for beneficiaries, and improve or expand guaranteed Medicare benefits +and protect access to Medicare providers. + +SEC. 3602. NO <<NOTE: 42 USC 1395w-21 note.>> CUTS IN GUARANTEED + BENEFITS. + + Nothing in this Act shall result in the reduction or elimination of +any benefits guaranteed by law to participants in Medicare Advantage +plans. + + TITLE IV--PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH + + Subtitle A--Modernizing Disease Prevention and Public Health Systems + +SEC. 4001. NATIONAL <<NOTE: 42 USC 300u-10.>> PREVENTION, HEALTH + PROMOTION AND PUBLIC HEALTH COUNCIL. + + (a) Establishment.--The President <<NOTE: President.>> shall +establish, within the Department of Health and Human Services, a council +to be known as the ``National Prevention, Health Promotion and Public +Health Council'' (referred to in this section as the ``Council''). + + (b) Chairperson.--The +President <<NOTE: President. Appointment.>> shall appoint the Surgeon +General to serve as the chairperson of the Council. + + (c) Composition.--The Council shall be composed of-- + (1) the Secretary of Health and Human Services; + (2) the Secretary of Agriculture; + (3) the Secretary of Education; + (4) the Chairman of the Federal Trade Commission; + (5) the Secretary of Transportation; + (6) the Secretary of Labor; + (7) the Secretary of Homeland Security; + +[[Page 124 STAT. 539]] + + (8) the Administrator of the Environmental Protection + Agency; + (9) the Director of the Office of National Drug Control + Policy; + (10) the Director of the Domestic Policy Council; + (11) the Assistant Secretary for Indian Affairs; + (12) the Chairman of the Corporation for National and + Community Service; and + (13) the head of any other Federal agency that the + chairperson determines is appropriate. + + (d) Purposes and Duties.--The Council shall-- + (1) provide coordination and leadership at the Federal + level, and among all Federal departments and agencies, with + respect to prevention, wellness and health promotion practices, + the public health system, and integrative health care in the + United States; + (2) after obtaining input from relevant stakeholders, + develop a national prevention, health promotion, public health, + and integrative health care strategy that incorporates the most + effective and achievable means of improving the health status of + Americans and reducing the incidence of preventable illness and + disability in the United States; + (3) provide recommendations to the President and Congress + concerning the most pressing health issues confronting the + United States and changes in Federal policy to achieve national + wellness, health promotion, and public health goals, including + the reduction of tobacco use, sedentary behavior, and poor + nutrition; + (4) consider and propose evidence-based models, policies, + and innovative approaches for the promotion of transformative + models of prevention, integrative health, and public health on + individual and community levels across the United States; + (5) establish processes for continual public input, + including input from State, regional, and local leadership + communities and other relevant stakeholders, including Indian + tribes and tribal organizations; + (6) submit the reports required under subsection (g); and + (7) carry out other activities determined appropriate by the + President. + + (e) Meetings.--The Council shall meet at the call of the +Chairperson. + (f) Advisory <<NOTE: President.>> Group.-- + (1) In general.--The <<NOTE: Establishment.>> President + shall establish an Advisory Group to the Council to be known as + the ``Advisory Group on Prevention, Health Promotion, and + Integrative and Public Health'' (hereafter referred to in this + section as the ``Advisory Group''). The Advisory Group shall be + within the Department of Health and Human Services and report to + the Surgeon General. + (2) Composition.-- + (A) In general.--The Advisory Group shall be + composed of not more than 25 non-Federal members to be + appointed by the President. + (B) Representation.--In appointing members under + subparagraph (A), the President shall ensure that the + Advisory Group includes a diverse group of licensed + health + +[[Page 124 STAT. 540]] + + professionals, including integrative health + practitioners who have expertise in-- + (i) worksite health promotion; + (ii) community services, including community + health centers; + (iii) preventive medicine; + (iv) health coaching; + (v) public health education; + (vi) geriatrics; and + (vii) rehabilitation medicine. + (3) Purposes and duties.--The Advisory Group shall develop + policy and program recommendations and advise the Council on + lifestyle-based chronic disease prevention and management, + integrative health care practices, and health promotion. + + (g) National Prevention and Health Promotion Strategy.-- +Not <<NOTE: Deadline. Public information.>> later than 1 year after the +date of enactment of this Act, the Chairperson, in consultation with the +Council, shall develop and make public a national prevention, health +promotion and public health strategy, and shall review and revise such +strategy periodically. Such strategy shall-- + (1) set specific goals and objectives for improving the + health of the United States through federally-supported + prevention, health promotion, and public health programs, + consistent with ongoing goal setting efforts conducted by + specific agencies; + (2) establish specific and measurable actions and timelines + to carry out the strategy, and determine accountability for + meeting those timelines, within and across Federal departments + and agencies; and + (3) make recommendations to improve Federal efforts relating + to prevention, health promotion, public health, and integrative + health care practices to ensure Federal efforts are consistent + with available standards and evidence. + + (h) Report.--Not later than July 1, 2010, and annually thereafter +through January 1, 2015, the Council shall submit to the President and +the relevant committees of Congress, a report that-- + (1) describes the activities and efforts on prevention, + health promotion, and public health and activities to develop a + national strategy conducted by the Council during the period for + which the report is prepared; + (2) describes the national progress in meeting specific + prevention, health promotion, and public health goals defined in + the strategy and further describes corrective actions + recommended by the Council and taken by relevant agencies and + organizations to meet these goals; + (3) contains a list of national priorities on health + promotion and disease prevention to address lifestyle behavior + modification (smoking cessation, proper nutrition, appropriate + exercise, mental health, behavioral health, substance use + disorder, and domestic violence screenings) and the prevention + measures for the 5 leading disease killers in the United States; + (4) contains specific science-based initiatives to achieve + the measurable goals of Healthy People 2010 regarding nutrition, + exercise, and smoking cessation, and targeting the 5 leading + disease killers in the United States; + (5) contains specific plans for consolidating Federal health + programs and Centers that exist to promote healthy behavior + +[[Page 124 STAT. 541]] + + and reduce disease risk (including eliminating programs and + offices determined to be ineffective in meeting the priority + goals of Healthy People 2010); + (6) contains specific plans to ensure that all Federal + health care programs are fully coordinated with science-based + prevention recommendations by the Director of the Centers for + Disease Control and Prevention; and + (7) contains specific plans to ensure that all non- + Department of Health and Human Services prevention programs are + based on the science-based guidelines developed by the Centers + for Disease Control and Prevention under paragraph (4). + + (i) Periodic Reviews.--The +Secretary <<NOTE: Deadlines. Evaluations.>> and the Comptroller General +of the United States shall jointly conduct periodic reviews, not less +than every 5 years, and evaluations of every Federal disease prevention +and health promotion initiative, program, and agency. Such <<NOTE: Web +posting.>> reviews shall be evaluated based on effectiveness in meeting +metrics-based goals with an analysis posted on such agencies' public +Internet websites. + +SEC. 4002. PREVENTION <<NOTE: 42 USC 300u-11.>> AND PUBLIC HEALTH FUND. + + (a) Purpose.--It is the purpose of this section to establish a +Prevention and Public Health Fund (referred to in this section as the +``Fund''), to be administered through the Department of Health and Human +Services, Office of the Secretary, to provide for expanded and sustained +national investment in prevention and public health programs to improve +health and help restrain the rate of growth in private and public sector +health care costs. + (b) Funding.--There are hereby authorized to be appropriated, and +appropriated, to the Fund, out of any monies in the Treasury not +otherwise appropriated-- + (1) for fiscal year 2010, $500,000,000; + (2) for fiscal year 2011, $750,000,000; + (3) for fiscal year 2012, $1,000,000,000; + (4) for fiscal year 2013, $1,250,000,000; + (5) for fiscal year 2014, $1,500,000,000; and + (6) for fiscal year 2015, and each fiscal year thereafter, + $2,000,000,000. + + (c) Use of Fund.--The Secretary shall transfer amounts in the Fund +to accounts within the Department of Health and Human Services to +increase funding, over the fiscal year 2008 level, for programs +authorized by the Public Health Service Act, for prevention, wellness, +and public health activities including prevention research and health +screenings, such as the Community Transformation grant program, the +Education and Outreach Campaign for Preventive Benefits, and +immunization programs. + (d) Transfer Authority.--The Committee on Appropriations of the +Senate and the Committee on Appropriations of the House of +Representatives may provide for the transfer of funds in the Fund to +eligible activities under this section, subject to subsection (c). + +SEC. 4003. CLINICAL AND COMMUNITY PREVENTIVE SERVICES. + + (a) Preventive Services Task Force.--Section 915 of the Public +Health Service Act (42 U.S.C. 299b-4) is amended by striking subsection +(a) and inserting the following: + ``(a) Preventive Services Task Force.-- + ``(1) Establishment and purpose.--The Director shall convene + an independent Preventive Services Task Force (referred + +[[Page 124 STAT. 542]] + + to in this subsection as the `Task Force') to be composed of + individuals with appropriate expertise. Such Task Force shall + review the scientific evidence related to the effectiveness, + appropriateness, and cost-effectiveness of clinical preventive + services for the purpose of developing recommendations for the + health care community, and updating previous clinical preventive + recommendations, to be published in the Guide to Clinical + Preventive Services (referred to in this section as the + `Guide'), for individuals and organizations delivering clinical + services, including primary care professionals, health care + systems, professional societies, employers, community + organizations, non-profit organizations, Congress and other + policy-makers, governmental public health agencies, health care + quality organizations, and organizations developing national + health objectives. Such recommendations shall consider clinical + preventive best practice recommendations from the Agency for + Healthcare Research and Quality, the National Institutes of + Health, the Centers for Disease Control and Prevention, the + Institute of Medicine, specialty medical associations, patient + groups, and scientific societies. + ``(2) Duties.--The duties of the Task Force shall include-- + ``(A) the development of additional topic areas for + new recommendations and interventions related to those + topic areas, including those related to specific sub- + populations and age groups; + ``(B) at least once during every 5-year period, + review interventions and update recommendations related + to existing topic areas, including new or improved + techniques to assess the health effects of + interventions; + ``(C) improved integration with Federal Government + health objectives and related target setting for health + improvement; + ``(D) the enhanced dissemination of recommendations; + ``(E) the provision of technical assistance to those + health care professionals, agencies and organizations + that request help in implementing the Guide + recommendations; and + ``(F) the submission of yearly reports to Congress + and related agencies identifying gaps in research, such + as preventive services that receive an insufficient + evidence statement, and recommending priority areas that + deserve further examination, including areas related to + populations and age groups not adequately addressed by + current recommendations. + ``(3) Role of agency.--The Agency shall provide ongoing + administrative, research, and technical support for the + operations of the Task Force, including coordinating and + supporting the dissemination of the recommendations of the Task + Force, ensuring adequate staff resources, and assistance to + those organizations requesting it for implementation of the + Guide's recommendations. + ``(4) Coordination with community preventive services task + force.--The Task Force shall take appropriate steps to + coordinate its work with the Community Preventive Services Task + Force and the Advisory Committee on Immunization Practices, + including the examination of how each task force's + recommendations interact at the nexus of clinic and community. + +[[Page 124 STAT. 543]] + + ``(5) Operation.--Operation. In carrying out the duties + under paragraph (2), the Task Force is not subject to the + provisions of Appendix 2 of title 5, United States Code. + ``(6) Independence.--All members of the Task Force convened + under this subsection, and any recommendations made by such + members, shall be independent and, to the extent practicable, + not subject to political pressure. + ``(7) Authorization of appropriations.--There are authorized + to be appropriated such sums as may be necessary for each fiscal + year to carry out the activities of the Task Force.''. + + (b) Community Preventive Services Task Force.-- + (1) In general.--Part P of title III of the Public Health + Service Act, as amended by paragraph (2), is amended by adding + at the end the following: + +``SEC. 399U. COMMUNITY <<NOTE: 42 USC 280g-10.>> PREVENTIVE SERVICES + TASK FORCE. + + ``(a) Establishment and Purpose.--The Director of the Centers for +Disease Control and Prevention shall convene an independent Community +Preventive Services Task Force (referred to in this subsection as the +`Task Force') to be composed of individuals with appropriate expertise. +Such <<NOTE: Review. Recommenda- tions. Publication.>> Task Force shall +review the scientific evidence related to the effectiveness, +appropriateness, and cost-effectiveness of community preventive +interventions for the purpose of developing recommendations, to be +published in the Guide to Community Preventive Services (referred to in +this section as the `Guide'), for individuals and organizations +delivering population-based services, including primary care +professionals, health care systems, professional societies, employers, +community organizations, non-profit organizations, schools, governmental +public health agencies, Indian tribes, tribal organizations and urban +Indian organizations, medical groups, Congress and other policy-makers. +Community preventive services include any policies, programs, processes +or activities designed to affect or otherwise affecting health at the +population level. + + ``(b) Duties.--The duties of the Task Force shall include-- + ``(1) the development of additional topic areas for new + recommendations and interventions related to those topic areas, + including those related to specific populations and age groups, + as well as the social, economic and physical environments that + can have broad effects on the health and disease of populations + and health disparities among sub-populations and age groups; + ``(2) at least once during every 5-year period, review + interventions and update recommendations related to existing + topic areas, including new or improved techniques to assess the + health effects of interventions, including health impact + assessment and population health modeling; + ``(3) improved integration with Federal Government health + objectives and related target setting for health improvement; + ``(4) the enhanced dissemination of recommendations; + ``(5) the provision of technical assistance to those health + care professionals, agencies, and organizations that request + help in implementing the Guide recommendations; and + ``(6) providing yearly reports to Congress and related + agencies identifying gaps in research and recommending priority + areas that deserve further examination, including areas related + +[[Page 124 STAT. 544]] + + to populations and age groups not adequately addressed by + current recommendations. + + ``(c) Role of Agency.--The Director shall provide ongoing +administrative, research, and technical support for the operations of +the Task Force, including coordinating and supporting the dissemination +of the recommendations of the Task Force, ensuring adequate staff +resources, and assistance to those organizations requesting it for +implementation of Guide recommendations. + ``(d) Coordination With Preventive Services Task Force.--The Task +Force shall take appropriate steps to coordinate its work with the U.S. +Preventive Services Task Force and the Advisory Committee on +Immunization Practices, including the examination of how each task +force's recommendations interact at the nexus of clinic and community. + ``(e) Operation.--In carrying out the duties under subsection (b), +the Task Force shall not be subject to the provisions of Appendix 2 of +title 5, United States Code. + ``(f) Authorization of Appropriations.--There are authorized to be +appropriated such sums as may be necessary for each fiscal year to carry +out the activities of the Task Force.''. + (2) Technical amendments.-- + (A) Section 399R of the Public Health Service Act + (as added by section 2 of the ALS Registry Act (Public + Law 110-373; 122 Stat. 4047)) <<NOTE: 42 USC 280g- + 7.>> is redesignated as section 399S. + (B) Section 399R of such Act (as added by section 3 + of the Prenatally and Postnatally Diagnosed Conditions + Awareness <<NOTE: 42 USC 280g-8.>> Act (Public Law 110- + 374; 122 Stat. 4051)) is redesignated as section 399T. + +SEC. 4004. EDUCATION <<NOTE: 42 USC 300u-12.>> AND OUTREACH CAMPAIGN + REGARDING PREVENTIVE BENEFITS. + + (a) In General.--The Secretary of Health and Human Services +(referred to in this section as the ``Secretary'') shall provide for the +planning and implementation of a national public-private partnership for +a prevention and health promotion outreach and education campaign to +raise public awareness of health improvement across the life span. Such +campaign shall include the dissemination of information that-- + (1) describes the importance of utilizing preventive + services to promote wellness, reduce health disparities, and + mitigate chronic disease; + (2) promotes the use of preventive services recommended by + the United States Preventive Services Task Force and the + Community Preventive Services Task Force; + (3) encourages healthy behaviors linked to the prevention of + chronic diseases; + (4) explains the preventive services covered under health + plans offered through a Gateway; + (5) describes additional preventive care supported by the + Centers for Disease Control and Prevention, the Health Resources + and Services Administration, the Substance Abuse and Mental + Health Services Administration, the Advisory Committee on + Immunization Practices, and other appropriate agencies; and + (6) includes general health promotion information. + +[[Page 124 STAT. 545]] + + (b) Consultation.--In coordinating the campaign under subsection +(a), the Secretary shall consult with the Institute of Medicine to +provide ongoing advice on evidence-based scientific information for +policy, program development, and evaluation. + (c) Media Campaign.-- + (1) In general.--Not <<NOTE: Deadline.>> later than 1 year + after the date of enactment of this Act, the Secretary, acting + through the Director of the Centers for Disease Control and + Prevention, shall establish and implement a national science- + based media campaign on health promotion and disease prevention. + (2) Requirement of campaign.--The campaign implemented under + paragraph (1)-- + (A) shall be designed to address proper nutrition, + regular exercise, smoking cessation, obesity reduction, + the 5 leading disease killers in the United States, and + secondary prevention through disease screening + promotion; + (B) shall be carried out through competitively bid + contracts awarded to entities providing for the + professional production and design of such campaign; + (C) may include the use of television, radio, + Internet, and other commercial marketing venues and may + be targeted to specific age groups based on peer- + reviewed social research; + (D) shall not be duplicative of any other Federal + efforts relating to health promotion and disease + prevention; and + (E) may include the use of humor and nationally + recognized positive role models. + (3) Evaluation.--The <<NOTE: Deadlines. Reports.>> Secretary + shall ensure that the campaign implemented under paragraph (1) + is subject to an independent evaluation every 2 years and shall + report every 2 years to Congress on the effectiveness of such + campaigns towards meeting science-based metrics. + + (d) Website.--The Secretary, in consultation with private-sector +experts, shall maintain or enter into a contract to maintain an Internet +website to provide science-based information on guidelines for +nutrition, regular exercise, obesity reduction, smoking cessation, and +specific chronic disease prevention. Such website shall be designed to +provide information to health care providers and consumers. + (e) Dissemination of <<NOTE: Plan.>> Information Through +Providers.--The Secretary, acting through the Centers for Disease +Control and Prevention, shall develop and implement a plan for the +dissemination of health promotion and disease prevention information +consistent with national priorities, to health care providers who +participate in Federal programs, including programs administered by the +Indian Health Service, the Department of Veterans Affairs, the +Department of Defense, and the Health Resources and Services +Administration, and Medicare and Medicaid. + + (f) Personalized Prevention Plans.-- + (1) Contract.--The Secretary, <<NOTE: Web site.>> acting + through the Director of the Centers for Disease Control and + Prevention, shall enter into a contract with a qualified entity + for the development and operation of a Federal Internet website + personalized prevention plan tool. + (2) Use.--The website developed under paragraph (1) shall be + designed to be used as a source of the most up-to-date + scientific evidence relating to disease prevention for use by + +[[Page 124 STAT. 546]] + + individuals. Such website shall contain a component that enables + an individual to determine their disease risk (based on personal + health and family history, BMI, and other relevant information) + relating to the 5 leading diseases in the United States, and + obtain personalized suggestions for preventing such diseases. + + (g) Internet Portal.--The Secretary shall establish an Internet +portal for accessing risk-assessment tools developed and maintained by +private and academic entities. + (h) Priority Funding.--Funding for the activities authorized under +this section shall take priority over funding provided through the +Centers for Disease Control and Prevention for grants to States and +other entities for similar purposes and goals as provided for in this +section. Not to exceed $500,000,000 shall be expended on the campaigns +and activities required under this section. + (i) Public Awareness of Preventive and Obesity-related Services.-- + (1) Information to states.--The Secretary of Health and + Human Services shall provide guidance and relevant information + to States and health care providers regarding preventive and + obesity-related services that are available to Medicaid + enrollees, including obesity screening and counseling for + children and adults. + (2) Information to enrollees.--Each State shall design a + public awareness campaign to educate Medicaid enrollees + regarding availability and coverage of such services, with the + goal of reducing incidences of obesity. + (3) Report.--Not later than January 1, 2011, and every 3 + years thereafter through January 1, 2017, the Secretary of + Health and Human Services shall report to Congress on the status + and effectiveness of efforts under paragraphs (1) and (2), + including summaries of the States' efforts to increase awareness + of coverage of obesity-related services. + + (j) Authorization of Appropriations.--There are authorized to be +appropriated such sums as may be necessary to carry out this section. + + Subtitle B--Increasing Access to Clinical Preventive Services + +SEC. 4101. SCHOOL-BASED HEALTH CENTERS. + + (a) Grants <<NOTE: 42 USC 280h-4.>> for the Establishment of School- +based Health Centers.-- + (1) Program.--The Secretary of Health and Human Services (in + this subsection referred to as the ``Secretary'') shall + establish a program to award grants to eligible entities to + support the operation of school-based health centers. + (2) Eligibility.--To be eligible for a grant under this + subsection, an entity shall-- + (A) be a school-based health center or a sponsoring + facility of a school-based health center; and + (B) submit an application at such time, in such + manner, and containing such information as the Secretary + may require, including at a minimum an assurance that + funds awarded under the grant shall not be used to + provide + +[[Page 124 STAT. 547]] + + any service that is not authorized or allowed by + Federal, State, or local law. + (3) Preference.--In awarding grants under this section, the + Secretary shall give preference to awarding grants for school- + based health centers that serve a large population of children + eligible for medical assistance under the State Medicaid plan + under title XIX of the Social Security Act or under a waiver of + such plan or children eligible for child health assistance under + the State child health plan under title XXI of that Act (42 + U.S.C. 1397aa et seq.). + (4) Limitation on use of funds.--An eligible entity shall + use funds provided under a grant awarded under this subsection + only for expenditures for facilities (including the acquisition + or improvement of land, or the acquisition, construction, + expansion, replacement, or other improvement of any building or + other facility), equipment, or similar expenditures, as + specified by the Secretary. No funds provided under a grant + awarded under this section shall be used for expenditures for + personnel or to provide health services. + (5) Appropriations.--Out of any funds in the Treasury not + otherwise appropriated, there is appropriated for each of fiscal + years 2010 through 2013, $50,000,000 for the purpose of carrying + out this subsection. Funds appropriated under this paragraph + shall remain available until expended. + (6) Definitions.--In this subsection, the terms ``school- + based health center'' and ``sponsoring facility'' have the + meanings given those terms in section 2110(c)(9) of the Social + Security Act (42 U.S.C. 1397jj(c)(9)). + + (b) Grants for the Operation of School-based Health Centers.--Part Q +of title III of the Public Health Service Act (42 U.S.C. 280h et seq.) +is amended by adding at the end the following: + +``SEC. 399Z-1. <<NOTE: 42 USC 280h-5.>> SCHOOL-BASED HEALTH CENTERS. + + ``(a) Definitions; Establishment of Criteria.--In this section: + ``(1) Comprehensive primary health services.--The term + `comprehensive primary health services' means the core services + offered by school-based health centers, which shall include the + following: + ``(A) Physical.--Comprehensive health assessments, + diagnosis, and treatment of minor, acute, and chronic + medical conditions, and referrals to, and follow-up for, + specialty care and oral health services. + ``(B) Mental health.--Mental health and substance + use disorder assessments, crisis intervention, + counseling, treatment, and referral to a continuum of + services including emergency psychiatric care, community + support programs, inpatient care, and outpatient + programs. + ``(2) Medically underserved children and adolescents.-- + ``(A) In general.--The term `medically underserved + children and adolescents' means a population of children + and adolescents who are residents of an area designated + as a medically underserved area or a health professional + shortage area by the Secretary. + ``(B) Criteria.--The Secretary shall prescribe + criteria for determining the specific shortages of + personal health + +[[Page 124 STAT. 548]] + + services for medically underserved children and + adolescents under subparagraph (A) that shall-- + ``(i) take into account any comments received + by the Secretary from the chief executive officer + of a State and local officials in a State; and + ``(ii) include factors indicative of the + health status of such children and adolescents of + an area, including the ability of the residents of + such area to pay for health services, the + accessibility of such services, the availability + of health professionals to such children and + adolescents, and other factors as determined + appropriate by the Secretary. + ``(3) School-based health center.--The term `school-based + health center' means a health clinic that-- + ``(A) meets the definition of a school-based health + center under section 2110(c)(9)(A) of the Social + Security Act and is administered by a sponsoring + facility (as defined in section 2110(c)(9)(B) of the + Social Security Act); + ``(B) provides, at a minimum, comprehensive primary + health services during school hours to children and + adolescents by health professionals in accordance with + established standards, community practice, reporting + laws, and other State laws, including parental consent + and notification laws that are not inconsistent with + Federal law; and + ``(C) does not perform abortion services. + + ``(b) Authority To Award Grants.--The Secretary shall award grants +for the costs of the operation of school-based health centers (referred +to in this section as `SBHCs') that meet the requirements of this +section. + ``(c) Applications.--To be eligible to receive a grant under this +section, an entity shall-- + ``(1) be an SBHC (as defined in subsection (a)(3)); and + ``(2) submit to the Secretary an application at such time, + in such manner, and containing-- + ``(A) evidence that the applicant meets all criteria + necessary to be designated an SBHC; + ``(B) evidence of local need for the services to be + provided by the SBHC; + ``(C) an assurance that-- + ``(i) SBHC services will be provided to those + children and adolescents for whom parental or + guardian consent has been obtained in cooperation + with Federal, State, and local laws governing + health care service provision to children and + adolescents; + ``(ii) the SBHC has made and will continue to + make every reasonable effort to establish and + maintain collaborative relationships with other + health care providers in the catchment area of the + SBHC; + ``(iii) the SBHC will provide on-site access + during the academic day when school is in session + and 24-hour coverage through an on-call system and + through its backup health providers to ensure + access to services on a year-round basis when the + school or the SBHC is closed; + ``(iv) the SBHC will be integrated into the + school environment and will coordinate health + services with school personnel, such as + administrators, teachers, + +[[Page 124 STAT. 549]] + + nurses, counselors, and support personnel, as well + as with other community providers co-located at + the school; + ``(v) the SBHC sponsoring facility assumes all + responsibility for the SBHC administration, + operations, and oversight; and + ``(vi) the SBHC will comply with Federal, + State, and local laws concerning patient privacy + and student records, including regulations + promulgated under the Health Insurance Portability + and Accountability Act of 1996 and section 444 of + the General Education Provisions Act; and + ``(D) such other information as the Secretary may + require. + + ``(d) Preferences and Consideration.--In reviewing applications: + ``(1) The Secretary may give preference to applicants who + demonstrate an ability to serve the following: + ``(A) Communities that have evidenced barriers to + primary health care and mental health and substance use + disorder prevention services for children and + adolescents. + ``(B) Communities with high per capita numbers of + children and adolescents who are uninsured, + underinsured, or enrolled in public health insurance + programs. + ``(C) Populations of children and adolescents that + have historically demonstrated difficulty in accessing + health and mental health and substance use disorder + prevention services. + ``(2) The Secretary may give consideration to whether an + applicant has received a grant under subsection (a) of section + 4101 of the Patient Protection and Affordable Care Act. + + ``(e) Waiver of Requirements.--The Secretary may-- + ``(1) under appropriate circumstances, waive the application + of all or part of the requirements of this subsection with + respect to an SBHC for not to exceed 2 years; and + ``(2) upon a showing of good cause, waive the requirement + that the SBHC provide all required comprehensive primary health + services for a designated period of time to be determined by the + Secretary. + + ``(f) Use of Funds.-- + ``(1) Funds.--Funds awarded under a grant under this + section-- + ``(A) may be used for-- + ``(i) acquiring and leasing equipment + (including the costs of amortizing the principle + of, and paying interest on, loans for such + equipment); + ``(ii) providing training related to the + provision of required comprehensive primary health + services and additional health services; + ``(iii) the management and operation of health + center programs; + ``(iv) the payment of salaries for physicians, + nurses, and other personnel of the SBHC; and + ``(B) may not be used to provide abortions. + ``(2) Construction.--The Secretary may award grants which + may be used to pay the costs associated with expanding and + modernizing existing buildings for use as an SBHC, + +[[Page 124 STAT. 550]] + + including the purchase of trailers or manufactured buildings to + install on the school property. + ``(3) Limitations.-- + ``(A) In general.--Any provider of services that is + determined by a State to be in violation of a State law + described in subsection (a)(3)(B) with respect to + activities carried out at a SBHC shall not be eligible + to receive additional funding under this section. + ``(B) No overlapping grant period.--No entity that + has received funding under section 330 for a grant + period shall be eligible for a grant under this section + for with respect to the same grant period. + + ``(g) Matching Requirement.-- + ``(1) In general.--Each eligible entity that receives a + grant under this section shall provide, from non-Federal + sources, an amount equal to 20 percent of the amount of the + grant (which may be provided in cash or in-kind) to carry out + the activities supported by the grant. + ``(2) Waiver.--The Secretary may waive all or part of the + matching requirement described in paragraph (1) for any fiscal + year for the SBHC if the Secretary determines that applying the + matching requirement to the SBHC would result in serious + hardship or an inability to carry out the purposes of this + section. + + ``(h) Supplement, Not Supplant.--Grant funds provided under this +section shall be used to supplement, not supplant, other Federal or +State funds. + ``(i) Evaluation.--The Secretary shall develop and implement a plan +for evaluating SBHCs and monitoring quality performance under the awards +made under this section. + ``(j) Age Appropriate Services.--An eligible entity receiving funds +under this section shall only provide age appropriate services through a +SBHC funded under this section to an individual. + ``(k) Parental Consent.--An eligible entity receiving funds under +this section shall not provide services through a SBHC funded under this +section to an individual without the consent of the parent or guardian +of such individual if such individual is considered a minor under +applicable State law. + ``(l) Authorization of Appropriations.--For purposes of carrying out +this section, there are authorized to be appropriated such sums as may +be necessary for each of the fiscal years 2010 through 2014.''. + +SEC. 4102. ORAL HEALTHCARE PREVENTION ACTIVITIES. + + (a) In General.--Title III of the Public Health Service Act (42 +U.S.C. 241 et seq.), as amended by section 3025, is amended by adding at +the end the following: + + ``PART T--ORAL HEALTHCARE PREVENTION ACTIVITIES + +``SEC. 399LL. ORAL <<NOTE: 42 USC 280k.>> HEALTHCARE PREVENTION + EDUCATION CAMPAIGN. + + ``(a) Establishment.--The Secretary, acting through the Director of +the Centers for Disease Control and Prevention and in consultation with +professional oral health organizations, shall, subject to the +availability of appropriations, establish a 5-year national, public +education campaign (referred to in this section + +[[Page 124 STAT. 551]] + +as the `campaign') that is focused on oral healthcare prevention and +education, including prevention of oral disease such as early childhood +and other caries, periodontal disease, and oral cancer. + ``(b) Requirements.--In establishing the campaign, the Secretary +shall-- + ``(1) ensure that activities are targeted towards specific + populations such as children, pregnant women, parents, the + elderly, individuals with disabilities, and ethnic and racial + minority populations, including Indians, Alaska Natives and + Native Hawaiians (as defined in section 4(c) of the Indian + Health Care Improvement Act) in a culturally and linguistically + appropriate manner; and + ``(2) utilize science-based strategies to convey oral health + prevention messages that include, but are not limited to, + community water fluoridation and dental sealants. + + ``(c) Planning and Implementation.--Not +later <<NOTE: Deadline.>> than 2 years after the date of enactment of +this section, the Secretary shall begin implementing the 5-year +campaign. During the 2-year period referred to in the previous sentence, +the Secretary shall conduct planning activities with respect to the +campaign. + +``SEC. 399LL-1. RESEARCH-BASED <<NOTE: Grants. 42 USC 280k-1.>> DENTAL + CARIES DISEASE MANAGEMENT. + + ``(a) In General.--The Secretary, acting through the Director of the +Centers for Disease Control and Prevention, shall award demonstration +grants to eligible entities to demonstrate the effectiveness of +research-based dental caries disease management activities. + ``(b) Eligibility.--To be eligible for a grant under this section, +an entity shall-- + ``(1) be a community-based provider of dental services (as + defined by the Secretary), including a Federally-qualified + health center, a clinic of a hospital owned or operated by a + State (or by an instrumentality or a unit of government within a + State), a State or local department of health, a dental program + of the Indian Health Service, an Indian tribe or tribal + organization, or an urban Indian organization (as such terms are + defined in section 4 of the Indian Health Care Improvement Act), + a health system provider, a private provider of dental services, + medical, dental, public health, nursing, nutrition educational + institutions, or national organizations involved in improving + children's oral health; and + ``(2) submit <<NOTE: Submission.>> to the Secretary an + application at such time, in such manner, and containing such + information as the Secretary may require. + + ``(c) Use of Funds.--A grantee shall use amounts received under a +grant under this section to demonstrate the effectiveness of research- +based dental caries disease management activities. + ``(d) Use of Information.--The Secretary shall utilize information +generated from grantees under this section in planning and implementing +the public education campaign under section 399LL. + +``SEC. 399LL-2. AUTHORIZATION <<NOTE: 42 USC 280k-2.>> OF + APPROPRIATIONS. + + ``There is authorized to be appropriated to carry out this part, +such sums as may be necessary.''. + (b) School-based Sealant Programs.--Section 317M(c)(1) of the Public +Health Service Act (42 U.S.C. 247b-14(c)(1)) is amended by striking +``may award grants to States and Indian tribes'' and + +[[Page 124 STAT. 552]] + +inserting ``shall award a grant to each of the 50 States and territories +and to Indians, Indian tribes, tribal organizations and urban Indian +organizations (as such terms are defined in section 4 of the Indian +Health Care Improvement Act)''. + (c) Oral Health Infrastructure.--Section 317M of the Public Health +Service Act (42 U.S.C. 247b-14) is amended-- + (1) by redesignating subsections (d) and (e) as subsections + (e) and (f), respectively; and + (2) by inserting after subsection (c), the following: + + ``(d) Oral Health Infrastructure.-- + ``(1) Cooperative agreements.--The Secretary, acting through + the Director of the Centers for Disease Control and Prevention, + shall enter into cooperative agreements with State, territorial, + and Indian tribes or tribal organizations (as those terms are + defined in section 4 of the Indian Health Care Improvement Act) + to establish oral health leadership and program guidance, oral + health data collection and interpretation, (including + determinants of poor oral health among vulnerable populations), + a multi-dimensional delivery system for oral health, and to + implement science-based programs (including dental sealants and + community water fluoridation) to improve oral health. + ``(2) Authorization of appropriations.--There is authorized + to be appropriated such sums as necessary to carry out this + subsection for fiscal years 2010 through 2014.''. + + (d) Updating <<NOTE: 42 USC 280k-3.>> National Oral Healthcare +Surveillance Activities.-- + (1) PRAMS.-- + (A) In general.--The Secretary of Health and Human + Services (referred to in this subsection as the + ``Secretary'') shall carry out activities to update and + improve the Pregnancy Risk Assessment Monitoring System + (referred to in this section as ``PRAMS'') as it relates + to oral healthcare. + (B) State reports and mandatory measurements.-- + (i) In general.--Not later than 5 years after + the date of enactment of this Act, and every 5 + years thereafter, a State shall submit to the + Secretary a report concerning activities conducted + within the State under PRAMS. + (ii) Measurements.--The oral healthcare + measurements developed by the Secretary for use + under PRAMS shall be mandatory with respect to + States for purposes of the State reports under + clause (i). + (C) Funding.--There is authorized to be appropriated + to carry out this paragraph, such sums as may be + necessary. + (2) National health and nutrition examination survey.--The + Secretary shall develop oral healthcare components that shall + include tooth-level surveillance for inclusion in the National + Health and Nutrition Examination Survey. + Such <<NOTE: Deadline.>> components shall be updated by the + Secretary at least every 6 years. + For <<NOTE: Definition.>> purposes of this paragraph, the term + ``tooth-level surveillance'' means a clinical examination where + an examiner looks at each dental surface, on each tooth in the + mouth and as expanded by the Division of Oral Health of the + Centers for Disease Control and Prevention. + +[[Page 124 STAT. 553]] + + (3) Medical expenditures panel survey.--The Secretary shall + ensure that the Medical Expenditures Panel Survey by the Agency + for Healthcare Research and Quality includes the verification of + dental utilization, expenditure, and coverage findings through + conduct of a look-back analysis. + (4) National oral health surveillance system.-- + (A) Appropriations.--There is authorized to be + appropriated, such sums as may be necessary for each of + fiscal years 2010 through 2014 to increase the + participation of States in the National Oral Health + Surveillance System from 16 States to all 50 States, + territories, and District of Columbia. + (B) Requirements.--The Secretary shall ensure that + the National Oral Health Surveillance System include the + measurement of early childhood caries. + +SEC. 4103. MEDICARE COVERAGE OF ANNUAL WELLNESS VISIT PROVIDING A + PERSONALIZED PREVENTION PLAN. + + (a) Coverage of Personalized Prevention Plan Services.-- + (1) In general.--Section 1861(s)(2) of the Social Security + Act (42 U.S.C. 1395x(s)(2)) is amended-- + (A) in subparagraph (DD), by striking ``and'' at the + end; + (B) in subparagraph (EE), by adding ``and'' at the + end; and + (C) by adding at the end the following new + subparagraph: + ``(FF) personalized prevention plan services (as defined in + subsection (hhh));''. + (2) Conforming amendments.--Clauses (i) and (ii) of section + 1861(s)(2)(K) of the Social Security Act (42 U.S.C. + 1395x(s)(2)(K)) are each amended by striking ``subsection + (ww)(1)'' and inserting ``subsections (ww)(1) and (hhh)''. + + (b) Personalized Prevention Plan Services Defined.--Section 1861 of +the Social Security Act (42 U.S.C. 1395x) is amended by adding at the +end the following new subsection: + + ``Annual Wellness Visit + + ``(hhh)(1) The term `personalized prevention plan services' means +the creation of a plan for an individual-- + ``(A) that includes a health risk assessment (that meets the + guidelines established by the Secretary under paragraph (4)(A)) + of the individual that is completed prior to or as part of the + same visit with a health professional described in paragraph + (3); and + ``(B) that-- + ``(i) takes into account the results of the health + risk assessment; and + ``(ii) may contain the elements described in + paragraph (2). + + ``(2) Subject to paragraph (4)(H), the elements described in this +paragraph are the following: + ``(A) The establishment of, or an update to, the + individual's medical and family history. + ``(B) A list of current providers and suppliers that are + regularly involved in providing medical care to the individual + (including a list of all prescribed medications). + +[[Page 124 STAT. 554]] + + ``(C) A measurement of height, weight, body mass index (or + waist circumference, if appropriate), blood pressure, and other + routine measurements. + ``(D) Detection of any cognitive impairment. + ``(E) The establishment of, or an update to, the following: + ``(i) A screening schedule for the next 5 to 10 + years, as appropriate, based on recommendations of the + United States Preventive Services Task Force and the + Advisory Committee on Immunization Practices, and the + individual's health status, screening history, and age- + appropriate preventive services covered under this + title. + ``(ii) A list of risk factors and conditions for + which primary, secondary, or tertiary prevention + interventions are recommended or are underway, including + any mental health conditions or any such risk factors or + conditions that have been identified through an initial + preventive physical examination (as described under + subsection (ww)(1)), and a list of treatment options and + their associated risks and benefits. + ``(F) The furnishing of personalized health advice and a + referral, as appropriate, to health education or preventive + counseling services or programs aimed at reducing identified + risk factors and improving self-management, or community-based + lifestyle interventions to reduce health risks and promote self- + management and wellness, including weight loss, physical + activity, smoking cessation, fall prevention, and nutrition. + ``(G) Any other element determined appropriate by the + Secretary. + + ``(3) A health professional described in this paragraph is-- + ``(A) a physician; + ``(B) a practitioner described in clause (i) of section + 1842(b)(18)(C); or + ``(C) a medical professional (including a health educator, + registered dietitian, or nutrition professional) or a team of + medical professionals, as determined appropriate by the + Secretary, under the supervision of a physician. + + ``(4)(A) For <<NOTE: Deadline. Public +information. Guidelines.>> purposes of paragraph (1)(A), the Secretary, +not later than 1 year after the date of enactment of this subsection, +shall establish publicly available guidelines for health risk +assessments. Such guidelines shall be developed in consultation with +relevant groups and entities and shall provide that a health risk +assessment-- + ``(i) identify chronic diseases, injury risks, modifiable + risk factors, and urgent health needs of the individual; and + ``(ii) may be furnished-- + ``(I) through an interactive telephonic or web-based + program that meets the standards established under + subparagraph (B); + ``(II) during an encounter with a health care + professional; + ``(III) through community-based prevention programs; + or + ``(IV) through any other means the Secretary + determines appropriate to maximize accessibility and + ease of use by beneficiaries, while ensuring the privacy + of such beneficiaries. + +[[Page 124 STAT. 555]] + + ``(B) Not <<NOTE: Deadline. Standards. Communications and tele- +communications. Web site.>> later than 1 year after the date of +enactment of this subsection, the Secretary shall establish standards +for interactive telephonic or web-based programs used to furnish health +risk assessments under subparagraph (A)(ii)(I). The Secretary may +utilize any health risk assessment developed under section 4004(f) of +the Patient Protection and Affordable Care Act as part of the +requirement to develop a personalized prevention plan to comply with +this subparagraph. + + ``(C)(i) Not later <<NOTE: Deadline. Public information. Assessment +model.>> than 18 months after the date of enactment of this subsection, +the Secretary shall develop and make available to the public a health +risk assessment model. Such model shall meet the guidelines under +subparagraph (A) and may be used to meet the requirement under paragraph +(1)(A). + + ``(ii) Any health risk assessment that meets the guidelines under +subparagraph (A) and is approved by the Secretary may be used to meet +the requirement under paragraph (1)(A). + ``(D) The Secretary may coordinate with community-based entities +(including State Health Insurance Programs, Area Agencies on Aging, +Aging and Disability Resource Centers, and the Administration on Aging) +to-- + ``(i) ensure that health risk assessments are accessible to + beneficiaries; and + ``(ii) provide appropriate support for the completion of + health risk assessments by beneficiaries. + + ``(E) The <<NOTE: Procedures.>> Secretary shall establish procedures +to make beneficiaries and providers aware of the requirement that a +beneficiary complete a health risk assessment prior to or at the same +time as receiving personalized prevention plan services. + + ``(F) To the extent practicable, the Secretary shall encourage the +use of, integration with, and coordination of health information +technology (including use of technology that is compatible with +electronic medical records and personal health records) and may +experiment with the use of personalized technology to aid in the +development of self-management skills and management of and adherence to +provider recommendations in order to improve the health status of +beneficiaries. + ``(G)(i) A beneficiary shall only be eligible to receive an initial +preventive physical examination (as defined under subsection (ww)(1)) at +any time during the 12-month period after the date that the +beneficiary's coverage begins under part B and shall be eligible to +receive personalized prevention plan services under this subsection +provided that the beneficiary has not received such services within the +preceding 12-month period. + ``(ii) The Secretary <<NOTE: Procedures.>> shall establish +procedures to make beneficiaries aware of the option to select an +initial preventive physical examination or personalized prevention plan +services during the period of 12 months after the date that a +beneficiary's coverage begins under part B, which shall include +information regarding any relevant differences between such services. + + ``(H) The <<NOTE: Guidance.>> Secretary shall issue guidance that-- + ``(i) identifies elements under paragraph (2) that are + required to be provided to a beneficiary as part of their first + visit for personalized prevention plan services; and + ``(ii) establishes a yearly schedule for appropriate + provision of such elements thereafter.''. + + (c) Payment and Elimination of Cost-Sharing.-- + +[[Page 124 STAT. 556]] + + (1) Payment and elimination of coinsurance.--Section + 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is + amended-- + (A) in subparagraph (N), by inserting ``other than + personalized prevention plan services (as defined in + section 1861(hhh)(1))'' after ``(as defined in section + 1848(j)(3))''; + (B) by striking ``and'' before ``(W)''; and + (C) by inserting before the semicolon at the end the + following: ``, and (X) with respect to personalized + prevention plan services (as defined in section + 1861(hhh)(1)), the amount paid shall be 100 percent of + the lesser of the actual charge for the services or the + amount determined under the payment basis determined + under section 1848''. + (2) Payment under physician fee schedule.--Section + 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w-4(j)(3)) + is amended by inserting ``(2)(FF) (including administration of + the health risk assessment) ,'' after ``(2)(EE),''. + (3) Elimination of coinsurance in outpatient hospital + settings.-- + (A) Exclusion from opd fee schedule.--Section + 1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. + 1395l(t)(1)(B)(iv)) is amended by striking ``and + diagnostic mammography'' and inserting ``, diagnostic + mammography, or personalized prevention plan services + (as defined in section 1861(hhh)(1))''. + (B) Conforming amendments.--Section 1833(a)(2) of + the Social Security Act (42 U.S.C. 1395l(a)(2)) is + amended-- + (i) in subparagraph (F), by striking ``and'' + at the end; + (ii) in subparagraph (G)(ii), by striking the + comma at the end and inserting ``; and''; and + (iii) by inserting after subparagraph (G)(ii) + the following new subparagraph: + ``(H) with respect to personalized prevention plan + services (as defined in section 1861(hhh)(1)) furnished + by an outpatient department of a hospital, the amount + determined under paragraph (1)(X),''. + (4) Waiver of application of deductible.--The first sentence + of section 1833(b) of the Social Security Act (42 U.S.C. + 1395l(b)) is amended-- + (A) by striking ``and'' before ``(9)''; and + (B) by inserting before the period the following: + ``, and (10) such deductible shall not apply with + respect to personalized prevention plan services (as + defined in section 1861(hhh)(1))''. + + (d) Frequency Limitation.--Section 1862(a) of the Social Security +Act (42 U.S.C. 1395y(a)) is amended-- + (1) in paragraph (1)-- + (A) in subparagraph (N), by striking ``and'' at the + end; + (B) in subparagraph (O), by striking the semicolon + at the end and inserting ``, and''; and + (C) by adding at the end the following new + subparagraph: + ``(P) in the case of personalized prevention plan services + (as defined in section 1861(hhh)(1)), which are performed more + frequently than is covered under such section;''; and + +[[Page 124 STAT. 557]] + + (2) in paragraph (7), by striking ``or (K)'' and inserting + ``(K), or (P)''. + + (e) Effective <<NOTE: 42 USC 1395l note.>> Date.--The amendments +made by this section shall apply to services furnished on or after +January 1, 2011. + +SEC. 4104. REMOVAL OF BARRIERS TO PREVENTIVE SERVICES IN MEDICARE. + + (a) Definition of Preventive Services.--Section 1861(ddd) of the +Social Security Act (42 U.S.C. 1395x(ddd)) is amended-- + (1) in the heading, by inserting ``; Preventive Services'' + after ``Services''; + (2) in paragraph (1), by striking ``not otherwise described + in this title'' and inserting ``not described in subparagraph + (A) or (C) of paragraph (3)''; and + (3) by adding at the end the following new paragraph: + + ``(3) The term `preventive services' means the following: + ``(A) The screening and preventive services described in + subsection (ww)(2) (other than the service described in + subparagraph (M) of such subsection). + ``(B) An initial preventive physical examination (as defined + in subsection (ww)). + ``(C) Personalized prevention plan services (as defined in + subsection (hhh)(1)).''. + + (b) Coinsurance.-- + (1) General application.-- + (A) In general.--Section 1833(a)(1) of the Social + Security Act (42 U.S.C. 1395l(a)(1)), as amended by + section 4103(c)(1), is amended-- + (i) in subparagraph (T), by inserting ``(or + 100 percent if such services are recommended with + a grade of A or B by the United States Preventive + Services Task Force for any indication or + population and are appropriate for the + individual)'' after ``80 percent''; + (ii) in subparagraph (W)-- + (I) in clause (i), by inserting + ``(if such subparagraph were applied, by + substituting `100 percent' for `80 + percent')'' after ``subparagraph (D)''; + and + (II) in clause (ii), by striking + ``80 percent'' and inserting ``100 + percent''; + (iii) by striking ``and'' before ``(X)''; and + (iv) by inserting before the semicolon at the + end the following: ``, and (Y) with respect to + preventive services described in subparagraphs (A) + and (B) of section 1861(ddd)(3) that are + appropriate for the individual and, in the case of + such services described in subparagraph (A), are + recommended with a grade of A or B by the United + States Preventive Services Task Force for any + indication or population, the amount paid shall be + 100 percent of the lesser of the actual charge for + the services or the amount determined under the + fee schedule that applies to such services under + this part''. + (2) Elimination of coinsurance in outpatient hospital + settings.-- + (A) Exclusion from opd fee schedule.--Section + 1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. + +[[Page 124 STAT. 558]] + + 1395l(t)(1)(B)(iv)), as amended by section + 4103(c)(3)(A), is amended-- + (i) by striking ``or'' before ``personalized + prevention plan services''; and + (ii) by inserting before the period the + following: ``, or preventive services described in + subparagraphs (A) and (B) of section 1861(ddd)(3) + that are appropriate for the individual and, in + the case of such services described in + subparagraph (A), are recommended with a grade of + A or B by the United States Preventive Services + Task Force for any indication or population''. + (B) Conforming amendments.--Section 1833(a)(2) of + the Social Security Act (42 U.S.C. 1395l(a)(2)), as + amended by section 4103(c)(3)(B), is amended-- + (i) in subparagraph (G)(ii), by striking + ``and'' after the semicolon at the end; + (ii) in subparagraph (H), by striking the + comma at the end and inserting ``; and''; and + (iii) by inserting after subparagraph (H) the + following new subparagraph: + ``(I) with respect to preventive services described + in subparagraphs (A) and (B) of section 1861(ddd)(3) + that are appropriate for the individual and are + furnished by an outpatient department of a hospital and, + in the case of such services described in subparagraph + (A), are recommended with a grade of A or B by the + United States Preventive Services Task Force for any + indication or population, the amount determined under + paragraph (1)(W) or (1)(Y),''. + + (c) Waiver of Application of Deductible for Preventive Services and +Colorectal Cancer Screening Tests.--Section 1833(b) of the Social +Security Act (42 U.S.C. 1395l(b)), as amended by section 4103(c)(4), is +amended-- + (1) in paragraph (1), by striking ``items and services + described in section 1861(s)(10)(A)'' and inserting ``preventive + services described in subparagraph (A) of section 1861(ddd)(3) + that are recommended with a grade of A or B by the United States + Preventive Services Task Force for any indication or population + and are appropriate for the individual.''; and + (2) by adding at the end the following new sentence: + ``Paragraph (1) of the first sentence of this subsection shall + apply with respect to a colorectal cancer screening test + regardless of the code that is billed for the establishment of a + diagnosis as a result of the test, or for the removal of tissue + or other matter or other procedure that is furnished in + connection with, as a result of, and in the same clinical + encounter as the screening test.''. + + (d) Effective <<NOTE: 42 USC 1395l note.>> Date.--The amendments +made by this section shall apply to items and services furnished on or +after January 1, 2011. + +SEC. 4105. EVIDENCE-BASED COVERAGE OF PREVENTIVE SERVICES IN MEDICARE. + + (a) Authority To Modify or Eliminate Coverage of Certain Preventive +Services.--Section 1834 of the Social Security Act (42 U.S.C. 1395m) is +amended by adding at the end the following new subsection: + +[[Page 124 STAT. 559]] + + ``(n) Authority To Modify or Eliminate Coverage of Certain +Preventive Services.--Notwithstanding <<NOTE: Effective date.>> any +other provision of this title, effective beginning on January 1, 2010, +if the Secretary determines appropriate, the Secretary may-- + ``(1) modify-- + ``(A) the coverage of any preventive service + described in subparagraph (A) of section 1861(ddd)(3) to + the extent that such modification is consistent with the + recommendations of the United States Preventive Services + Task Force; and + ``(B) the services included in the initial + preventive physical examination described in + subparagraph (B) of such section; and + ``(2) provide that no payment shall be made under this title + for a preventive service described in subparagraph (A) of such + section that has not received a grade of A, B, C, or I by such + Task Force.''. + + (b) Construction.--Nothing <<NOTE: 42 USC 1395m note.>> in the +amendment made by paragraph (1) shall be construed to affect the +coverage of diagnostic or treatment services under title XVIII of the +Social Security Act. + +SEC. 4106. IMPROVING ACCESS TO PREVENTIVE SERVICES FOR ELIGIBLE ADULTS + IN MEDICAID. + + (a) Clarification of Inclusion of Services.--Section 1905(a)(13) of +the Social Security Act (42 U.S.C. 1396d(a)(13)) is amended to read as +follows: + ``(13) other diagnostic, screening, preventive, and + rehabilitative services, including-- + ``(A) any clinical preventive services that are + assigned a grade of A or B by the United States + Preventive Services Task Force; + ``(B) with respect to an adult individual, approved + vaccines recommended by the Advisory Committee on + Immunization Practices (an advisory committee + established by the Secretary, acting through the + Director of the Centers for Disease Control and + Prevention) and their administration; and + ``(C) any medical or remedial services (provided in + a facility, a home, or other setting) recommended by a + physician or other licensed practitioner of the healing + arts within the scope of their practice under State law, + for the maximum reduction of physical or mental + disability and restoration of an individual to the best + possible functional level;''. + + (b) Increased Fmap.--Section 1905(b) of the Social Security Act (42 +U.S.C. 1396d(b)), as amended by sections 2001(a)(3)(A) and 2004(c)(1), +is amended in the first sentence-- + (1) by striking ``, and (4)'' and inserting ``, (4)''; and + (2) by inserting before the period the following: ``, and + (5) in the case of a State that provides medical assistance for + services and vaccines described in subparagraphs (A) and (B) of + subsection (a)(13), and prohibits cost-sharing for such services + and vaccines, the Federal medical assistance percentage, as + determined under this subsection and subsection (y) (without + regard to paragraph (1)(C) of such subsection), shall be + increased by 1 percentage point with respect to medical + +[[Page 124 STAT. 560]] + + assistance for such services and vaccines and for items and + services described in subsection (a)(4)(D)''. + + (c) Effective <<NOTE: 42 USC 1396d note.>> Date.--The amendments +made under this section shall take effect on January 1, 2013. + +SEC. 4107. COVERAGE OF COMPREHENSIVE TOBACCO CESSATION SERVICES FOR + PREGNANT WOMEN IN MEDICAID. + + (a) Requiring Coverage of Counseling and Pharmacotherapy for +Cessation of Tobacco Use by Pregnant Women.--Section 1905 of the Social +Security Act (42 U.S.C. 1396d), as amended by sections 2001(a)(3)(B) and +2303, is further amended-- + (1) in subsection (a)(4)-- + (A) by striking ``and'' before ``(C)''; and + (B) by inserting before the semicolon at the end the + following new subparagraph: ``; and (D) counseling and + pharmacotherapy for cessation of tobacco use by pregnant + women (as defined in subsection (bb))''; and + (2) by adding at the end the following: + + ``(bb)(1) For <<NOTE: Definition.>> purposes of this title, the term +`counseling and pharmacotherapy for cessation of tobacco use by pregnant +women' means diagnostic, therapy, and counseling services and +pharmacotherapy (including the coverage of prescription and +nonprescription tobacco cessation agents approved by the Food and Drug +Administration) for cessation of tobacco use by pregnant women who use +tobacco products or who are being treated for tobacco use that is +furnished-- + ``(A) by or under the supervision of a physician; or + ``(B) by any other health care professional who-- + ``(i) is legally authorized to furnish such services + under State law (or the State regulatory mechanism + provided by State law) of the State in which the + services are furnished; and + ``(ii) is authorized to receive payment for other + services under this title or is designated by the + Secretary for this purpose. + + ``(2) Subject to paragraph (3), such term is limited to-- + ``(A) services recommended with respect to pregnant women in + `Treating Tobacco Use and Dependence: 2008 Update: A Clinical + Practice Guideline', published by the Public Health Service in + May 2008, or any subsequent modification of such Guideline; and + ``(B) such other services that the Secretary recognizes to + be effective for cessation of tobacco use by pregnant women. + + ``(3) Such term shall not include coverage for drugs or biologicals +that are not otherwise covered under this title.''. + (b) Exception From Optional Restriction Under Medicaid Prescription +Drug Coverage.--Section 1927(d)(2)(F) of the Social Security Act (42 +U.S.C. 1396r-8(d)(2)(F)), as redesignated by section 2502(a), is amended +by inserting before the period at the end the following: ``, except, in +the case of pregnant women when recommended in accordance with the +Guideline referred to in section 1905(bb)(2)(A), agents approved by the +Food and Drug Administration under the over-the-counter monograph +process for purposes of promoting, and when used to promote, tobacco +cessation''. + +[[Page 124 STAT. 561]] + + (c) Removal of Cost-Sharing for Counseling and Pharmacotherapy for +Cessation of Tobacco Use by Pregnant Women.-- + (1) General cost-sharing limitations.--Section 1916 of the + Social Security Act (42 U.S.C. 1396o) is amended in each of + subsections (a)(2)(B) and (b)(2)(B) by inserting ``, and + counseling and pharmacotherapy for cessation of tobacco use by + pregnant women (as defined in section 1905(bb)) and covered + outpatient drugs (as defined in subsection (k)(2) of section + 1927 and including nonprescription drugs described in subsection + (d)(2) of such section) that are prescribed for purposes of + promoting, and when used to promote, tobacco cessation by + pregnant women in accordance with the Guideline referred to in + section 1905(bb)(2)(A)'' after ``complicate the pregnancy''. + (2) Application to alternative cost-sharing.--Section + 1916A(b)(3)(B)(iii) of such Act (42 U.S.C. 1396o- + 1(b)(3)(B)(iii)) is amended by inserting ``, and counseling and + pharmacotherapy for cessation of tobacco use by pregnant women + (as defined in section 1905(bb))'' after ``complicate the + pregnancy''. + + (d) Effective <<NOTE: 42 USC 1396d note.>> Date.--The amendments +made by this section shall take effect on October 1, 2010. + +SEC. 4108. INCENTIVES <<NOTE: Grants. 42 USC 1396a note.>> FOR + PREVENTION OF CHRONIC DISEASES IN MEDICAID. + + (a) Initiatives.-- + (1) Establishment.-- + (A) In general.--The Secretary shall award grants to + States to carry out initiatives to provide incentives to + Medicaid beneficiaries who-- + (i) successfully participate in a program + described in paragraph (3); and + (ii) upon completion of such participation, + demonstrate changes in health risk and outcomes, + including the adoption and maintenance of healthy + behaviors by meeting specific targets (as + described in subsection (c)(2)). + (B) Purpose.--The purpose of the initiatives under + this section is to test approaches that may encourage + behavior modification and determine scalable solutions. + (2) Duration.-- + (A) Initiation <<NOTE: Effective date.>> of program; + resources.--The Secretary shall awards grants to States + beginning on January 1, 2011, or beginning on the date + on which the Secretary develops program criteria, + whichever is <<NOTE: Criteria.>> earlier. The Secretary + shall develop program criteria for initiatives under + this section using relevant evidence-based research and + resources, including the Guide to Community Preventive + Services, the Guide to Clinical Preventive Services, and + the National Registry of Evidence-Based Programs and + Practices. + (B) Duration <<NOTE: Deadline.>> of program.--A + State awarded a grant to carry out initiatives under + this section shall carry out such initiatives within the + 5-year period beginning on January 1, 2011, or beginning + on the date on which the Secretary develops program + criteria, whichever is earlier. Initiatives under this + section shall be carried out by a State for a period of + not less than 3 years. + +[[Page 124 STAT. 562]] + + (3) Program described.-- + (A) In general.--A program described in this + paragraph is a comprehensive, evidence-based, widely + available, and easily accessible program, proposed by + the State and approved by the Secretary, that is + designed and uniquely suited to address the needs of + Medicaid beneficiaries and has demonstrated success in + helping individuals achieve one or more of the + following: + (i) Ceasing use of tobacco products. + (ii) Controlling or reducing their weight. + (iii) Lowering their cholesterol. + (iv) Lowering their blood pressure. + (v) Avoiding the onset of diabetes or, in the + case of a diabetic, improving the management of + that condition. + (B) Co-morbidities.--A program under this section + may also address co-morbidities (including depression) + that are related to any of the conditions described in + subparagraph (A). + (C) Waiver authority.--The Secretary may waive the + requirements of section 1902(a)(1) (relating to + statewideness) of the Social Security Act for a State + awarded a grant to conduct an initiative under this + section and shall ensure that a State makes any program + described in subparagraph (A) available and accessible + to Medicaid beneficiaries. + (D) Flexibility in implementation.--A State may + enter into arrangements with providers participating in + Medicaid, community-based organizations, faith-based + organizations, public-private partnerships, Indian + tribes, or similar entities or organizations to carry + out programs described in subparagraph (A). + (4) Application.--Following the development of program + criteria by the Secretary, a State may submit an application, in + such manner and containing such information as the Secretary may + require, that shall include a proposal for programs described in + paragraph (3)(A) and a plan to make Medicaid beneficiaries and + providers participating in Medicaid who reside in the State + aware and informed about such programs. + + (b) Education and Outreach Campaign.-- + (1) State awareness.--The Secretary shall conduct an + outreach and education campaign to make States aware of the + grants under this section. + (2) Provider and beneficiary education.--A State awarded a + grant to conduct an initiative under this section shall conduct + an outreach and education campaign to make Medicaid + beneficiaries and providers participating in Medicaid who reside + in the State aware of the programs described in subsection + (a)(3) that are to be carried out by the State under the grant. + + (c) Impact.--A State awarded a grant to conduct an initiative under +this section shall develop and implement a system to-- + (1) track Medicaid beneficiary participation in the program + and validate changes in health risk and outcomes with clinical + data, including the adoption and maintenance of health behaviors + by such beneficiaries; + +[[Page 124 STAT. 563]] + + (2) to the extent practicable, establish standards and + health status targets for Medicaid beneficiaries participating + in the program and measure the degree to which such standards + and targets are met; + (3) evaluate the effectiveness of the program and provide + the Secretary with such evaluations; + (4) report <<NOTE: Reports.>> to the Secretary on processes + that have been developed and lessons learned from the program; + and + (5) report <<NOTE: Reports.>> on preventive services as part + of reporting on quality measures for Medicaid managed care + programs. + + (d) Evaluations and Reports.-- + (1) Independent <<NOTE: Contracts.>> assessment.--The + Secretary shall enter into a contract with an independent entity + or organization to conduct an evaluation and assessment of the + initiatives carried out by States under this section, for the + purpose of determining-- + (A) the effect of such initiatives on the use of + health care services by Medicaid beneficiaries + participating in the program; + (B) the extent to which special populations + (including adults with disabilities, adults with chronic + illnesses, and children with special health care needs) + are able to participate in the program; + (C) the level of satisfaction of Medicaid + beneficiaries with respect to the accessibility and + quality of health care services provided through the + program; and + (D) the administrative costs incurred by State + agencies that are responsible for administration of the + program. + (2) State reporting.--A State awarded a grant to carry out + initiatives under this section shall submit reports to the + Secretary, on a semi-annual basis, regarding the programs that + are supported by the grant funds. Such report shall include + information, as specified by the Secretary, regarding-- + (A) the specific uses of the grant funds; + (B) an assessment of program implementation and + lessons learned from the programs; + (C) an assessment of quality improvements and + clinical outcomes under such programs; and + (D) estimates of cost savings resulting from such + programs. + (3) Initial report.--Not later than January 1, 2014, the + Secretary shall submit to Congress an initial report on such + initiatives based on information provided by States through + reports required under paragraph (2). The initial report shall + include an interim evaluation of the effectiveness of the + initiatives carried out with grants awarded under this section + and a recommendation regarding whether funding for expanding or + extending the initiatives should be extended beyond January 1, + 2016. + (4) Final report.--Not later than July 1, 2016, the + Secretary shall submit to Congress a final report on the program + that includes the results of the independent assessment required + under paragraph (1), together with recommendations for such + legislation and administrative action as the Secretary + determines appropriate. + +[[Page 124 STAT. 564]] + + (e) No Effect on Eligibility for, or Amount of, Medicaid or Other +Benefits.--Any incentives provided to a Medicaid beneficiary +participating in a program described in subsection (a)(3) shall not be +taken into account for purposes of determining the beneficiary's +eligibility for, or amount of, benefits under the Medicaid program or +any program funded in whole or in part with Federal funds. + (f) Funding.--Out of any funds in the Treasury not otherwise +appropriated, there are appropriated for the 5-year period beginning on +January 1, 2011, $100,000,000 to the Secretary to carry out this +section. Amounts appropriated under this subsection shall remain +available until expended. + (g) Definitions.--In this section: + (1) Medicaid beneficiary.--The term ``Medicaid beneficiary'' + means an individual who is eligible for medical assistance under + a State plan or waiver under title XIX of the Social Security + Act (42 U.S.C. 1396 et seq.) and is enrolled in such plan or + waiver. + (2) State.--The term ``State'' has the meaning given that + term for purposes of title XIX of the Social Security Act (42 + U.S.C. 1396 et seq.). + + Subtitle C--Creating Healthier Communities + +SEC. 4201. COMMUNITY <<NOTE: 42 USC 300u-13.>> TRANSFORMATION GRANTS. + + (a) In General.--The Secretary of Health and Human Services +(referred to in this section as the ``Secretary''), acting through the +Director of the Centers for Disease Control and Prevention (referred to +in this section as the ``Director''), shall award competitive grants to +State and local governmental agencies and community-based organizations +for the implementation, evaluation, and dissemination of evidence-based +community preventive health activities in order to reduce chronic +disease rates, prevent the development of secondary conditions, address +health disparities, and develop a stronger evidence-base of effective +prevention programming. + (b) Eligibility.--To be eligible to receive a grant under subsection +(a), an entity shall-- + (1) be-- + (A) a State governmental agency; + (B) a local governmental agency; + (C) a national network of community-based + organizations; + (D) a State or local non-profit organization; or + (E) an Indian tribe; and + (2) submit to the Director an application at such time, in + such a manner, and containing such information as the Director + may require, including a description of the program to be + carried out under the grant; and + (3) demonstrate a history or capacity, if funded, to develop + relationships necessary to engage key stakeholders from multiple + sectors within and beyond health care and across a community, + such as healthy futures corps and health care providers. + + (c) Use of Funds.-- + +[[Page 124 STAT. 565]] + + (1) In general.--An eligible entity shall use amounts + received under a grant under this section to carry out programs + described in this subsection. + (2) Community transformation plan.-- + (A) In general.--An eligible entity that receives a + grant under this section shall submit to the Director + (for approval) a detailed plan that includes the policy, + environmental, programmatic, and as appropriate + infrastructure changes needed to promote healthy living + and reduce disparities. + (B) Activities.--Activities within the plan may + focus on (but not be limited to)-- + (i) creating healthier school environments, + including increasing healthy food options, + physical activity opportunities, promotion of + healthy lifestyle, emotional wellness, and + prevention curricula, and activities to prevent + chronic diseases; + (ii) creating the infrastructure to support + active living and access to nutritious foods in a + safe environment; + (iii) developing and promoting programs + targeting a variety of age levels to increase + access to nutrition, physical activity and smoking + cessation, improve social and emotional wellness, + enhance safety in a community, or address any + other chronic disease priority area identified by + the grantee; + (iv) assessing and implementing worksite + wellness programming and incentives; + (v) working to highlight healthy options at + restaurants and other food venues; + (vi) prioritizing strategies to reduce racial + and ethnic disparities, including social, + economic, and geographic determinants of health; + and + (vii) addressing special populations needs, + including all age groups and individuals with + disabilities, and individuals in both urban and + rural areas. + (3) Community-based prevention health activities.-- + (A) In general.--An eligible entity shall use + amounts received under a grant under this section to + implement a variety of programs, policies, and + infrastructure improvements to promote healthier + lifestyles. + (B) Activities.--An eligible entity shall implement + activities detailed in the community transformation plan + under paragraph (2). + (C) In-kind support.--An eligible entity may provide + in-kind resources such as staff, equipment, or office + space in carrying out activities under this section. + (4) Evaluation.-- + (A) In general.--An eligible entity shall use + amounts provided under a grant under this section to + conduct activities to measure changes in the prevalence + of chronic disease risk factors among community members + participating in preventive health activities + (B) Types of measures.--In carrying out subparagraph + (A), the eligible entity shall, with respect to + residents in the community, measure-- + (i) changes in weight; + +[[Page 124 STAT. 566]] + + (ii) changes in proper nutrition; + (iii) changes in physical activity; + (iv) changes in tobacco use prevalence; + (v) changes in emotional well-being and + overall mental health; + (vi) other factors using community-specific + data from the Behavioral Risk Factor Surveillance + Survey; and + (vii) other factors as determined by the + Secretary. + (C) Reporting.--An eligible entity shall annually + submit to the Director a report containing an evaluation + of activities carried out under the grant. + (5) Dissemination.--A grantee under this section shall-- + (A) meet at least annually in regional or national + meetings to discuss challenges, best practices, and + lessons learned with respect to activities carried out + under the grant; and + (B) develop models for the replication of successful + programs and activities and the mentoring of other + eligible entities. + + (d) Training.-- + (1) In general.--The Director shall develop a program to + provide training for eligible entities on effective strategies + for the prevention and control of chronic disease and the link + between physical, emotional, and social well-being. + (2) Community transformation plan.--The Director shall + provide appropriate feedback and technical assistance to + grantees to establish community transformation plans + (3) Evaluation.--The Director shall provide a literature + review and framework for the evaluation of programs conducted as + part of the grant program under this section, in addition to + working with academic institutions or other entities with + expertise in outcome evaluation. + + (e) Prohibition.--A grantee shall not use funds provided under a +grant under this section to create video games or to carry out any other +activities that may lead to higher rates of obesity or inactivity. + (f) Authorization of Appropriations.--There are authorized to be +appropriated to carry out this section, such sums as may be necessary +for each fiscal years 2010 through 2014. + +SEC. 4202. HEALTHY <<NOTE: 42 USC 300u-14.>> AGING, LIVING WELL; + EVALUATION OF COMMUNITY-BASED PREVENTION AND WELLNESS + PROGRAMS FOR MEDICARE BENEFICIARIES. + + (a) Healthy Aging, Living Well.-- + (1) In general.--The Secretary of Health and Human Services + (referred to in this section as the ``Secretary''), acting + through the Director of the Centers for Disease Control and + Prevention, shall award grants to State or local health + departments and Indian tribes to carry out 5-year pilot programs + to provide public health community interventions, screenings, + and where necessary, clinical referrals for individuals who are + between 55 and 64 years of age. + (2) Eligibility.--To be eligible to receive a grant under + paragraph (1), an entity shall-- + (A) be-- + (i) a State health department; + +[[Page 124 STAT. 567]] + + (ii) a local health department; or + (iii) an Indian tribe; + (B) submit to the Secretary an application at such + time, in such manner, and containing such information as + the Secretary may require including a description of the + program to be carried out under the grant; + (C) design a strategy for improving the health of + the 55-to-64 year-old population through community-based + public health interventions; and + (D) demonstrate the capacity, if funded, to develop + the relationships necessary with relevant health + agencies, health care providers, community-based + organizations, and insurers to carry out the activities + described in paragraph (3), such relationships to + include the identification of a community-based clinical + partner, such as a community health center or rural + health clinic. + (3) Use of funds.-- + (A) In general.--A State or local health department + shall use amounts received under a grant under this + subsection to carry out a program to provide the + services described in this paragraph to individuals who + are between 55 and 64 years of age. + (B) Public health interventions.-- + (i) In general.--In developing and + implementing such activities, a grantee shall + collaborate with the Centers for Disease Control + and Prevention and the Administration on Aging, + and relevant local agencies and organizations. + (ii) Types of intervention activities.-- + Intervention activities conducted under this + subparagraph may include efforts to improve + nutrition, increase physical activity, reduce + tobacco use and substance abuse, improve mental + health, and promote healthy lifestyles among the + target population. + (C) Community preventive screenings.-- + (i) In general.--In addition to community-wide + public health interventions, a State or local + health department shall use amounts received under + a grant under this subsection to conduct ongoing + health screening to identify risk factors for + cardiovascular disease, cancer, stroke, and + diabetes among individuals in both urban and rural + areas who are between 55 and 64 years of age. + (ii) Types of screening activities.--Screening + activities conducted under this subparagraph may + include-- + (I) mental health/behavioral health + and substance use disorders; + (II) physical activity, smoking, and + nutrition; and + (III) any other measures deemed + appropriate by the Secretary. + (iii) Monitoring.-- + Grantees <<NOTE: Records.>> under this section + shall maintain records of screening results under + this subparagraph to establish the baseline data + for monitoring the targeted population + +[[Page 124 STAT. 568]] + + (D) Clinical referral/treatment for chronic + diseases.-- + (i) In general.--A State or local health + department shall use amounts received under a + grant under this subsection to ensure that + individuals between 55 and 64 years of age who are + found to have chronic disease risk factors through + the screening activities described in subparagraph + (C)(ii), receive clinical referral/treatment for + follow-up services to reduce such risk. + (ii) Mechanism.-- + (I) Identification and determination + of status.--With respect to each + individual with risk factors for or + having heart disease, stroke, diabetes, + or any other condition for which such + individual was screened under + subparagraph (C), a grantee under this + section shall determine whether or not + such individual is covered under any + public or private health insurance + program. + (II) Insured individuals.--An + individual determined to be covered + under a health insurance program under + subclause (I) shall be referred by the + grantee to the existing providers under + such program or, if such individual does + not have a current provider, to a + provider who is in-network with respect + to the program involved. + (III) Uninsured individuals.--With + respect to an individual determined to + be uninsured under subclause (I), the + grantee's community-based clinical + partner described in paragraph (4)(D) + shall assist the individual in + determining eligibility for available + public coverage options and identify + other appropriate community health care + resources and assistance programs. + (iii) Public health intervention program.--A + State or local health department shall use amounts + received under a grant under this subsection to + enter into contracts with community health centers + or rural health clinics and mental health and + substance use disorder service providers to assist + in the referral/treatment of at risk patients to + community resources for clinical follow-up and + help determine eligibility for other public + programs. + (E) Grantee evaluation.--An eligible entity shall + use amounts provided under a grant under this subsection + to conduct activities to measure changes in the + prevalence of chronic disease risk factors among + participants. + (4) Pilot program evaluation.--The Secretary shall conduct + an annual evaluation of the effectiveness of the pilot program + under this subsection. In determining such effectiveness, the + Secretary shall consider changes in the prevalence of + uncontrolled chronic disease risk factors among new Medicare + enrollees (or individuals nearing enrollment, including those + who are 63 and 64 years of age) who reside in States or + localities receiving grants under this section as compared with + national and historical data for those States and localities for + the same population. + +[[Page 124 STAT. 569]] + + (5) Authorization of appropriations.--There are authorized + to be appropriated to carry out this subsection, such sums as + may be necessary for each of fiscal years 2010 through 2014. + + (b) Evaluation and Plan for Community-based Prevention and Wellness +Programs for Medicare Beneficiaries.-- + (1) In general.--The Secretary shall conduct an evaluation + of community-based prevention and wellness programs and develop + a plan for promoting healthy lifestyles and chronic disease + self-management for Medicare beneficiaries. + (2) Medicare evaluation of prevention and wellness + programs.-- + (A) In general.--The Secretary shall evaluate + community prevention and wellness programs including + those that are sponsored by the Administration on Aging, + are evidence-based, and have demonstrated potential to + help Medicare beneficiaries (particularly beneficiaries + that have attained 65 years of age) reduce their risk of + disease, disability, and injury by making healthy + lifestyle choices, including exercise, diet, and self- + management of chronic diseases. + (B) Evaluation.--The evaluation under subparagraph + (A) shall consist of the following: + (i) Evidence review.--The Secretary shall + review available evidence, literature, best + practices, and resources that are relevant to + programs that promote healthy lifestyles and + reduce risk factors for the Medicare population. + The Secretary may determine the scope of the + evidence review and such issues to be considered, + which shall include, at a minimum-- + (I) physical activity, nutrition, + and obesity; + (II) falls; + (III) chronic disease self- + management; and + (IV) mental health. + (ii) Independent evaluation of evidence-based + community prevention and wellness programs.--The + Administrator of the Centers for Medicare & + Medicaid Services, in consultation with the + Assistant Secretary for Aging, shall, to the + extent feasible and practicable, conduct an + evaluation of existing community prevention and + wellness programs that are sponsored by the + Administration on Aging to assess the extent to + which Medicare beneficiaries who participate in + such programs-- + (I) reduce their health risks, + improve their health outcomes, and adopt + and maintain healthy behaviors; + (II) improve their ability to manage + their chronic conditions; and + (III) reduce their utilization of + health services and associated costs + under the Medicare program for + conditions that are amenable to + improvement under such programs. + (3) Report.--Not later than September 30, 2013, the + Secretary shall submit to Congress a report that includes-- + (A) recommendations for such legislation and + administrative action as the Secretary determines + appropriate to + +[[Page 124 STAT. 570]] + + promote healthy lifestyles and chronic disease self- + management for Medicare beneficiaries; + (B) any relevant findings relating to the evidence + review under paragraph (2)(B)(i); and + (C) the results of the evaluation under paragraph + (2)(B)(ii). + (4) Funding.--For purposes of carrying out this subsection, + the Secretary shall provide for the transfer, from the Federal + Hospital Insurance Trust Fund under section 1817 of the Social + Security Act (42 U.S.C. 1395i) and the Federal Supplemental + Medical Insurance Trust Fund under section 1841 of such Act (42 + U.S.C. 1395t), in such proportion as the Secretary determines + appropriate, of $50,000,000 to the Centers for Medicare & + Medicaid Services Program Management Account. Amounts + transferred under the preceding sentence shall remain available + until expended. + (5) Administration.--Chapter 35 of title 44, United States + Code shall not apply to the this subsection. + (6) Medicare <<NOTE: Definition.>> beneficiary.--In this + subsection, the term ``Medicare beneficiary'' means an + individual who is entitled to benefits under part A of title + XVIII of the Social Security Act and enrolled under part B of + such title. + +SEC. 4203. REMOVING BARRIERS AND IMPROVING ACCESS TO WELLNESS FOR + INDIVIDUALS WITH DISABILITIES. + + Title V of the Rehabilitation Act of 1973 (29 U.S.C. 791 et seq.) is +amended by adding at the end of the following: + +``SEC. 510. ESTABLISHMENT <<NOTE: 29 USC 794f.>> OF STANDARDS FOR + ACCESSIBLE MEDICAL DIAGNOSTIC EQUIPMENT. + + ``(a) Standards.--Not <<NOTE: Deadline.>> later than 24 months after +the date of enactment of the Affordable Health Choices Act, the +Architectural and Transportation Barriers Compliance Board shall, in +consultation with the Commissioner of the Food and Drug Administration, +promulgate regulatory standards in accordance with the Administrative +Procedure Act (2 U.S.C. 551 et seq.) setting forth the minimum technical +criteria for medical diagnostic equipment used in (or in conjunction +with) physician's offices, clinics, emergency rooms, hospitals, and +other medical settings. The standards shall ensure that such equipment +is accessible to, and usable by, individuals with accessibility needs, +and shall allow independent entry to, use of, and exit from the +equipment by such individuals to the maximum extent possible. + + ``(b) Medical Diagnostic Equipment Covered.--The standards issued +under subsection (a) for medical diagnostic equipment shall apply to +equipment that includes examination tables, examination chairs +(including chairs used for eye examinations or procedures, and dental +examinations or procedures), weight scales, mammography equipment, x-ray +machines, and other radiological equipment commonly used for diagnostic +purposes by health professionals. + ``(c) Review and Amendment.--The Architectural and Transportation +Barriers Compliance Board, in consultation with the Commissioner of the +Food and Drug Administration, shall periodically review and, as +appropriate, amend the standards in accordance with the Administrative +Procedure Act (2 U.S.C. 551 et seq.).''. + +[[Page 124 STAT. 571]] + +SEC. 4204. IMMUNIZATIONS. + + (a) State Authority To Purchase Recommended Vaccines for Adults.-- +Section 317 of the Public Health Service Act (42 U.S.C. 247b) is amended +by adding at the end the following: + ``(l) Authority to Purchase Recommended Vaccines for Adults.-- + ``(1) In general.--The Secretary may negotiate and enter + into contracts with manufacturers of vaccines for the purchase + and delivery of vaccines for adults as provided for under + subsection (e). + ``(2) State purchase.--A State may obtain additional + quantities of such adult vaccines (subject to amounts specified + to the Secretary by the State in advance of negotiations) + through the purchase of vaccines from manufacturers at the + applicable price negotiated by the Secretary under this + subsection.''. + + (b) Demonstration Program to Improve Immunization Coverage.--Section +317 of the Public Health Service Act (42 U.S.C. 247b), as amended by +subsection (a), is further amended by adding at the end the following: + ``(m) Demonstration <<NOTE: Grants.>> Program To Improve +Immunization Coverage.-- + ``(1) In general.--The Secretary, acting through the + Director of the Centers for Disease Control and Prevention, + shall establish a demonstration program to award grants to + States to improve the provision of recommended immunizations for + children, adolescents, and adults through the use of evidence- + based, population-based interventions for high-risk populations. + ``(2) State plan.--To be eligible for a grant under + paragraph (1), a State shall submit to the Secretary an + application at such time, in such manner, and containing such + information as the Secretary may require, including a State plan + that describes the interventions to be implemented under the + grant and how such interventions match with local needs and + capabilities, as determined through consultation with local + authorities. + ``(3) Use of funds.--Funds received under a grant under this + subsection shall be used to implement interventions that are + recommended by the Task Force on Community Preventive Services + (as established by the Secretary, acting through the Director of + the Centers for Disease Control and Prevention) or other + evidence-based interventions, including-- + ``(A) providing immunization reminders or recalls + for target populations of clients, patients, and + consumers; + ``(B) educating targeted populations and health care + providers concerning immunizations in combination with + one or more other interventions; + ``(C) reducing out-of-pocket costs for families for + vaccines and their administration; + ``(D) carrying out immunization-promoting strategies + for participants or clients of public programs, + including assessments of immunization status, referrals + to health care providers, education, provision of on- + site immunizations, or incentives for immunization; + +[[Page 124 STAT. 572]] + + ``(E) providing for home visits that promote + immunization through education, assessments of need, + referrals, provision of immunizations, or other + services; + ``(F) providing reminders or recalls for + immunization providers; + ``(G) conducting assessments of, and providing + feedback to, immunization providers; + ``(H) any combination of one or more interventions + described in this paragraph; or + ``(I) immunization information systems to allow all + States to have electronic databases for immunization + records. + ``(4) Consideration.--In awarding grants under this + subsection, the Secretary shall consider any reviews or + recommendations of the Task Force on Community Preventive + Services. + ``(5) Evaluation.--Not <<NOTE: Deadline.>> later than 3 + years after the date on which a State receives a grant under + this subsection, the State shall submit to the Secretary an + evaluation of progress made toward improving immunization + coverage rates among high-risk populations within the State. + ``(6) Report to congress.--Not later than 4 years after the + date of enactment of the Affordable Health Choices Act, the + Secretary shall submit to Congress a report concerning the + effectiveness of the demonstration program established under + this subsection together with recommendations on whether to + continue and expand such program. + ``(7) Authorization of appropriations.--There is authorized + to be appropriated to carry out this subsection, such sums as + may be necessary for each of fiscal years 2010 through 2014.''. + + (c) Reauthorization of Immunization Program.--Section 317(j) of the +Public Health Service Act (42 U.S.C. 247b(j)) is amended-- + (1) in paragraph (1), by striking ``for each of the fiscal + years 1998 through 2005''; and + (2) in paragraph (2), by striking ``after October 1, + 1997,''. + + (d) Rule of <<NOTE: 42 USC 247b note.>> Construction Regarding +Access to Immunizations.--Nothing in this section (including the +amendments made by this section), or any other provision of this Act +(including any amendments made by this Act) shall be construed to +decrease children's access to immunizations. + + (e) GAO Study and Report on Medicare Beneficiary Access to +Vaccines.-- + (1) Study.--The Comptroller General of the United States (in + this section referred to as the ``Comptroller General'') shall + conduct a study on the ability of Medicare beneficiaries who + were 65 years of age or older to access routinely recommended + vaccines covered under the prescription drug program under part + D of title XVIII of the Social Security Act over the period + since the establishment of such program. Such study shall + include the following: + (A) An analysis and determination of-- + (i) the number of Medicare beneficiaries who + were 65 years of age or older and were eligible + for a routinely recommended vaccination that was + covered under part D; + +[[Page 124 STAT. 573]] + + (ii) the number of such beneficiaries who + actually received a routinely recommended + vaccination that was covered under part D; and + (iii) any barriers to access by such + beneficiaries to routinely recommended + vaccinations that were covered under part D. + (B) A summary of the findings and recommendations by + government agencies, departments, and advisory bodies + (as well as relevant professional organizations) on the + impact of coverage under part D of routinely recommended + adult immunizations for access to such immunizations by + Medicare beneficiaries. + (2) Report.--Not later than June 1, 2011, the Comptroller + General shall submit to the appropriate committees of + jurisdiction of the House of Representatives and the Senate a + report containing the results of the study conducted under + paragraph (1), together with recommendations for such + legislation and administrative action as the Comptroller General + determines appropriate. + (3) Funding.--Out of any funds in the Treasury not otherwise + appropriated, there are appropriated $1,000,000 for fiscal year + 2010 to carry out this subsection. + +SEC. 4205. NUTRITION LABELING OF STANDARD MENU ITEMS AT CHAIN + RESTAURANTS. + + (a) Technical Amendments.--Section 403(q)(5)(A) of the Federal Food, +Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)(A)) is amended-- + (1) in subitem (i), by inserting at the beginning ``except + as provided in clause (H)(ii)(III),''; and + (2) in subitem (ii), by inserting at the beginning ``except + as provided in clause (H)(ii)(III),''. + + (b) Labeling Requirements.--Section 403(q)(5) of the Federal Food, +Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)) is amended by adding at the +end the following: + ``(H) Restaurants, Retail Food Establishments, and Vending +Machines.-- + ``(i) General requirements for restaurants and similar + retail food establishments.--Except for food described in + subclause (vii), in the case of food that is a standard menu + item that is offered for sale in a restaurant or similar retail + food establishment that is part of a chain with 20 or more + locations doing business under the same name (regardless of the + type of ownership of the locations) and offering for sale + substantially the same menu items, the restaurant or similar + retail food establishment shall disclose the information + described in subclauses (ii) and (iii). + ``(ii) Information required to be disclosed by restaurants + and retail food establishments.--Except as provided in subclause + (vii), the restaurant or similar retail food establishment shall + disclose in a clear and conspicuous manner-- + ``(I)(aa) in a nutrient content disclosure statement + adjacent to the name of the standard menu item, so as to + be clearly associated with the standard menu item, on + the menu listing the item for sale, the number of + calories + +[[Page 124 STAT. 574]] + + contained in the standard menu item, as usually prepared + and offered for sale; and + ``(bb) a succinct statement concerning suggested + daily caloric intake, as specified by the Secretary by + regulation and posted prominently on the menu and + designed to enable the public to understand, in the + context of a total daily diet, the significance of the + caloric information that is provided on the menu; + ``(II)(aa) in a nutrient content disclosure + statement adjacent to the name of the standard menu + item, so as to be clearly associated with the standard + menu item, on the menu board, including a drive-through + menu board, the number of calories contained in the + standard menu item, as usually prepared and offered for + sale; and + ``(bb) a succinct statement concerning suggested + daily caloric intake, as specified by the Secretary by + regulation and posted prominently on the menu board, + designed to enable the public to understand, in the + context of a total daily diet, the significance of the + nutrition information that is provided on the menu + board; + ``(III) in a written form, available on the premises of the + restaurant or similar retail establishment and to the consumer + upon request, the nutrition information required under clauses + (C) and (D) of subparagraph (1); and + ``(IV) on the menu or menu board, a prominent, clear, and + conspicuous statement regarding the availability of the + information described in item (III). + ``(iii) Self-service food and food on display.--Except as + provided in subclause (vii), in the case of food sold at a salad + bar, buffet line, cafeteria line, or similar self-service + facility, and for self-service beverages or food that is on + display and that is visible to customers, a restaurant or + similar retail food establishment shall place adjacent to each + food offered a sign that lists calories per displayed food item + or per serving. + ``(iv) Reasonable basis.--For the purposes of this clause, a + restaurant or similar retail food establishment shall have a + reasonable basis for its nutrient content disclosures, including + nutrient databases, cookbooks, laboratory analyses, and other + reasonable means, as described in section 101.10 of title 21, + Code of Federal Regulations (or any successor regulation) or in + a related guidance of the Food and Drug Administration. + ``(v) Menu variability and combination meals.--The Secretary + shall establish by regulation standards for determining and + disclosing the nutrient content for standard menu items that + come in different flavors, varieties, or combinations, but which + are listed as a single menu item, such as soft drinks, ice + cream, pizza, doughnuts, or children's combination meals, + through means determined by the Secretary, including ranges, + averages, or other methods. + ``(vi) Additional information.--If the Secretary determines + that a nutrient, other than a nutrient required under subclause + (ii)(III), should be disclosed for the purpose of providing + information to assist consumers in maintaining healthy dietary + practices, the Secretary may require, by regulation, disclosure + of such nutrient in the written form required under subclause + (ii)(III). + ``(vii) Nonapplicability to certain food.-- + +[[Page 124 STAT. 575]] + + ``(I) In general.--Subclauses (i) through (vi) do + not apply to-- + ``(aa) items that are not listed on a menu or + menu board (such as condiments and other items + placed on the table or counter for general use); + ``(bb) daily specials, temporary menu items + appearing on the menu for less than 60 days per + calendar year, or custom orders; or + ``(cc) such other food that is part of a + customary market test appearing on the menu for + less than 90 days, under terms and conditions + established by the Secretary. + ``(II) Written <<NOTE: Applicability.>> forms.-- + Subparagraph (5)(C) shall apply to any regulations + promulgated under subclauses (ii)(III) and (vi). + ``(viii) Vending machines.-- + ``(I) In general.--In the case of an article of food + sold from a vending machine that-- + ``(aa) does not permit a prospective purchaser + to examine the Nutrition Facts Panel before + purchasing the article or does not otherwise + provide visible nutrition information at the point + of purchase; and + ``(bb) is operated by a person who is engaged + in the business of owning or operating 20 or more + vending machines, + the vending machine operator shall provide a sign in + close proximity to each article of food or the selection + button that includes a clear and conspicuous statement + disclosing the number of calories contained in the + article. + ``(ix) Voluntary provision of nutrition information.-- + ``(I) In general.--An authorized official of any + restaurant or similar retail food establishment or + vending machine operator not subject to the requirements + of this clause may elect to be subject to the + requirements of such clause, by registering biannually + the name and address of such restaurant or similar + retail food establishment or vending machine operator + with the Secretary, as specified by the Secretary by + regulation. + ``(II) Registration.-- + Within <<NOTE: Deadline. Notice. Federal Register, + publication.>> 120 days of enactment of this clause, the + Secretary shall publish a notice in the Federal Register + specifying the terms and conditions for implementation + of item (I), pending promulgation of regulations. + ``(III) Rule of construction.--Nothing in this + subclause shall be construed to authorize the Secretary + to require an application, review, or licensing process + for any entity to register with the Secretary, as + described in such item. + ``(x) Regulations.-- + ``(I) Proposed <<NOTE: Deadline.>> regulation.--Not + later than 1 year after the date of enactment of this + clause, the Secretary shall promulgate proposed + regulations to carry out this clause. + ``(II) Contents.--In promulgating regulations, the + Secretary shall-- + ``(aa) consider standardization of recipes and + methods of preparation, reasonable variation in + serving + +[[Page 124 STAT. 576]] + + size and formulation of menu items, space on menus + and menu boards, inadvertent human error, training + of food service workers, variations in + ingredients, and other factors, as the Secretary + determines; and + ``(bb) specify the format and manner of the + nutrient content disclosure requirements under + this subclause. + ``(III) Reporting.--The Secretary shall submit to + the Committee on Health, Education, Labor, and Pensions + of the Senate and the Committee on Energy and Commerce + of the House of Representatives a quarterly report that + describes the Secretary's progress toward promulgating + final regulations under this subparagraph. + ``(xi) Definition.--In this clause, the term `menu' or `menu + board' means the primary writing of the restaurant or other + similar retail food establishment from which a consumer makes an + order selection.'' + + (c) National Uniformity.--Section 403A(a)(4) of the Federal Food, +Drug, and Cosmetic Act (21 U.S.C. 343-1(a)(4)) is amended by striking +``except a requirement for nutrition labeling of food which is exempt +under subclause (i) or (ii) of section 403(q)(5)(A)'' and inserting +``except that this paragraph does not apply to food that is offered for +sale in a restaurant or similar retail food establishment that is not +part of a chain with 20 or more locations doing business under the same +name (regardless of the type of ownership of the locations) and offering +for sale substantially the same menu items unless such restaurant or +similar retail food establishment complies with the voluntary provision +of nutrition information requirements under section 403(q)(5)(H)(ix)''. + (d) Rule of <<NOTE: 21 USC 343 note.>> Construction.--Nothing in the +amendments made by this section shall be construed-- + (1) to preempt any provision of State or local law, unless + such provision establishes or continues into effect nutrient + content disclosures of the type required under section + 403(q)(5)(H) of the Federal Food, Drug, and Cosmetic Act (as + added by subsection (b)) and is expressly preempted under + subsection (a)(4) of such section; + (2) to apply to any State or local requirement respecting a + statement in the labeling of food that provides for a warning + concerning the safety of the food or component of the food; or + (3) except as provided in section 403(q)(5)(H)(ix) of the + Federal Food, Drug, and Cosmetic Act (as added by subsection + (b)), to apply to any restaurant or similar retail food + establishment other than a restaurant or similar retail food + establishment described in section 403(q)(5)(H)(i) of such Act. + +SEC. 4206. DEMONSTRATION PROJECT CONCERNING INDIVIDUALIZED WELLNESS + PLAN. + + Section 330 of the Public Health Service Act (42 U.S.C. 245b) is +amended by adding at the end the following: + ``(s) Demonstration Program for Individualized Wellness Plans.-- + ``(1) In general.--The Secretary shall establish a pilot + program to test the impact of providing at-risk populations who + utilize community health centers funded under this section an + individualized wellness plan that is designed to reduce risk + +[[Page 124 STAT. 577]] + + factors for preventable conditions as identified by a + comprehensive risk-factor assessment. + ``(2) Agreements.--The Secretary shall enter into agreements + with not more than 10 community health centers funded under this + section to conduct activities under the pilot program under + paragraph (1). + ``(3) Wellness plans.-- + ``(A) In general.--An individualized wellness plan + prepared under the pilot program under this subsection + may include one or more of the following as appropriate + to the individual's identified risk factors: + ``(i) Nutritional counseling. + ``(ii) A physical activity plan. + ``(iii) Alcohol and smoking cessation + counseling and services. + ``(iv) Stress management. + ``(v) Dietary supplements that have health + claims approved by the Secretary. + ``(vi) Compliance assistance provided by a + community health center employee. + ``(B) Risk factors.--Wellness plan risk factors + shall include-- + ``(i) weight; + ``(ii) tobacco and alcohol use; + ``(iii) exercise rates; + ``(iv) nutritional status; and + ``(v) blood pressure. + ``(C) Comparisons.--Individualized wellness plans + shall make comparisons between the individual involved + and a control group of individuals with respect to the + risk factors described in subparagraph (B). + ``(4) Authorization of appropriations.--There is authorized + to be appropriated to carry out this subsection, such sums as + may be necessary.''. + +SEC. 4207. REASONABLE BREAK TIME FOR NURSING MOTHERS. + + Section 7 of the Fair Labor Standards Act of 1938 (29 U.S.C. 207) is +amended by adding at the end the following: + ``(r)(1) An employer shall provide-- + ``(A) a reasonable break time for an employee to express + breast milk for her nursing child for 1 year after the child's + birth each time such employee has need to express the milk; and + ``(B) a place, other than a bathroom, that is shielded from + view and free from intrusion from coworkers and the public, + which may be used by an employee to express breast milk. + + ``(2) An employer shall not be required to compensate an employee +receiving reasonable break time under paragraph (1) for any work time +spent for such purpose. + ``(3) An employer that employs less than 50 employees shall not be +subject to the requirements of this subsection, if such requirements +would impose an undue hardship by causing the employer significant +difficulty or expense when considered in relation to the size, financial +resources, nature, or structure of the employer's business. + +[[Page 124 STAT. 578]] + + ``(4) Nothing in this subsection shall preempt a State law that +provides greater protections to employees than the protections provided +for under this subsection.''. + + Subtitle D--Support for Prevention and Public Health Innovation + +SEC. 4301. RESEARCH <<NOTE: 42 USC 300u-15.>> ON OPTIMIZING THE DELIVERY + OF PUBLIC HEALTH SERVICES. + + (a) In General.--The Secretary of Health and Human Services +(referred to in this section as the ``Secretary''), acting through the +Director of the Centers for Disease Control and Prevention, shall +provide funding for research in the area of public health services and +systems. + (b) Requirements of Research.--Research supported under this section +shall include-- + (1) examining evidence-based practices relating to + prevention, with a particular focus on high priority areas as + identified by the Secretary in the National Prevention Strategy + or Healthy People 2020, and including comparing community-based + public health interventions in terms of effectiveness and cost; + (2) analyzing the translation of interventions from academic + settings to real world settings; and + (3) identifying effective strategies for organizing, + financing, or delivering public health services in real world + community settings, including comparing State and local health + department structures and systems in terms of effectiveness and + cost. + + (c) Existing Partnerships.--Research supported under this section +shall be coordinated with the Community Preventive Services Task Force +and carried out by building on existing partnerships within the Federal +Government while also considering initiatives at the State and local +levels and in the private sector. + (d) Annual Report.--The Secretary shall, on an annual basis, submit +to Congress a report concerning the activities and findings with respect +to research supported under this section. + +SEC. 4302. UNDERSTANDING HEALTH DISPARITIES: DATA COLLECTION AND + ANALYSIS. + + (a) Uniform Categories and Collection Requirements.--The Public +Health Service Act (42 U.S.C. 201 et seq.) is amended by adding at the +end the following: + + ``TITLE XXXI--DATA COLLECTION, ANALYSIS, AND QUALITY + +``SEC. 3101. <<NOTE: 42 USC 300kk.>> DATA COLLECTION, ANALYSIS, AND + QUALITY. + + ``(a) Data Collection.-- + ``(1) In <<NOTE: Deadline.>> general.--The Secretary shall + ensure that, by not later than 2 years after the date of + enactment of this title, any federally conducted or supported + health care or public health program, activity or survey + (including Current Population Surveys and American Community + Surveys conducted + +[[Page 124 STAT. 579]] + + by the Bureau of Labor Statistics and the Bureau of the Census) + collects and reports, to the extent practicable-- + ``(A) data on race, ethnicity, sex, primary + language, and disability status for applicants, + recipients, or participants; + ``(B) data at the smallest geographic level such as + State, local, or institutional levels if such data can + be aggregated; + ``(C) sufficient data to generate statistically + reliable estimates by racial, ethnic, sex, primary + language, and disability status subgroups for + applicants, recipients or participants using, if needed, + statistical oversamples of these subpopulations; and + ``(D) any other demographic data as deemed + appropriate by the Secretary regarding health + disparities. + ``(2) Collection standards.--In collecting data described in + paragraph (1), the Secretary or designee shall-- + ``(A) use Office of Management and Budget standards, + at a minimum, for race and ethnicity measures; + ``(B) develop standards for the measurement of sex, + primary language, and disability status; + ``(C) develop standards for the collection of data + described in paragraph (1) that, at a minimum-- + ``(i) collects self-reported data by the + applicant, recipient, or participant; and + ``(ii) collects data from a parent or legal + guardian if the applicant, recipient, or + participant is a minor or legally incapacitated; + ``(D) survey health care providers and establish + other procedures in order to assess access to care and + treatment for individuals with disabilities and to + identify-- + ``(i) locations where individuals with + disabilities access primary, acute (including + intensive), and long-term care; + ``(ii) the number of providers with accessible + facilities and equipment to meet the needs of the + individuals with disabilities, including medical + diagnostic equipment that meets the minimum + technical criteria set forth in section 510 of the + Rehabilitation Act of 1973; and + ``(iii) the number of employees of health care + providers trained in disability awareness and + patient care of individuals with disabilities; and + ``(E) require that any reporting requirement imposed + for purposes of measuring quality under any ongoing or + federally conducted or supported health care or public + health program, activity, or survey includes + requirements for the collection of data on individuals + receiving health care items or services under such + programs activities by race, ethnicity, sex, primary + language, and disability status. + ``(3) Data management.--In collecting data described in + paragraph (1), the Secretary, acting through the National + Coordinator for Health Information Technology shall-- + ``(A) develop <<NOTE: Standards.>> national + standards for the management of data collected; and + ``(B) develop interoperability and security systems + for data management. + +[[Page 124 STAT. 580]] + + ``(b) Data Analysis.-- + ``(1) In general.--For each federally conducted or supported + health care or public health program or activity, the Secretary + shall analyze data collected under paragraph (a) to detect and + monitor trends in health disparities (as defined for purposes of + section 485E) at the Federal and State levels. + + ``(c) Data Reporting and Dissemination.-- + ``(1) In general.--The Secretary shall make the analyses + described in (b) available to-- + ``(A) the Office of Minority Health; + ``(B) the National Center on Minority Health and + Health Disparities; + ``(C) the Agency for Healthcare Research and + Quality; + ``(D) the Centers for Disease Control and + Prevention; + ``(E) the Centers for Medicare & Medicaid Services; + ``(F) the Indian Health Service and epidemiology + centers funded under the Indian Health Care Improvement + Act; + ``(G) the Office of Rural health; + ``(H) other agencies within the Department of Health + and Human Services; and + ``(I) other entities as determined appropriate by + the Secretary. + ``(2) Reporting of data.--The Secretary shall report data + and analyses described in (a) and (b) through-- + ``(A) public <<NOTE: Public information. Web + sites.>> postings on the Internet websites of the + Department of Health and Human Services; and + ``(B) any other reporting or dissemination + mechanisms determined appropriate by the Secretary. + ``(3) Availability of data.--The Secretary may make data + described in (a) and (b) available for additional research, + analyses, and dissemination to other Federal agencies, non- + governmental entities, and the public, in accordance with any + Federal agency's data user agreements. + + ``(d) Limitations on Use of Data.--Nothing in this section shall be +construed to permit the use of information collected under this section +in a manner that would adversely affect any individual. + ``(e) Protection and Sharing of Data.-- + ``(1) Privacy and other safeguards.--The Secretary shall + ensure (through the promulgation of regulations or otherwise) + that-- + ``(A) all data collected pursuant to subsection (a) + is protected-- + ``(i) under privacy protections that are at + least as broad as those that the Secretary applies + to other health data under the regulations + promulgated under section 264(c) of the Health + Insurance Portability and Accountability Act of + 1996 (Public Law 104-191; 110 Stat. 2033); and + ``(ii) from all inappropriate internal use by + any entity that collects, stores, or receives the + data, including use of such data in determinations + of eligibility (or continued eligibility) in + health plans, and from other inappropriate uses, + as defined by the Secretary; and + +[[Page 124 STAT. 581]] + + ``(B) all appropriate information security + safeguards are used in the collection, analysis, and + sharing of data collected pursuant to subsection (a). + ``(2) Data <<NOTE: Procedures.>> sharing.--The Secretary + shall establish procedures for sharing data collected pursuant + to subsection (a), measures relating to such data, and analyses + of such data, with other relevant Federal and State agencies + including the agencies, centers, and entities within the + Department of Health and Human Services specified in subsection + (c)(1).. + + ``(f) Data on Rural Underserved Populations.--The Secretary shall +ensure that any data collected in accordance with this section regarding +racial and ethnic minority groups are also collected regarding +underserved rural and frontier populations. + ``(g) Authorization of Appropriations.--For the purpose of carrying +out this section, there are authorized to be appropriated such sums as +may be necessary for each of fiscal years 2010 through 2014. + ``(h) Requirement for Implementation.--Notwithstanding any other +provision of this section, data may not be collected under this section +unless funds are directly appropriated for such purpose in an +appropriations Act. + ``(i) Consultation.--The Secretary shall consult with the Director +of the Office of Personnel Management, the Secretary of Defense, the +Secretary of Veterans Affairs, the Director of the Bureau of the Census, +the Commissioner of Social Security, and the head of other appropriate +Federal agencies in carrying out this section.''. + (b) Addressing Health Care Disparities in Medicaid and CHIP.-- + (1) Standardized collection requirements included in state + plans.-- + (A) Medicaid.--Section 1902(a) of the Social + Security Act (42 U.S.C. 1396a(a)), as amended by section + 2001(d), is amended-- + (i) in paragraph 4), by striking ``and'' at + the end; + (ii) in paragraph (75), by striking the period + at the end and inserting ``; and''; and + (iii) by inserting after paragraph (75) the + following new paragraph: + ``(76) provide that any data collected under the State plan + meets the requirements of section 3101 of the Public Health + Service Act.''. + (B) CHIP.--Section 2108(e) of the Social Security + Act (42 U.S.C. 1397hh(e)) is amended by adding at the + end the following new paragraph: + ``(7) Data collected and reported in accordance with section + 3101 of the Public Health Service Act, with respect to + individuals enrolled in the State child health plan (and, in the + case of enrollees under 19 years of age, their parents or legal + guardians), including data regarding the primary language of + such individuals, parents, and legal guardians.''. + (2) Extending medicare requirement to address health + disparities data collection to medicaid and chip.--Title XIX of + the Social Security Act (42 U.S.C. 1396 et seq.), as amended by + section 2703 is amended by adding at the end the following new + section: + +[[Page 124 STAT. 582]] + +``SEC. 1946. <<NOTE: 42 USC 1396w-5.>> ADDRESSING HEALTH CARE + DISPARITIES. + + ``(a) Evaluating Data Collection Approaches.--The Secretary shall +evaluate approaches for the collection of data under this title and +title XXI, to be performed in conjunction with existing quality +reporting requirements and programs under this title and title XXI, that +allow for the ongoing, accurate, and timely collection and evaluation of +data on disparities in health care services and performance on the basis +of race, ethnicity, sex, primary language, and disability status. In +conducting such evaluation, the Secretary shall consider the following +objectives: + ``(1) Protecting patient privacy. + ``(2) Minimizing the administrative burdens of data + collection and reporting on States, providers, and health plans + participating under this title or title XXI. + ``(3) Improving program data under this title and title XXI + on race, ethnicity, sex, primary language, and disability + status. + + ``(b) Reports to Congress.-- + ``(1) Report on evaluation.--Not later than 18 months after + the date of the enactment of this section, the Secretary shall + submit to Congress a report on the evaluation conducted under + subsection (a). Such report shall, taking into consideration the + results of such evaluation-- + ``(A) identify approaches (including defining + methodologies) for identifying and collecting and + evaluating data on health care disparities on the basis + of race, ethnicity, sex, primary language, and + disability status for the programs under this title and + title XXI; and + ``(B) include recommendations on the most effective + strategies and approaches to reporting HEDIS quality + measures as required under section 1852(e)(3) and other + nationally recognized quality performance measures, as + appropriate, on such bases. + ``(2) Reports on data analyses.--Not later than 4 years + after the date of the enactment of this section, and 4 years + thereafter, the Secretary shall submit to Congress a report that + includes recommendations for improving the identification of + health care disparities for beneficiaries under this title and + under title XXI based on analyses of the data collected under + subsection (c). + + ``(c) Implementing <<NOTE: Deadline.>> Effective Approaches.--Not +later than 24 months after the date of the enactment of this section, +the Secretary shall implement the approaches identified in the report +submitted under subsection (b)(1) for the ongoing, accurate, and timely +collection and evaluation of data on health care disparities on the +basis of race, ethnicity, sex, primary language, and disability +status.''. + +SEC. 4303. CDC AND EMPLOYER-BASED WELLNESS PROGRAMS. + + Title III of the Public Health Service Act (42 U.S.C. 241 et seq.), +by section 4102, is further amended by adding at the end the following: + +[[Page 124 STAT. 583]] + + ``PART U--EMPLOYER-BASED WELLNESS PROGRAM + +``SEC. 399MM. <<NOTE: 42 USC 280l.>> TECHNICAL ASSISTANCE FOR EMPLOYER- + BASED WELLNESS PROGRAMS. + + ``In order to expand the utilization of evidence-based prevention +and health promotion approaches in the workplace, the Director shall-- + ``(1) provide employers (including small, medium, and large + employers, as determined by the Director) with technical + assistance, consultation, tools, and other resources in + evaluating such employers' employer-based wellness programs, + including-- + ``(A) measuring the participation and methods to + increase participation of employees in such programs; + ``(B) developing standardized measures that assess + policy, environmental and systems changes necessary to + have a positive health impact on employees' health + behaviors, health outcomes, and health care + expenditures; and + ``(C) evaluating such programs as they relate to + changes in the health status of employees, the + absenteeism of employees, the productivity of employees, + the rate of workplace injury, and the medical costs + incurred by employees; and + ``(2) build evaluation capacity among workplace staff by + training employers on how to evaluate employer-based wellness + programs by ensuring evaluation resources, technical assistance, + and consultation are available to workplace staff as needed + through such mechanisms as web portals, call centers, or other + means. + +``SEC. 399MM-1. <<NOTE: 42 USC 280l-1.>> NATIONAL WORKSITE HEALTH + POLICIES AND PROGRAMS STUDY. + + ``(a) In <<NOTE: Deadline. Determination.>> General.--In order to +assess, analyze, and monitor over time data about workplace policies and +programs, and to develop instruments to assess and evaluate +comprehensive workplace chronic disease prevention and health promotion +programs, policies and practices, not later than 2 years after the date +of enactment of this part, and at regular intervals (to be determined by +the Director) thereafter, the Director shall conduct a national worksite +health policies and programs survey to assess employer-based health +policies and programs. + + ``(b) Report.--Upon the completion of each study under subsection +(a), the Director shall submit to Congress a report that includes the +recommendations of the Director for the implementation of effective +employer-based health policies and programs. + +``SEC. 399MM-2. <<NOTE: 42 USC 280l-2.>> PRIORITIZATION OF EVALUATION BY + SECRETARY. + + ``The Secretary shall evaluate, in accordance with this part, all +programs funded through the Centers for Disease Control and Prevention +before conducting such an evaluation of privately funded programs unless +an entity with a privately funded wellness program requests such an +evaluation. + +``SEC. 399MM-3. <<NOTE: 42 USC 280l-3.>> PROHIBITION OF FEDERAL + WORKPLACE WELLNESS REQUIREMENTS. + + ``Notwithstanding any other provision of this part, any +recommendations, data, or assessments carried out under this part + +[[Page 124 STAT. 584]] + +shall not be used to mandate requirements for workplace wellness +programs.''. + +SEC. 4304. EPIDEMIOLOGY-LABORATORY CAPACITY GRANTS. + + Title XXVIII of the Public Health Service Act (42 U.S.C. 300hh et +seq.) is amended by adding at the end the following: + + ``Subtitle C--Strengthening Public Health Surveillance Systems + +``SEC. 2821. <<NOTE: 42 USC 300hh-31.>> EPIDEMIOLOGY-LABORATORY CAPACITY + GRANTS. + + ``(a) In General.--Subject to the availability of appropriations, +the Secretary, acting through the Director of the Centers for Disease +Control and Prevention, shall establish an Epidemiology and Laboratory +Capacity Grant Program to award grants to State health departments as +well as local health departments and tribal jurisdictions that meet such +criteria as the Director determines appropriate. Academic centers that +assist State and eligible local and tribal health departments may also +be eligible for funding under this section as the Director determines +appropriate. Grants shall be awarded under this section to assist public +health agencies in improving surveillance for, and response to, +infectious diseases and other conditions of public health importance +by-- + ``(1) strengthening epidemiologic capacity to identify and + monitor the occurrence of infectious diseases and other + conditions of public health importance; + ``(2) enhancing laboratory practice as well as systems to + report test orders and results electronically; + ``(3) improving information systems including developing and + maintaining an information exchange using national guidelines + and complying with capacities and functions determined by an + advisory council established and appointed by the Director; and + ``(4) developing and implementing prevention and control + strategies. + + ``(b) Authorization of Appropriations.--There are authorized to be +appropriated to carry out this section $190,000,000 for each of fiscal +years 2010 through 2013, of which-- + ``(1) not less than $95,000,000 shall be made available each + such fiscal year for activities under paragraphs (1) and (4) of + subsection (a); + ``(2) not less than $60,000,000 shall be made available each + such fiscal year for activities under subsection (a)(3); and + ``(3) not less than $32,000,000 shall be made available each + such fiscal year for activities under subsection (a)(2).''. + +SEC. 4305. ADVANCING RESEARCH AND TREATMENT FOR PAIN CARE MANAGEMENT. + + (a) Institute of Medicine Conference on Pain.-- + (1) Convening.--Not <<NOTE: Deadline. Contracts.>> later + than 1 year after funds are appropriated to carry out this + subsection, the Secretary of Health and Human Services shall + seek to enter into an agreement with the Institute of Medicine + of the National Academies to convene a Conference on Pain (in + this subsection referred to as ``the Conference''). + +[[Page 124 STAT. 585]] + + (2) Purposes.--The purposes of the Conference shall be to-- + (A) increase the recognition of pain as a + significant public health problem in the United States; + (B) evaluate the adequacy of assessment, diagnosis, + treatment, and management of acute and chronic pain in + the general population, and in identified racial, + ethnic, gender, age, and other demographic groups that + may be disproportionately affected by inadequacies in + the assessment, diagnosis, treatment, and management of + pain; + (C) identify barriers to appropriate pain care; + (D) establish an agenda for action in both the + public and private sectors that will reduce such + barriers and significantly improve the state of pain + care research, education, and clinical care in the + United States. + (3) Other appropriate entity.--If the Institute of Medicine + declines to enter into an agreement under paragraph (1), the + Secretary of Health and Human Services may enter into such + agreement with another appropriate entity. + (4) Report.--A report summarizing the Conference's findings + and recommendations shall be submitted to the Congress not later + than June 30, 2011. + (5) Authorization of appropriations.--For the purpose of + carrying out this subsection, there is authorized to be + appropriated such sums as may be necessary for each of fiscal + years 2010 and 2011. + + (b) Pain Research at National Institutes of Health.--Part B of title +IV of the Public Health Service Act (42 U.S.C. 284 et seq.) is amended +by adding at the end the following: + +``SEC. 409J. <<NOTE: 42 USC 284q.>> PAIN RESEARCH. + + ``(a) Research Initiatives.-- + ``(1) In general.--The Director of NIH is encouraged to + continue and expand, through the Pain Consortium, an aggressive + program of basic and clinical research on the causes of and + potential treatments for pain. + ``(2) Annual recommendations.--Not less than annually, the + Pain Consortium, in consultation with the Division of Program + Coordination, Planning, and Strategic Initiatives, shall develop + and submit to the Director of NIH recommendations on appropriate + pain research initiatives that could be undertaken with funds + reserved under section 402A(c)(1) for the Common Fund or + otherwise available for such initiatives. + ``(3) Definition.--In this subsection, the term `Pain + Consortium' means the Pain Consortium of the National Institutes + of Health or a similar trans-National Institutes of Health + coordinating entity designated by the Secretary for purposes of + this subsection. + + ``(b) Interagency Pain Research Coordinating Committee.-- + ``(1) Establishment.--The <<NOTE: Deadline.>> Secretary + shall establish not later than 1 year after the date of the + enactment of this section and as necessary maintain a committee, + to be known as the Interagency Pain Research Coordinating + Committee (in this section referred to as the `Committee'), to + coordinate all efforts within the Department of Health and Human + Services and other Federal agencies that relate to pain + research. + +[[Page 124 STAT. 586]] + + ``(2) Membership.-- + ``(A) In general.--The Committee shall be composed + of the following voting members: + ``(i) Not more than 7 voting Federal + representatives appoint by the Secretary from + agencies that conduct pain care research and + treatment. + ``(ii) 12 additional voting members appointed + under subparagraph (B). + ``(B) Additional members.--The Committee shall + include additional voting members appointed by the + Secretary as follows: + ``(i) 6 non-Federal members shall be appointed + from among scientists, physicians, and other + health professionals. + ``(ii) 6 members shall be appointed from + members of the general public, who are + representatives of leading research, advocacy, and + service organizations for individuals with pain- + related conditions. + ``(C) Nonvoting members.--The Committee shall + include such nonvoting members as the Secretary + determines to be appropriate. + ``(3) Chairperson.--The voting members of the Committee + shall select a chairperson from among such members. The + selection of a chairperson shall be subject to the approval of + the Director of NIH. + ``(4) Meetings.--The Committee shall meet at the call of the + chairperson of the Committee or upon the request of the Director + of NIH, but in no case less often than once each year. + ``(5) Duties.--The Committee shall-- + ``(A) develop a summary of advances in pain care + research supported or conducted by the Federal agencies + relevant to the diagnosis, prevention, and treatment of + pain and diseases and disorders associated with pain; + ``(B) identify critical gaps in basic and clinical + research on the symptoms and causes of pain; + ``(C) make recommendations to ensure that the + activities of the National Institutes of Health and + other Federal agencies are free of unnecessary + duplication of effort; + ``(D) make recommendations on how best to + disseminate information on pain care; and + ``(E) make recommendations on how to expand + partnerships between public entities and private + entities to expand collaborative, cross-cutting + research. + ``(6) Review.--The Secretary shall review the necessity of + the Committee at least once every 2 years.''. + + (c) Pain Care Education and Training.--Part D of title VII of the +Public Health Service Act (42 U.S.C. 294 et seq.) is amended by adding +at the end the following new section: + +``SEC. 759. PROGRAM <<NOTE: 42 USC 294i.>> FOR EDUCATION AND TRAINING IN + PAIN CARE. + + ``(a) In General.--The Secretary may make awards of grants, +cooperative agreements, and contracts to health professions schools, +hospices, and other public and private entities for the development and +implementation of programs to provide education and training to health +care professionals in pain care. + +[[Page 124 STAT. 587]] + + ``(b) Certain Topics.--An award may be made under subsection (a) +only if the applicant for the award agrees that the program carried out +with the award will include information and education on-- + ``(1) recognized means for assessing, diagnosing, treating, + and managing pain and related signs and symptoms, including the + medically appropriate use of controlled substances; + ``(2) applicable laws, regulations, rules, and policies on + controlled substances, including the degree to which + misconceptions and concerns regarding such laws, regulations, + rules, and policies, or the enforcement thereof, may create + barriers to patient access to appropriate and effective pain + care; + ``(3) interdisciplinary approaches to the delivery of pain + care, including delivery through specialized centers providing + comprehensive pain care treatment expertise; + ``(4) cultural, linguistic, literacy, geographic, and other + barriers to care in underserved populations; and + ``(5) recent findings, developments, and improvements in the + provision of pain care. + + ``(c) Evaluation <<NOTE: Grants. Contracts.>> of Programs.--The +Secretary shall (directly or through grants or contracts) provide for +the evaluation of programs implemented under subsection (a) in order to +determine the effect of such programs on knowledge and practice of pain +care. + + ``(d) Pain Care Defined.--For purposes of this section the term +`pain care' means the assessment, diagnosis, treatment, or management of +acute or chronic pain regardless of causation or body location. + ``(e) Authorization of Appropriations.--There is authorized to be +appropriated to carry out this section, such sums as may be necessary +for each of the fiscal years 2010 through 2012. Amounts appropriated +under this subsection shall remain available until expended.''. + +SEC. 4306. FUNDING FOR CHILDHOOD OBESITY DEMONSTRATION PROJECT. + + Section 1139A(e)(8) of the Social Security Act (42 U.S.C. 1320b- +9a(e)(8)) is amended to read as follows: + ``(8) Appropriation.--Out of any funds in the Treasury not + otherwise appropriated, there is appropriated to carry out this + subsection, $25,000,000 for the period of fiscal years 2010 + through 2014.''. + + Subtitle E--Miscellaneous Provisions + +SEC. 4401. SENSE OF THE SENATE CONCERNING CBO SCORING. + + (a) Finding.--The Senate finds that the costs of prevention programs +are difficult to estimate due in part because prevention initiatives are +hard to measure and results may occur outside the 5 and 10 year budget +windows. + (b) Sense of Congress.--It is the sense of the Senate that Congress +should work with the Congressional Budget Office to develop better +methodologies for scoring progress to be made in prevention and wellness +programs. + +[[Page 124 STAT. 588]] + +SEC. 4402. EFFECTIVENESS OF FEDERAL HEALTH AND WELLNESS INITIATIVES. + + To determine whether existing Federal health and wellness +initiatives are effective in achieving their stated goals, the Secretary +of Health and Human Services shall-- + (1) conduct <<NOTE: Evaluation.>> an evaluation of such + programs as they relate to changes in health status of the + American public and specifically on the health status of the + Federal workforce, including absenteeism of employees, the + productivity of employees, the rate of workplace injury, and the + medical costs incurred by employees, and health conditions, + including workplace fitness, healthy food and beverages, and + incentives in the Federal Employee Health Benefits Program; and + (2) <<NOTE: Reports.>> submit to Congress a report + concerning such evaluation, which shall include conclusions + concerning the reasons that such existing programs have proven + successful or not successful and what factors contributed to + such conclusions. + + TITLE V--HEALTH CARE WORKFORCE + + Subtitle A--Purpose and Definitions + +SEC. 5001. <<NOTE: 42 USC 294q note.>> PURPOSE. + + The purpose of this title is to improve access to and the delivery +of health care services for all individuals, particularly low income, +underserved, uninsured, minority, health disparity, and rural +populations by-- + (1) gathering and assessing comprehensive data in order for + the health care workforce to meet the health care needs of + individuals, including research on the supply, demand, + distribution, diversity, and skills needs of the health care + workforce; + (2) increasing the supply of a qualified health care + workforce to improve access to and the delivery of health care + services for all individuals; + (3) enhancing health care workforce education and training + to improve access to and the delivery of health care services + for all individuals; and + (4) providing support to the existing health care workforce + to improve access to and the delivery of health care services + for all individuals. + +SEC. 5002. <<NOTE: 42 USC 294q note.>> DEFINITIONS. + + (a) This Title.--In this title: + (1) Allied health professional.--The term ``allied health + professional'' means an allied health professional as defined in + section 799B(5) of the Public Heath Service Act (42 U.S.C. + 295p(5)) who-- + (A) has graduated and received an allied health + professions degree or certificate from an institution of + higher education; and + (B) is employed with a Federal, State, local or + tribal public health agency, or in a setting where + patients might require health care services, including + acute care facilities, ambulatory care facilities, + personal residences, and other + +[[Page 124 STAT. 589]] + + settings located in health professional shortage areas, + medically underserved areas, or medically underserved + populations, as recognized by the Secretary of Health + and Human Services. + (2) Health care career pathway.--The term ``healthcare + career pathway'' means a rigorous, engaging, and high quality + set of courses and services that-- + (A) includes an articulated sequence of academic and + career courses, including 21st century skills; + (B) is aligned with the needs of healthcare + industries in a region or State; + (C) prepares students for entry into the full range + of postsecondary education options, including registered + apprenticeships, and careers; + (D) provides academic and career counseling in + student-to-counselor ratios that allow students to make + informed decisions about academic and career options; + (E) meets State academic standards, State + requirements for secondary school graduation and is + aligned with requirements for entry into postsecondary + education, and applicable industry standards; and + (F) leads to 2 or more credentials, including-- + (i) a secondary school diploma; and + (ii) a postsecondary degree, an apprenticeship + or other occupational certification, a + certificate, or a license. + (3) Institution of higher education.--The term ``institution + of higher education'' has the meaning given the term in sections + 101 and 102 of the Higher Education Act of 1965 (20 U.S.C. 1001 + and 1002). + (4) Low income individual, state workforce investment board, + and local workforce investment board.-- + (A) Low-income individual.--The term ``low-income + individual'' has the meaning given that term in section + 101 of the Workforce investment Act of 1998 (29 U.S.C. + 2801). + (B) State workforce investment board; local + workforce investment board.--The terms ``State workforce + investment board'' and ``local workforce investment + board'', refer to a State workforce investment board + established under section 111 of the Workforce + Investment Act of 1998 (29 U.S.C. 2821) and a local + workforce investment board established under section 117 + of such Act (29 U.S.C. 2832), respectively. + (5) Postsecondary education.--The term ``postsecondary + education'' means-- + (A) a 4-year program of instruction, or not less + than a 1-year program of instruction that is acceptable + for credit toward an associate or a baccalaureate + degree, offered by an institution of higher education; + or + (B) a certificate or registered apprenticeship + program at the postsecondary level offered by an + institution of higher education or a non-profit + educational institution. + (6) Registered apprenticeship program.--The term + ``registered apprenticeship program'' means an industry skills + training program at the postsecondary level that combines + technical and theoretical training through structure on the job + +[[Page 124 STAT. 590]] + + learning with related instruction (in a classroom or through + distance learning) while an individual is employed, working + under the direction of qualified personnel or a mentor, and + earning incremental wage increases aligned to enhance job + proficiency, resulting in the acquisition of a nationally + recognized and portable certificate, under a plan approved by + the Office of Apprenticeship or a State agency recognized by the + Department of Labor. + + (b) Title VII of the Public Health Service Act.--Section 799B of the +Public Health Service Act (42 U.S.C. 295p) is amended-- + (1) by striking paragraph (3) and inserting the following: + ``(3) Physician assistant education program.--The term + `physician assistant education program' means an educational + program in a public or private institution in a State that-- + ``(A) has as its objective the education of + individuals who, upon completion of their studies in the + program, be qualified to provide primary care medical + services with the supervision of a physician; and + ``(B) is accredited by the Accreditation Review + Commission on Education for the Physician Assistant.''; + and + (2) by adding at the end the following: + ``(12) Area health education center.--The term `area health + education center' means a public or nonprofit private + organization that has a cooperative agreement or contract in + effect with an entity that has received an award under + subsection (a)(1) or (a)(2) of section 751, satisfies the + requirements in section 751(d)(1), and has as one of its + principal functions the operation of an area health education + center. Appropriate organizations may include hospitals, health + organizations with accredited primary care training programs, + accredited physician assistant educational programs associated + with a college or university, and universities or colleges not + operating a school of medicine or osteopathic medicine. + ``(13) Area health education center program.--The term `area + health education center program' means cooperative program + consisting of an entity that has received an award under + subsection (a)(1) or (a)(2) of section 751 for the purpose of + planning, developing, operating, and evaluating an area health + education center program and one or more area health education + centers, which carries out the required activities described in + section 751(c), satisfies the program requirements in such + section, has as one of its principal functions identifying and + implementing strategies and activities that address health care + workforce needs in its service area, in coordination with the + local workforce investment boards. + ``(14) Clinical social worker.--The term `clinical social + worker' has the meaning given the term in section 1861(hh)(1) of + the Social Security Act (42 U.S.C. 1395x(hh)(1)). + ``(15) Cultural competency.--The term `cultural competency' + shall be defined by the Secretary in a manner consistent with + section 1707(d)(3). + ``(16) Direct care worker.--The term `direct care worker' + has the meaning given that term in the 2010 Standard + Occupational Classifications of the Department of Labor for Home + Health Aides [31-1011], Psychiatric Aides [31-1013], Nursing + Assistants [31-1014], and Personal Care Aides [39-9021]. + +[[Page 124 STAT. 591]] + + ``(17) Federally qualified health center.--The term + `Federally qualified health center' has the meaning given that + term in section 1861(aa) of the Social Security Act (42 U.S.C. + 1395x(aa)). + ``(18) Frontier health professional shortage area.--The term + `frontier health professional shortage area' means an area-- + ``(A) with a population density less than 6 persons + per square mile within the service area; and + ``(B) with respect to which the distance or time for + the population to access care is excessive. + ``(19) Graduate psychology.--The term `graduate psychology' + means an accredited program in professional psychology. + ``(20) Health disparity population.--The term `health + disparity population' has the meaning given such term in section + 903(d)(1). + ``(21) Health literacy.--The term `health literacy' means + the degree to which an individual has the capacity to obtain, + communicate, process, and understand health information and + services in order to make appropriate health decisions. + ``(22) Mental health service professional.--The term `mental + health service professional' means an individual with a graduate + or postgraduate degree from an accredited institution of higher + education in psychiatry, psychology, school psychology, + behavioral pediatrics, psychiatric nursing, social work, school + social work, substance abuse disorder prevention and treatment, + marriage and family counseling, school counseling, or + professional counseling. + ``(23) One-stop delivery system center.--The term `one-stop + delivery system' means a one-stop delivery system described in + section 134(c) of the Workforce Investment Act of 1998 (29 + U.S.C. 2864(c)). + ``(24) Paraprofessional child and adolescent mental health + worker.--The term `paraprofessional child and adolescent mental + health worker' means an individual who is not a mental or + behavioral health service professional, but who works at the + first stage of contact with children and families who are + seeking mental or behavioral health services, including + substance abuse prevention and treatment services. + ``(25) Racial and ethnic minority group; racial and ethnic + minority population.--The terms `racial and ethnic minority + group' and `racial and ethnic minority population' have the + meaning given the term `racial and ethnic minority group' in + section 1707. + ``(26) Rural health clinic.--The term `rural health clinic' + has the meaning given that term in section 1861(aa) of the + Social Security Act (42 U.S.C. 1395x(aa)).''. + + (c) Title VIII of the Public Health Service Act.--Section 801 of the +Public Health Service Act (42 U.S.C. 296) is amended-- + (1) in paragraph (2)-- + (A) by striking ``means a'' and inserting ``means an + accredited (as defined in paragraph 6)''; and + (B) by striking the period as inserting the + following: ``where graduates are-- + ``(A) authorized to sit for the National Council + Licensure EXamination-Registered Nurse (NCLEX-RN); or + +[[Page 124 STAT. 592]] + + ``(B) licensed registered nurses who will receive a + graduate or equivalent degree or training to become an + advanced education nurse as defined by section + 811(b).''; and + (2) by adding at the end the following: + ``(16) Accelerated nursing degree program.--The term + `accelerated nursing degree program' means a program of + education in professional nursing offered by an accredited + school of nursing in which an individual holding a bachelors + degree in another discipline receives a BSN or MSN degree in an + accelerated time frame as determined by the accredited school of + nursing. + ``(17) Bridge or degree completion program.--The term + `bridge or degree completion program' means a program of + education in professional nursing offered by an accredited + school of nursing, as defined in paragraph (2), that leads to a + baccalaureate degree in nursing. Such programs may include, + Registered Nurse (RN) to Bachelor's of Science of Nursing (BSN) + programs, RN to MSN (Master of Science of Nursing) programs, or + BSN to Doctoral programs.''. + + Subtitle B--Innovations in the Health Care Workforce + +SEC. 5101. <<NOTE: 42 USC 294q.>> NATIONAL HEALTH CARE WORKFORCE + COMMISSION. + + (a) Purpose.--It is the purpose of this section to establish a +National Health Care Workforce Commission that-- + (1) serves as a national resource for Congress, the + President, States, and localities; + (2) communicates and coordinates with the Departments of + Health and Human Services, Labor, Veterans Affairs, Homeland + Security, and Education on related activities administered by + one or more of such Departments; + (3) develops and commissions evaluations of education and + training activities to determine whether the demand for health + care workers is being met; + (4) identifies barriers to improved coordination at the + Federal, State, and local levels and recommend ways to address + such barriers; and + (5) encourages innovations to address population needs, + constant changes in technology, and other environmental factors. + + (b) Establishment.--There is hereby established the National Health +Care Workforce Commission (in this section referred to as the +``Commission''). + (c) Membership.-- + (1) Number and appointment.--The Commission shall be + composed of 15 members to be appointed by the Comptroller + General, without regard to section 5 of the Federal Advisory + Committee Act (5 U.S.C. App.). + (2) Qualifications.-- + (A) In general.--The membership of the Commission + shall include individuals-- + (i) with national recognition for their + expertise in health care labor market analysis, + including health care workforce analysis; health + care finance and + +[[Page 124 STAT. 593]] + + economics; health care facility management; health + care plans and integrated delivery systems; health + care workforce education and training; health care + philanthropy; providers of health care services; + and other related fields; and + (ii) who will provide a combination of + professional perspectives, broad geographic + representation, and a balance between urban, + suburban, rural, and frontier representatives. + (B) Inclusion.-- + (i) In general.--The membership of the + Commission shall include no less than one + representative of-- + (I) the health care workforce and + health professionals; + (II) employers; + (III) third-party payers; + (IV) individuals skilled in the + conduct and interpretation of health + care services and health economics + research; + (V) representatives of consumers; + (VI) labor unions; + (VII) State or local workforce + investment boards; and + (VIII) educational institutions + (which may include elementary and + secondary institutions, institutions of + higher education, including 2 and 4 year + institutions, or registered + apprenticeship programs). + (ii) Additional members.--The remaining + membership may include additional representatives + from clause (i) and other individuals as + determined appropriate by the Comptroller General + of the United States. + (C) Majority non-providers.--Individuals who are + directly involved in health professions education or + practice shall not constitute a majority of the + membership of the Commission. + (D) Ethical <<NOTE: Public + information.>> disclosure.--The Comptroller General + shall establish a system for public disclosure by + members of the Commission of financial and other + potential conflicts of interest relating to such + members. Members of the Commission shall be treated as + employees of Congress for purposes of applying title I + of the Ethics in Government Act of 1978. Members of the + Commission shall not be treated as special government + employees under title 18, United States Code. + (3) Terms.-- + (A) In general.--The terms of members of the + Commission shall be for 3 years except that the + Comptroller General shall designate staggered terms for + the members first appointed. + (B) Vacancies.--Any member appointed to fill a + vacancy occurring before the expiration of the term for + which the member's predecessor was appointed shall be + appointed only for the remainder of that term. A member + may serve after the expiration of that member's term + until a successor has taken office. A vacancy in the + Commission + +[[Page 124 STAT. 594]] + + shall be filled in the manner in which the original + appointment was made. + (C) Initial appointments.-- + The <<NOTE: Deadline.>> Comptroller General shall make + initial appointments of members to the Commission not + later than September 30, 2010. + (4) Compensation.--While serving on the business of the + Commission (including travel time), a member of the Commission + shall be entitled to compensation at the per diem equivalent of + the rate provided for level IV of the Executive Schedule under + section 5315 of tile 5, United States Code, and while so serving + away from home and the member's regular place of business, a + member may be allowed travel expenses, as authorized by the + Chairman of the <<NOTE: Applicability.>> Commission. Physicians + serving as personnel of the Commission may be provided a + physician comparability allowance by the Commission in the same + manner as Government physicians may be provided such an + allowance by an agency under section 5948 of title 5, United + States Code, and for such purpose subsection (i) of such section + shall apply to the Commission in the same manner as it applies + to the Tennessee Valley Authority. For purposes of pay (other + than pay of members of the Commission) and employment benefits, + rights, and privileges, all personnel of the Commission shall be + treated as if they were employees of the United States Senate. + Personnel of the Commission shall not be treated as employees of + the Government Accountability Office for any purpose. + (5) Chairman, vice chairman.-- + The <<NOTE: Designation.>> Comptroller General shall designate a + member of the Commission, at the time of appointment of the + member, as Chairman and a member as Vice Chairman for that term + of appointment, except that in the case of vacancy of the + chairmanship or vice chairmanship, the Comptroller General may + designate another member for the remainder of that member's + term. + (6) Meetings.--The Commission shall meet at the call of the + chairman, but no less frequently than on a quarterly basis. + + (d) Duties.-- + (1) Recognition, dissemination, and communication.--The + Commission shall-- + (A) recognize efforts of Federal, State, and local + partnerships to develop and offer health care career + pathways of proven effectiveness; + (B) disseminate information on promising retention + practices for health care professionals; and + (C) communicate information on important policies + and practices that affect the recruitment, education and + training, and retention of the health care workforce. + (2) Review of health care workforce and annual reports.--In + order to develop a fiscally sustainable integrated workforce + that supports a high-quality, readily accessible health care + delivery system that meets the needs of patients and + populations, the Commission, in consultation with relevant + Federal, State, and local agencies, shall-- + (A) review current and projected health care + workforce supply and demand, including the topics + described in paragraph (3); + +[[Page 124 STAT. 595]] + + (B) make recommendations to Congress and the + Administration concerning national health care workforce + priorities, goals, and policies; + (C) by not later than October 1 of each year + (beginning with 2011), submit a report to Congress and + the Administration containing the results of such + reviews and recommendations concerning related policies; + and + (D) by not later than April 1 of each year + (beginning with 2011), submit a report to Congress and + the Administration containing a review of, and + recommendations on, at a minimum one high priority area + as described in paragraph (4). + (3) Specific topics to be reviewed.--The topics described in + this paragraph include-- + (A) current health care workforce supply and + distribution, including demographics, skill sets, and + demands, with projected demands during the subsequent 10 + and 25 year periods; + (B) health care workforce education and training + capacity, including the number of students who have + completed education and training, including registered + apprenticeships; the number of qualified faculty; the + education and training infrastructure; and the education + and training demands, with projected demands during the + subsequent 10 and 25 year periods; + (C) the education loan and grant programs in titles + VII and VIII of the Public Health Service Act (42 U.S.C. + 292 et seq. and 296 et seq.), with recommendations on + whether such programs should become part of the Higher + Education Act of 1965 (20 U.S.C. 1001 et seq); + (D) the implications of new and existing Federal + policies which affect the health care workforce, + including Medicare and Medicaid graduate medical + education policies, titles VII and VIII of the Public + Health Service Act (42 U.S.C. 292 et seq. and 296 et + seq.), the National Health Service Corps (with + recommendations for aligning such programs with national + health workforce priorities and goals), and other health + care workforce programs, including those supported + through the Workforce Investment Act of 1998 (29 U.S.C. + 2801 et seq.), the Carl D. Perkins Career and Technical + Education Act of 2006 (20 U.S.C. 2301 et seq.), the + Higher Education Act of 1965 (20 U.S.C. 1001 et seq.), + and any other Federal health care workforce programs; + (E) the health care workforce needs of special + populations, such as minorities, rural populations, + medically underserved populations, gender specific + needs, individuals with disabilities, and geriatric and + pediatric populations with recommendations for new and + existing Federal policies to meet the needs of these + special populations; and + (F) recommendations creating or revising national + loan repayment programs and scholarship programs to + require low-income, minority medical students to serve + in their home communities, if designated as medical + underserved community. + (4) High priority areas.-- + +[[Page 124 STAT. 596]] + + (A) In general.--The initial high priority topics + described in this paragraph include each of the + following: + (i) Integrated health care workforce planning + that identifies health care professional skills + needed and maximizes the skill sets of health care + professionals across disciplines. + (ii) An analysis of the nature, scopes of + practice, and demands for health care workers in + the enhanced information technology and management + workplace. + (iii) An analysis of how to align Medicare and + Medicaid graduate medical education policies with + national workforce goals. + (iv) The education and training capacity, + projected demands, and integration with the health + care delivery system of each of the following: + (I) Nursing workforce capacity at + all levels. + (II) Oral health care workforce + capacity at all levels. + (III) Mental and behavioral health + care workforce capacity at all levels. + (IV) Allied health and public health + care workforce capacity at all levels. + (V) Emergency medical service + workforce capacity, including the + retention and recruitment of the + volunteer workforce, at all levels. + (VI) The geographic distribution of + health care providers as compared to the + identified health care workforce needs + of States and regions. + (B) Future determinations.--The Commission may + require that additional topics be included under + subparagraph (A). The appropriate committees of Congress + may recommend to the Commission the inclusion of other + topics for health care workforce development areas that + require special attention. + (5) Grant program.--The Commission shall-- + (A) review <<NOTE: Review. Reports.>> implementation + progress reports on, and report to Congress about, the + State Health Care Workforce Development Grant program + established in section 5102; + (B) in collaboration with the Department of Labor + and in coordination with the Department of Education and + other relevant Federal agencies, make recommendations to + the fiscal and administrative agent under section + 5102(b) for grant recipients under section 5102; + (C) assess the implementation of the grants under + such section; and + (D) collect performance and report information, + including identified models and best practices, on + grants from the fiscal and administrative agent under + such section and distribute this information to + Congress, relevant Federal agencies, and to the public. + (6) Study.--The Commission shall study effective mechanisms + for financing education and training for careers in health care, + including public health and allied health. + (7) Recommendations.--The Commission shall submit + recommendations to Congress, the Department of Labor, and the + Department of Health and Human Services about improving + +[[Page 124 STAT. 597]] + + safety, health, and worker protections in the workplace for the + health care workforce. + (8) Assessment.--The Commission shall assess and receive + reports from the National Center for Health Care Workforce + Analysis established under section 761(b) of the Public Service + Health Act (as amended by section 5103). + + (e) Consultation With Federal, State, and Local Agencies, Congress, +and Other Organizations.-- + (1) In general.--The Commission shall consult with Federal + agencies (including the Departments of Health and Human + Services, Labor, Education, Commerce, Agriculture, Defense, and + Veterans Affairs and the Environmental Protection Agency), + Congress, the Medicare Payment Advisory Commission, the Medicaid + and CHIP Payment and Access Commission, and, to the extent + practicable, with State and local agencies, Indian tribes, + voluntary health care organizations, professional societies, and + other relevant public-private health care partnerships. + (2) Obtaining official data.--The Commission, consistent + with established privacy rules, may secure directly from any + department or agency of the Executive Branch information + necessary to enable the Commission to carry out this section. + (3) Detail of federal government employees.--An employee of + the Federal Government may be detailed to the Commission without + reimbursement. The detail of such an employee shall be without + interruption or loss of civil service status. + + (f) Director and Staff; Experts and Consultants.--Subject to such +review as the Comptroller General of the United States determines to be +necessary to ensure the efficient administration of the Commission, the +Commission may-- + (1) employ and fix the compensation of an executive director + that shall not exceed the rate of basic pay payable for level V + of the Executive Schedule and such other personnel as may be + necessary to carry out its duties (without regard to the + provisions of title 5, United States Code, governing + appointments in the competitive service); + (2) seek such assistance and support as may be required in + the performance of its duties from appropriate Federal + departments and agencies; + (3) enter into contracts or make other arrangements, as may + be necessary for the conduct of the work of the Commission + (without regard to section 3709 of the Revised Statutes (41 + U.S.C. 5)); + (4) make advance, progress, and other payments which relate + to the work of the Commission; + (5) provide transportation and subsistence for persons + serving without compensation; and + (6) prescribe such rules and regulations as the Commission + determines to be necessary with respect to the internal + organization and operation of the Commission. + + (g) Powers.-- + (1) Data collection.--In order to carry out its functions + under this section, the Commission shall-- + (A) utilize existing information, both published and + unpublished, where possible, collected and assessed + either by its own staff or under other arrangements made + in + +[[Page 124 STAT. 598]] + + accordance with this section, including coordination + with the Bureau of Labor Statistics; + (B) carry out, or award grants or contracts for the + carrying out of, original research and development, + where existing information is inadequate, and + (C) adopt procedures allowing interested parties to + submit information for the Commission's use in making + reports and recommendations. + (2) Access of the government accountability office to + information.--The Comptroller General of the United States shall + have unrestricted access to all deliberations, records, and data + of the Commission, immediately upon request. + (3) Periodic audit.--The Commission shall be subject to + periodic audit by an independent public accountant under + contract to the Commission. + + (h) Authorization of Appropriations.-- + (1) Request for appropriations.--The Commission shall submit + requests for appropriations in the same manner as the + Comptroller General of the United States submits requests for + appropriations. Amounts so appropriated for the Commission shall + be separate from amounts appropriated for the Comptroller + General. + (2) Authorization.--There are authorized to be appropriated + such sums as may be necessary to carry out this section. + (3) Gifts and services.--The Commission may not accept + gifts, bequeaths, or donations of property, but may accept and + use donations of services for purposes of carrying out this + section. + + (i) Definitions.--In this section: + (1) Health care workforce.--The term ``health care + workforce'' includes all health care providers with direct + patient care and support responsibilities, such as physicians, + nurses, nurse practitioners, primary care providers, preventive + medicine physicians, optometrists, ophthalmologists, physician + assistants, pharmacists, dentists, dental hygienists, and other + oral healthcare professionals, allied health professionals, + doctors of chiropractic, community health workers, health care + paraprofessionals, direct care workers, psychologists and other + behavioral and mental health professionals (including substance + abuse prevention and treatment providers), social workers, + physical and occupational therapists, certified nurse midwives, + podiatrists, the EMS workforce (including professional and + volunteer ambulance personnel and firefighters who perform + emergency medical services), licensed complementary and + alternative medicine providers, integrative health + practitioners, public health professionals, and any other health + professional that the Comptroller General of the United States + determines appropriate. + (2) Health professionals.--The term ``health professionals'' + includes-- + (A) dentists, dental hygienists, primary care + providers, specialty physicians, nurses, nurse + practitioners, physician assistants, psychologists and + other behavioral and mental health professionals + (including substance abuse prevention and treatment + providers), social workers, physical and occupational + therapists, public health professionals, clinical + +[[Page 124 STAT. 599]] + + pharmacists, allied health professionals, doctors of + chiropractic, community health workers, school nurses, + certified nurse midwives, podiatrists, licensed + complementary and alternative medicine providers, the + EMS workforce (including professional and volunteer + ambulance personnel and firefighters who perform + emergency medical services), and integrative health + practitioners; + (B) national representatives of health + professionals; + (C) representatives of schools of medicine, + osteopathy, nursing, dentistry, optometry, pharmacy, + chiropractic, allied health, educational programs for + public health professionals, behavioral and mental + health professionals (as so defined), social workers, + pharmacists, physical and occupational therapists, oral + health care industry dentistry and dental hygiene, and + physician assistants; + (D) representatives of public and private teaching + hospitals, and ambulatory health facilities, including + Federal medical facilities; and + (E) any other health professional the Comptroller + General of the United States determines appropriate. + +SEC. 5102. STATE <<NOTE: 42 USC 294r.>> HEALTH CARE WORKFORCE + DEVELOPMENT GRANTS. + + (a) Establishment.--There is established a competitive health care +workforce development grant program (referred to in this section as the +``program'') for the purpose of enabling State partnerships to complete +comprehensive planning and to carry out activities leading to coherent +and comprehensive health care workforce development strategies at the +State and local levels. + (b) Fiscal and Administrative Agent.--The Health Resources and +Services Administration of the Department of Health and Human Services +(referred to in this section as the ``Administration'') shall be the +fiscal and administrative agent for the grants awarded under +this <<NOTE: Review.>> section. The Administration is authorized to +carry out the program, in consultation with the National Health Care +Workforce Commission (referred to in this section as the +``Commission''), which shall review reports on the development, +implementation, and evaluation activities of the grant program, +including-- + (1) administering the grants; + (2) providing technical assistance to grantees; and + (3) reporting performance information to the Commission. + + (c) Planning Grants.-- + (1) Amount and duration.--A planning grant shall be awarded + under this subsection for a period of not more than one year and + the maximum award may not be more than $150,000. + (2) Eligibility.--To be eligible to receive a planning + grant, an entity shall be an eligible partnership. An eligible + partnership shall be a State workforce investment board, if it + includes or modifies the members to include at least one + representative from each of the following: health care employer, + labor organization, a public 2-year institution of higher + education, a public 4-year institution of higher education, the + recognized State federation of labor, the State public secondary + education agency, the State P-16 or P-20 Council if such a + council exists, and a philanthropic organization that is + actively engaged in providing learning, mentoring, and work + opportunities to recruit, + +[[Page 124 STAT. 600]] + + educate, and train individuals for, and retain individuals in, + careers in health care and related industries. + (3) Fiscal and administrative agent.--The Governor of the + State receiving a planning grant has the authority to appoint a + fiscal and an administrative agency for the partnership. + (4) Application.--Each State partnership desiring a planning + grant shall submit an application to the Administrator of the + Administration at such time and in such manner, and accompanied + by such information as the Administrator may reasonable require. + Each application submitted for a planning grant shall describe + the members of the State partnership, the activities for which + assistance is sought, the proposed performance benchmarks to be + used to measure progress under the planning grant, a budget for + use of the funds to complete the required activities described + in paragraph (5), and such additional assurance and information + as the Administrator determines to be essential to ensure + compliance with the grant program requirements. + (5) Required activities.--A State partnership receiving a + planning grant shall carry out the following: + (A) Analyze State labor market information in order + to create health care career pathways for students and + adults, including dislocated workers. + (B) Identify current and projected high demand State + or regional health care sectors for purposes of planning + career pathways. + (C) Identify existing Federal, State, and private + resources to recruit, educate or train, and retain a + skilled health care workforce and strengthen + partnerships. + (D) Describe the academic and health care industry + skill standards for high school graduation, for entry + into postsecondary education, and for various + credentials and licensure. + (E) Describe State secondary and postsecondary + education and training policies, models, or practices + for the health care sector, including career information + and guidance counseling. + (F) Identify Federal or State policies or rules to + developing a coherent and comprehensive health care + workforce development strategy and barriers and a plan + to resolve these barriers. + (G) Participate in the Administration's evaluation + and reporting activities. + (6) Performance and evaluation.--Before the State + partnership receives a planning grant, such partnership and the + Administrator of the Administration shall jointly determine the + performance benchmarks that will be established for the purposes + of the planning grant. + (7) Match.--Each State partnership receiving a planning + grant shall provide an amount, in cash or in kind, that is not + less that 15 percent of the amount of the grant, to carry out + the activities supported by the grant. The matching requirement + may be provided from funds available under other Federal, State, + local or private sources to carry out the activities. + (8) Report.-- + +[[Page 124 STAT. 601]] + + (A) Report to administration.--Not later than 1 year + after a State partnership receives a planning grant, the + partnership shall submit a report to the Administration + on the State's performance of the activities under the + grant, including the use of funds, including matching + funds, to carry out required activities, and a + description of the progress of the State workforce + investment board in meeting the performance benchmarks. + (B) Report to congress.--The Administration shall + submit a report to Congress analyzing the planning + activities, performance, and fund utilization of each + State grant recipient, including an identification of + promising practices and a profile of the activities of + each State grant recipient. + + (d) Implementation Grants.-- + (1) In general.--The Administration shall-- + (A) competitively award implementation grants to + State partnerships to enable such partnerships to + implement activities that will result in a coherent and + comprehensive plan for health workforce development that + will address current and projected workforce demands + within the State; and + (B) inform the Commission and Congress about the + awards made. + (2) Duration.--An implementation grant shall be awarded for + a period of no more than 2 years, except in those cases where + the Administration determines that the grantee is high + performing and the activities supported by the grant warrant up + to 1 additional year of funding. + (3) Eligibility.--To be eligible for an implementation + grant, a State partnership shall have-- + (A) received a planning grant under subsection (c) + and completed all requirements of such grant; or + (B) completed a satisfactory application, including + a plan to coordinate with required partners and complete + the required activities during the 2 year period of the + implementation grant. + (4) Fiscal and administrative agent.--A State partnership + receiving an implementation grant shall appoint a fiscal and an + administration agent for the implementation of such grant. + (5) Application.--Each eligible State partnership desiring + an implementation grant shall submit an application to the + Administration at such time, in such manner, and accompanied by + such information as the Administration may reasonably require. + Each application submitted shall include-- + (A) a description of the members of the State + partnership; + (B) a description of how the State partnership + completed the required activities under the planning + grant, if applicable; + (C) a description of the activities for which + implementation grant funds are sought, including grants + to regions by the State partnership to advance coherent + and comprehensive regional health care workforce + planning activities; + (D) a description of how the State partnership will + coordinate with required partners and complete the + +[[Page 124 STAT. 602]] + + required partnership activities during the duration of + an implementation grant; + (E) a budget proposal of the cost of the activities + supported by the implementation grant and a timeline for + the provision of matching funds required; + (F) proposed performance benchmarks to be used to + assess and evaluate the progress of the partnership + activities; + (G) a description of how the State partnership will + collect data to report progress in grant activities; and + (H) such additional assurances as the Administration + determines to be essential to ensure compliance with + grant requirements. + (6) Required activities.-- + (A) In general.--A State partnership that receives + an implementation grant may reserve not less than 60 + percent of the grant funds to make grants to be + competitively awarded by the State partnership, + consistent with State procurement rules, to encourage + regional partnerships to address health care workforce + development needs and to promote innovative health care + workforce career pathway activities, including career + counseling, learning, and employment. + (B) Eligible partnership duties.--An eligible State + partnership receiving an implementation grant shall-- + (i) identify and convene regional leadership + to discuss opportunities to engage in statewide + health care workforce development planning, + including the potential use of competitive grants + to improve the development, distribution, and + diversity of the regional health care workforce; + the alignment of curricula for health care + careers; and the access to quality career + information and guidance and education and + training opportunities; + (ii) in consultation with key stakeholders and + regional leaders, take appropriate steps to reduce + Federal, State, or local barriers to a + comprehensive and coherent strategy, including + changes in State or local policies to foster + coherent and comprehensive health care workforce + development activities, including health care + career pathways at the regional and State levels, + career planning information, retraining for + dislocated workers, and as appropriate, requests + for Federal program or administrative waivers; + (iii) develop, disseminate, and review with + key stakeholders a preliminary statewide strategy + that addresses short- and long-term health care + workforce development supply versus demand; + (iv) convene State partnership members on a + regular basis, and at least on a semiannual basis; + (v) assist leaders at the regional level to + form partnerships, including technical assistance + and capacity building activities; + +[[Page 124 STAT. 603]] + + (vi) collect and assess data on and report on + the performance benchmarks selected by the State + partnership and the Administration for + implementation activities carried out by regional + and State partnerships; and + (vii) participate in the Administration's + evaluation and reporting activities. + (7) Performance and evaluation.--Before the State + partnership receives an implementation grant, it and the + Administrator shall jointly determine the performance benchmarks + that shall be established for the purposes of the implementation + grant. + (8) Match.--Each State partnership receiving an + implementation grant shall provide an amount, in cash or in kind + that is not less than 25 percent of the amount of the grant, to + carry out the activities supported by the grant. The matching + funds may be provided from funds available from other Federal, + State, local, or private sources to carry out such activities. + (9) Reports.-- + (A) Report to administration.--For each year of the + implementation grant, the State partnership receiving + the implementation grant shall submit a report to the + Administration on the performance of the State of the + grant activities, including a description of the use of + the funds, including matched funds, to complete + activities, and a description of the performance of the + State partnership in meeting the performance benchmarks. + (B) Report to congress.--The Administration shall + submit a report to Congress analyzing implementation + activities, performance, and fund utilization of the + State grantees, including an identification of promising + practices and a profile of the activities of each State + grantee. + + (e) Authorization for Appropriations.-- + (1) Planning grants.--There are authorized to be + appropriated to award planning grants under subsection (c) + $8,000,000 for fiscal year 2010, and such sums as may be + necessary for each subsequent fiscal year. + (2) Implementation grants.--There are authorized to be + appropriated to award implementation grants under subsection + (d), $150,000,000 for fiscal year 2010, and such sums as may be + necessary for each subsequent fiscal year. + +SEC. 5103. HEALTH CARE WORKFORCE ASSESSMENT. + + (a) In <<NOTE: 42 USC 294n.>> General.--Section 761 of the Public +Health Service Act (42 U.S.C. 294m) is amended-- + (1) by redesignating subsection (c) as subsection (e); + (2) by striking subsection (b) and inserting the following: + + ``(b) National Center for Health Care Workforce Analysis.-- + ``(1) Establishment.--The Secretary shall establish the + National Center for Health Workforce Analysis (referred to in + this section as the `National Center'). + ``(2) Purposes.--The National Center, in coordination to the + extent practicable with the National Health Care Workforce + +[[Page 124 STAT. 604]] + + Commission (established in section 5101 of the Patient + Protection and Affordable Care Act), and relevant regional and + State centers and agencies, shall-- + ``(A) provide for the development of information + describing and analyzing the health care workforce and + workforce related issues; + ``(B) carry out the activities under section 792(a); + ``(C) annually evaluate programs under this title; + ``(D) develop and publish performance measures and + benchmarks for programs under this title; and + ``(E) establish, <<NOTE: Internet + registry.>> maintain, and publicize a national Internet + registry of each grant awarded under this title and a + database to collect data from longitudinal evaluations + (as described in subsection (d)(2)) on performance + measures (as developed under sections 749(d)(3), + 757(d)(3), and 762(a)(3)). + ``(3) Collaboration and data sharing.-- + ``(A) In general.--The National Center shall + collaborate with Federal agencies and relevant + professional and educational organizations or societies + for the purpose of linking data regarding grants awarded + under this title. + ``(B) Contracts for health workforce analysis.--For + the purpose of carrying out the activities described in + subparagraph (A), the National Center may enter into + contracts with relevant professional and educational + organizations or societies. + + ``(c) State and Regional Centers for Health Workforce Analysis.-- + ``(1) In general.-- + The <<NOTE: Grants. Contracts.>> Secretary shall award grants + to, or enter into contracts with, eligible entities for purposes + of-- + ``(A) collecting, analyzing, and reporting data + regarding programs under this title to the National + Center and to the public; and + ``(B) providing technical assistance to local and + regional entities on the collection, analysis, and + reporting of data. + ``(2) Eligible entities.--To be eligible for a grant or + contract under this subsection, an entity shall-- + ``(A) be a State, a State workforce investment + board, a public health or health professions school, an + academic health center, or an appropriate public or + private nonprofit entity; and + ``(B) submit to the Secretary an application at such + time, in such manner, and containing such information as + the Secretary may require. + + ``(d) Increase in Grants for Longitudinal Evaluations.-- + ``(1) In general.--The Secretary shall increase the amount + awarded to an eligible entity under this title for a + longitudinal evaluation of individuals who have received + education, training, or financial assistance from programs under + this title. + ``(2) Capability.--A longitudinal evaluation shall be + capable of-- + ``(A) studying practice patterns; and + ``(B) collecting and reporting data on performance + measures developed under sections 749(d)(3), 757(d)(3), + and 762(a)(3). + +[[Page 124 STAT. 605]] + + ``(3) Guidelines.--A longitudinal evaluation shall comply + with guidelines issued under sections 749(d)(4), 757(d)(4), and + 762(a)(4). + ``(4) Eligible entities.--To be eligible to obtain an + increase under this section, an entity shall be a recipient of a + grant or contract under this title.''; and + (3) in subsection (e), as so redesignated-- + (A) by striking paragraph (1) and inserting the + following: + ``(1) In <<NOTE: Appropriation authorization.>> general.-- + ``(A) National center.--To carry out subsection (b), + there are authorized to be appropriated $7,500,000 for + each of fiscal years 2010 through 2014. + ``(B) State and regional centers.--To carry out + subsection (c), there are authorized to be appropriated + $4,500,000 for each of fiscal years 2010 through 2014. + ``(C) Grants for longitudinal evaluations.--To carry + out subsection (d), there are authorized to be + appropriated such sums as may be necessary for fiscal + years 2010 through 2014.''; and + (4) in paragraph (2), by striking ``subsection (a)'' and + inserting ``paragraph (1)''. + + (b) Transfers.--Not <<NOTE: Deadline. 42 USC 294n note.>> later than +180 days after the date of enactment of this Act, the responsibilities +and resources of the National Center for Health Workforce Analysis, as +in effect on the date before the date of enactment of this Act, shall be +transferred to the National Center for Health Care Workforce Analysis +established under section 761 of the Public Health Service Act, as +amended by subsection (a). + + (c) Use of Longitudinal Evaluations.--Section 791(a)(1) of the +Public Health Service Act (42 U.S.C. 295j(a)(1)) is amended-- + (1) in subparagraph (A), by striking ``or'' at the end; + (2) in subparagraph (B), by striking the period and + inserting ``; or''; and + (3) by adding at the end the following: + ``(C) utilizes a longitudinal evaluation (as + described in section 761(d)(2)) and reports data from + such system to the national workforce database (as + established under section 761(b)(2)(E)).''. + + (d) Performance Measures; Guidelines for Longitudinal Evaluations.-- + (1) Advisory <<NOTE: 42 USC 293l.>> committee on training in + primary care medicine and dentistry.--Section 748(d) of the + Public Health Service Act is amended-- + (A) in paragraph (1), by striking ``and'' at the + end; + (B) in paragraph (2), by striking the period and + inserting a semicolon; and + (C) by adding at the end the following: + ``(3) develop, publish, and implement performance measures + for programs under this part; + ``(4) develop and publish guidelines for longitudinal + evaluations (as described in section 761(d)(2)) for programs + under this part; and + ``(5) recommend appropriation levels for programs under this + part.''. + +[[Page 124 STAT. 606]] + + (2) Advisory committee on interdisciplinary, community-based + linkages.--Section 756(d) of the Public Health Service + Act <<NOTE: 42 USC 294f.>> is amended-- + (A) in paragraph (1), by striking ``and'' at the + end; + (B) in paragraph (2), by striking the period and + inserting a semicolon; and + (C) by adding at the end the following: + ``(3) develop, publish, and implement performance measures + for programs under this part; + ``(4) develop and publish guidelines for longitudinal + evaluations (as described in section 761(d)(2)) for programs + under this part; and + ``(5) recommend appropriation levels for programs under this + part.''. + (3) Advisory council on graduate medical education.--Section + 762(a) of the Public Health Service Act (42 U.S.C. 294o(a)) is + amended-- + (A) in paragraph (1), by striking ``and'' at the + end; + (B) in paragraph (2), by striking the period and + inserting a semicolon; and + (C) by adding at the end the following: + ``(3) develop, publish, and implement performance measures + for programs under this title, except for programs under part C + or D; + ``(4) develop and publish guidelines for longitudinal + evaluations (as described in section 761(d)(2)) for programs + under this title, except for programs under part C or D; and + ``(5) recommend appropriation levels for programs under this + title, except for programs under part C or D.''. + + Subtitle C--Increasing the Supply of the Health Care Workforce + +SEC. 5201. FEDERALLY SUPPORTED STUDENT LOAN FUNDS. + + (a) Medical Schools and Primary Health Care.--Section 723 of the +Public Health Service Act (42 U.S.C. 292s) is amended-- + (1) in subsection (a)-- + (A) in paragraph (1), by striking subparagraph (B) + and inserting the following: + ``(B) to practice in such care for 10 years + (including residency training in primary health care) or + through the date on which the loan is repaid in full, + whichever occurs first.''; and + (B) by striking paragraph (3) and inserting the + following: + ``(3) Noncompliance by student.--Each agreement entered into + with a student pursuant to paragraph (1) shall provide that, if + the student fails to comply with such agreement, the loan + involved will begin to accrue interest at a rate of 2 percent + per year greater than the rate at which the student would pay if + compliant in such year.''; and + (2) by adding at the end the following: + + ``(d) Sense of Congress.--It is the sense of Congress that funds +repaid under the loan program under this section should not be +transferred to the Treasury of the United States or otherwise used for +any other purpose other than to carry out this section.''. + +[[Page 124 STAT. 607]] + + (b) Student <<NOTE: 42 USC 292s note.>> Loan Guidelines.--The +Secretary of Health and Human Services shall not require parental +financial information for an independent student to determine financial +need under section 723 of the Public Health Service Act (42 U.S.C. 292s) +and the determination of need for such information shall be at the +discretion of applicable school loan officer. The Secretary shall amend +guidelines issued by the Health Resources and Services Administration in +accordance with the preceding sentence. + +SEC. 5202. NURSING STUDENT LOAN PROGRAM. + + (a) Loan Agreements.--Section 836(a) of the Public Health Service +Act (42 U.S.C. 297b(a)) is amended-- + (1) by striking ``$2,500'' and inserting ``$3,300''; + (2) by striking ``$4,000'' and inserting ``$5,200''; and + (3) by striking ``$13,000'' and all that follows through the + period and inserting ``$17,000 in the case of any student during + fiscal years 2010 and 2011. After fiscal year 2011, such amounts + shall be adjusted to provide for a cost-of-attendance increase + for the yearly loan rate and the aggregate of the loans.''. + + (b) Loan Provisions.--Section 836(b) of the Public Health Service +Act (42 U.S.C. 297b(b)) is amended-- + (1) in paragraph (1)(C), by striking ``1986'' and inserting + ``2000''; and + (2) in paragraph (3), by striking ``the date of enactment of + the Nurse Training Amendments of 1979'' and inserting + ``September 29, 1995''. + +SEC. 5203. HEALTH CARE WORKFORCE LOAN REPAYMENT PROGRAMS. + + Part E of title VII of the Public Health Service Act (42 U.S.C. 294n +et seq.) is amended by adding at the end the following: + + ``Subpart 3--Recruitment and Retention Programs + +``SEC. 775. INVESTMENT <<NOTE: 42 USC 295f.>> IN TOMORROW'S PEDIATRIC + HEALTH CARE WORKFORCE. + + ``(a) Establishment.--The Secretary shall establish and carry out a +pediatric specialty loan repayment program under which the eligible +individual agrees to be employed full-time for a specified period (which +shall not be less than 2 years) in providing pediatric medical +subspecialty, pediatric surgical specialty, or child and adolescent +mental and behavioral health care, including substance abuse prevention +and treatment services. + ``(b) Program Administration.--Through <<NOTE: Contracts.>> the +program established under this section, the Secretary shall enter into +contracts with qualified health professionals under which-- + ``(1) such qualified health professionals will agree to + provide pediatric medical subspecialty, pediatric surgical + specialty, or child and adolescent mental and behavioral health + care in an area with a shortage of the specified pediatric + subspecialty that has a sufficient pediatric population to + support such pediatric subspecialty, as determined by the + Secretary; and + ``(2) the Secretary agrees to make payments on the principal + and interest of undergraduate, graduate, or graduate medical + education loans of professionals described in paragraph (1) of + not more than $35,000 a year for each year of agreed upon + service under such paragraph for a period of not more than 3 + years during the qualified health professional's-- + +[[Page 124 STAT. 608]] + + ``(A) participation in an accredited pediatric + medical subspecialty, pediatric surgical specialty, or + child and adolescent mental health subspecialty + residency or fellowship; or + ``(B) employment as a pediatric medical + subspecialist, pediatric surgical specialist, or child + and adolescent mental health professional serving an + area or population described in such paragraph. + + ``(c) In General.-- + ``(1) Eligible <<NOTE: Definitions.>> individuals.-- + ``(A) Pediatric medical specialists and pediatric + surgical specialists.--For purposes of contracts with + respect to pediatric medical specialists and pediatric + surgical specialists, the term `qualified health + professional' means a licensed physician who-- + ``(i) is entering or receiving training in an + accredited pediatric medical subspecialty or + pediatric surgical specialty residency or + fellowship; or + ``(ii) has completed (but not prior to the end + of the calendar year in which this section is + enacted) the training described in subparagraph + (B). + ``(B) Child and adolescent mental and behavioral + health.--For purposes of contracts with respect to child + and adolescent mental and behavioral health care, the + term `qualified health professional' means a health care + professional who-- + ``(i) has received specialized training or + clinical experience in child and adolescent mental + health in psychiatry, psychology, school + psychology, behavioral pediatrics, psychiatric + nursing, social work, school social work, + substance abuse disorder prevention and treatment, + marriage and family therapy, school counseling, or + professional counseling; + ``(ii) has a license or certification in a + State to practice allopathic medicine, osteopathic + medicine, psychology, school psychology, + psychiatric nursing, social work, school social + work, marriage and family therapy, school + counseling, or professional counseling; or + ``(iii) is a mental health service + professional who completed (but not before the end + of the calendar year in which this section is + enacted) specialized training or clinical + experience in child and adolescent mental health + described in clause (i). + ``(2) Additional eligibility requirements.--The Secretary + may not enter into a contract under this subsection with an + eligible individual unless-- + ``(A) the individual agrees to work in, or for a + provider serving, a health professional shortage area or + medically underserved area, or to serve a medically + underserved population; + ``(B) the individual is a United States citizen or a + permanent legal United States resident; and + ``(C) if the individual is enrolled in a graduate + program, the program is accredited, and the individual + has an acceptable level of academic standing (as + determined by the Secretary). + +[[Page 124 STAT. 609]] + + ``(d) Priority.--In entering into contracts under this subsection, +the Secretary shall give priority to applicants who-- + ``(1) are or will be working in a school or other pre- + kindergarten, elementary, or secondary education setting; + ``(2) have familiarity with evidence-based methods and + cultural and linguistic competence health care services; and + ``(3) demonstrate financial need. + + ``(e) Authorization of Appropriations.--There is authorized to be +appropriated $30,000,000 for each of fiscal years 2010 through 2014 to +carry out subsection (c)(1)(A) and $20,000,000 for each of fiscal years +2010 through 2013 to carry out subsection (c)(1)(B).''. + +SEC. 5204. PUBLIC HEALTH WORKFORCE RECRUITMENT AND RETENTION PROGRAMS. + + Part E of title VII of the Public Health Service Act (42 U.S.C. 294n +et seq.), as amended by section 5203, is further amended by adding at +the end the following: + +``SEC. 776. PUBLIC <<NOTE: 42 USC 295f-1.>> HEALTH WORKFORCE LOAN + REPAYMENT PROGRAM. + + ``(a) Establishment.--The Secretary shall establish the Public +Health Workforce Loan Repayment Program (referred to in this section as +the `Program') to assure an adequate supply of public health +professionals to eliminate critical public health workforce shortages in +Federal, State, local, and tribal public health agencies. + ``(b) Eligibility.--To be eligible to participate in the Program, an +individual shall-- + ``(1)(A) be accepted for enrollment, or be enrolled, as a + student in an accredited academic educational institution in a + State or territory in the final year of a course of study or + program leading to a public health or health professions degree + or certificate; and have accepted employment with a Federal, + State, local, or tribal public health agency, or a related + training fellowship, as recognized by the Secretary, to commence + upon graduation; + ``(B)(i) have graduated, during the preceding 10-year + period, from an accredited educational institution in a State or + territory and received a public health or health professions + degree or certificate; and + ``(ii) be employed by, or have accepted employment with, a + Federal, State, local, or tribal public health agency or a + related training fellowship, as recognized by the Secretary; + ``(2) be a United States citizen; and + ``(3)(A) submit an application to the Secretary to + participate in the Program; + ``(B) execute a written contract as required in subsection + (c); and + ``(4) not have received, for the same service, a reduction + of loan obligations under section 455(m), 428J, 428K, 428L, or + 460 of the Higher Education Act of 1965. + + ``(c) Contract.--The written contract (referred to in this section +as the `written contract') between the Secretary and an individual shall +contain-- + ``(1) an agreement on the part of the Secretary that the + Secretary will repay on behalf of the individual loans incurred + by the individual in the pursuit of the relevant degree or + certificate in accordance with the terms of the contract; + ``(2) an agreement on the part of the individual that the + individual will serve in the full-time employment of a Federal, + +[[Page 124 STAT. 610]] + + State, local, or tribal public health agency or a related + fellowship program in a position related to the course of study + or program for which the contract was awarded for a period of + time (referred to in this section as the `period of obligated + service') equal to the greater of-- + ``(A) 3 years; or + ``(B) such longer period of time as determined + appropriate by the Secretary and the individual; + ``(3) an agreement, as appropriate, on the part of the + individual to relocate to a priority service area (as determined + by the Secretary) in exchange for an additional loan repayment + incentive amount to be determined by the Secretary; + ``(4) a provision that any financial obligation of the + United States arising out of a contract entered into under this + section and any obligation of the individual that is conditioned + thereon, is contingent on funds being appropriated for loan + repayments under this section; + ``(5) a statement of the damages to which the United States + is entitled, under this section for the individual's breach of + the contract; and + ``(6) such other statements of the rights and liabilities of + the Secretary and of the individual, not inconsistent with this + section. + + ``(d) Payments.-- + ``(1) In general.--A loan repayment provided for an + individual under a written contract under the Program shall + consist of payment, in accordance with paragraph (2), on behalf + of the individual of the principal, interest, and related + expenses on government and commercial loans received by the + individual regarding the undergraduate or graduate education of + the individual (or both), which loans were made for tuition + expenses incurred by the individual. + ``(2) Payments for years served.--For each year of obligated + service that an individual contracts to serve under subsection + (c) the Secretary may pay up to $35,000 on behalf of the + individual for loans described in paragraph (1). With respect to + participants under the Program whose total eligible loans are + less than $105,000, the Secretary shall pay an amount that does + not exceed \1/3\ of the eligible loan balance for each year of + obligated service of the individual. + ``(3) Tax liability.--For the purpose of providing + reimbursements for tax liability resulting from payments under + paragraph (2) on behalf of an individual, the Secretary shall, + in addition to such payments, make payments to the individual in + an amount not to exceed 39 percent of the total amount of loan + repayments made for the taxable year involved. + + ``(e) Postponing Obligated Service.--With respect to an individual +receiving a degree or certificate from a health professions or other +related school, the date of the initiation of the period of obligated +service may be postponed as approved by the Secretary. + ``(f) Breach of Contract.--An <<NOTE: Penalty.>> individual who +fails to comply with the contract entered into under subsection (c) +shall be subject to the same financial penalties as provided for under +section 338E for breaches of loan repayment contracts under section +338B. + + ``(g) Authorization of Appropriations.--There is authorized to be +appropriated to carry out this section $195,000,000 for fiscal + +[[Page 124 STAT. 611]] + +year 2010, and such sums as may be necessary for each of fiscal years +2011 through 2015.''. + +SEC. 5205. ALLIED HEALTH WORKFORCE RECRUITMENT AND RETENTION PROGRAMS. + + (a) Purpose.--The <<NOTE: 20 USC 1078-11 note.>> purpose of this +section is to assure an adequate supply of allied health professionals +to eliminate critical allied health workforce shortages in Federal, +State, local, and tribal public health agencies or in settings where +patients might require health care services, including acute care +facilities, ambulatory care facilities, personal residences and other +settings, as recognized by the Secretary of Health and Human Services by +authorizing an Allied Health Loan Forgiveness Program. + + (b) Allied Health Workforce Recruitment and Retention Program.-- +Section 428K of the Higher Education Act of 1965 (20 U.S.C. 1078-11) is +amended-- + (1) in subsection (b), by adding at the end the following: + ``(18) Allied health professionals.--The individual is + employed full-time as an allied health professional-- + ``(A) in a Federal, State, local, or tribal public + health agency; or + ``(B) in a setting where patients might require + health care services, including acute care facilities, + ambulatory care facilities, personal residences and + other settings located in health professional shortage + areas, medically underserved areas, or medically + underserved populations, as recognized by the Secretary + of Health and Human Services.''; and + (2) in subsection (g)-- + (A) by redesignating paragraphs (1) through (9) as + paragraphs (2) through (10), respectively; and + (B) by inserting before paragraph (2) (as + redesignated by subparagraph (A)) the following: + ``(1) Allied <<NOTE: Definition.>> health professional.--The + term `allied health professional' means an allied health + professional as defined in section 799B(5) of the Public Heath + Service Act (42 U.S.C. 295p(5)) who-- + ``(A) has graduated and received an allied health + professions degree or certificate from an institution of + higher education; and + ``(B) is employed with a Federal, State, local or + tribal public health agency, or in a setting where + patients might require health care services, including + acute care facilities, ambulatory care facilities, + personal residences and other settings located in health + professional shortage areas, medically underserved + areas, or medically underserved populations, as + recognized by the Secretary of Health and Human + Services.''. + +SEC. 5206. GRANTS FOR STATE AND LOCAL PROGRAMS. + + (a) In General.--Section 765(d) of the Public Health Service Act (42 +U.S.C. 295(d)) is amended-- + (1) in paragraph (7), by striking ``; or'' and inserting a + semicolon; + (2) by redesignating paragraph (8) as paragraph (9); and + (3) by inserting after paragraph (7) the following: + ``(8) public health workforce loan repayment programs; or''. + +[[Page 124 STAT. 612]] + + (b) Training for Mid-career Public Health Professionals.--Part E of +title VII of the Public Health Service Act (42 U.S.C. 294n et seq.), as +amended by section 5204, is further amended by adding at the end the +following: + +``SEC. 777. TRAINING <<NOTE: 42 USC 295f-2.>> FOR MID-CAREER PUBLIC AND + ALLIED HEALTH PROFESSIONALS. + + ``(a) In General.--The Secretary may make grants to, or enter into +contracts with, any eligible entity to award scholarships to eligible +individuals to enroll in degree or professional training programs for +the purpose of enabling mid-career professionals in the public health +and allied health workforce to receive additional training in the field +of public health and allied health. + ``(b) <<NOTE: Definitions.>> Eligibility.-- + ``(1) Eligible entity.--The term `eligible entity' indicates + an accredited educational institution that offers a course of + study, certificate program, or professional training program in + public or allied health or a related discipline, as determined + by the Secretary + ``(2) Eligible individuals.--The term `eligible individuals' + includes those individuals employed in public and allied health + positions at the Federal, State, tribal, or local level who are + interested in retaining or upgrading their education. + + ``(c) Authorization of Appropriations.--There is authorized to be +appropriated to carry out this section, $60,000,000 for fiscal year 2010 +and such sums as may be necessary for each of fiscal years 2011 through +2015. Fifty percent of appropriated funds shall be allotted to public +health mid-career professionals and 50 percent shall be allotted to +allied health mid-career professionals.''. + +SEC. 5207. FUNDING FOR NATIONAL HEALTH SERVICE CORPS. + + Section 338H(a) of the Public Health Service Act (42 U.S.C. 254q(a)) +is amended to read as follows: + ``(a) Authorization of Appropriations.--For the purpose of carrying +out this section, there is authorized to be appropriated, out of any +funds in the Treasury not otherwise appropriated, the following: + ``(1) For fiscal year 2010, $320,461,632. + ``(2) For fiscal year 2011, $414,095,394. + ``(3) For fiscal year 2012, $535,087,442. + ``(4) For fiscal year 2013, $691,431,432. + ``(5) For fiscal year 2014, $893,456,433. + ``(6) For fiscal year 2015, $1,154,510,336. + ``(7) For fiscal year 2016, and each subsequent fiscal year, + the amount appropriated for the preceding fiscal year adjusted + by the product of-- + ``(A) one plus the average percentage increase in + the costs of health professions education during the + prior fiscal year; and + ``(B) one plus the average percentage change in the + number of individuals residing in health professions + shortage areas designated under section 333 during the + prior fiscal year, relative to the number of individuals + residing in such areas during the previous fiscal + year.''. + +SEC. 5208. NURSE-MANAGED HEALTH CLINICS. + + (a) Purpose.--The <<NOTE: 42 USC 254c-1a note.>> purpose of this +section is to fund the development and operation of nurse-managed health +clinics. + +[[Page 124 STAT. 613]] + + (b) Grants.--Subpart 1 of part D of title III of the Public Health +Service Act (42 U.S.C. 254b et seq.) is amended by inserting after +section 330A the following: + +``SEC. 330A-1. <<NOTE: 42 USC 254c-1a.>> GRANTS TO NURSE-MANAGED HEALTH + CLINICS. + + ``(a) Definitions.-- + ``(1) Comprehensive primary health care services.--In this + section, the term `comprehensive primary health care services' + means the primary health services described in section + 330(b)(1). + ``(2) Nurse-managed health clinic.--The term `nurse-managed + health clinic' means a nurse-practice arrangement, managed by + advanced practice nurses, that provides primary care or wellness + services to underserved or vulnerable populations and that is + associated with a school, college, university or department of + nursing, federally qualified health center, or independent + nonprofit health or social services agency. + + ``(b) Authority to Award Grants.--The Secretary shall award grants +for the cost of the operation of nurse-managed health clinics that meet +the requirements of this section. + ``(c) Applications.--To be eligible to receive a grant under this +section, an entity shall-- + ``(1) be an NMHC; and + ``(2) submit to the Secretary an application at such time, + in such manner, and containing-- + ``(A) assurances that nurses are the major providers + of services at the NMHC and that at least 1 advanced + practice nurse holds an executive management position + within the organizational structure of the NMHC; + ``(B) an assurance that the NMHC will continue + providing comprehensive primary health care services or + wellness services without regard to income or insurance + status of the patient for the duration of the grant + period; and + ``(C) an assurance that, not later than 90 days of + receiving a grant under this section, the NMHC will + establish a community advisory committee, for which a + majority of the members shall be individuals who are + served by the NMHC. + + ``(d) Grant Amount.--The <<NOTE: Determination.>> amount of any +grant made under this section for any fiscal year shall be determined by +the Secretary, taking into account-- + ``(1) the financial need of the NMHC, considering State, + local, and other operational funding provided to the NMHC; and + ``(2) other factors, as the Secretary determines + appropriate. + + ``(e) Authorization of Appropriations.--For the purposes of carrying +out this section, there are authorized to be appropriated $50,000,000 +for the fiscal year 2010 and such sums as may be necessary for each of +the fiscal years 2011 through 2014.''. + +SEC. 5209. <<NOTE: 42 USC 238f note.>> ELIMINATION OF CAP ON + COMMISSIONED CORPS. + + Section 202 of the Department of Health and Human Services +Appropriations Act, 1993 (Public Law 102-394) is amended by striking +``not to exceed 2,800''. + +[[Page 124 STAT. 614]] + +SEC. 5210. ESTABLISHING A READY RESERVE CORPS. + + Section 203 of the Public Health Service Act (42 U.S.C. 204) is +amended to read as follows: + +``SEC. 203. COMMISSIONED CORPS AND READY RESERVE CORPS. + + ``(a) Establishment.-- + ``(1) In general.--There shall be in the Service a + commissioned Regular Corps and a Ready Reserve Corps for service + in time of national emergency. + ``(2) Requirement.--All commissioned officers shall be + citizens of the United States and shall be appointed without + regard to the civil-service laws and compensated without regard + to the Classification Act of 1923, as amended. + ``(3) Appointment.-- + Commissioned <<NOTE: President.>> officers of the Ready Reserve + Corps shall be appointed by the President and commissioned + officers of the Regular Corps shall be appointed by the + President with the advice and consent of the Senate. + ``(4) Active duty.--Commissioned officers of the Ready + Reserve Corps shall at all times be subject to call to active + duty by the Surgeon General, including active duty for the + purpose of training. + ``(5) Warrant officers.--Warrant officers may be appointed + to the Service for the purpose of providing support to the + health and delivery systems maintained by the Service and any + warrant officer appointed to the Service shall be considered for + purposes of this Act and title 37, United States Code, to be a + commissioned officer within the Commissioned Corps of the + Service. + + ``(b) Assimilating Reserve Corp Officers Into the Regular Corps.-- +Effective <<NOTE: Effective date.>> on the date of enactment of the +Patient Protection and Affordable Care Act, all individuals classified +as officers in the Reserve Corps under this section (as such section +existed on the day before the date of enactment of such Act) and serving +on active duty shall be deemed to be commissioned officers of the +Regular Corps. + + ``(c) Purpose and Use of Ready Research.-- + ``(1) Purpose.--The purpose of the Ready Reserve Corps is to + fulfill the need to have additional Commissioned Corps personnel + available on short notice (similar to the uniformed service's + reserve program) to assist regular Commissioned Corps personnel + to meet both routine public health and emergency response + missions. + ``(2) Uses.--The Ready Reserve Corps shall-- + ``(A) participate in routine training to meet the + general and specific needs of the Commissioned Corps; + ``(B) be available and ready for involuntary calls + to active duty during national emergencies and public + health crises, similar to the uniformed service reserve + personnel; + ``(C) be available for backfilling critical + positions left vacant during deployment of active duty + Commissioned Corps members, as well as for deployment to + respond to public health emergencies, both foreign and + domestic; and + ``(D) be available for service assignment in + isolated, hardship, and medically underserved + communities (as defined in section 799B) to improve + access to health services. + +[[Page 124 STAT. 615]] + + ``(d) Funding.--For the purpose of carrying out the duties and +responsibilities of the Commissioned Corps under this section, there are +authorized to be appropriated $5,000,000 for each of fiscal years 2010 +through 2014 for recruitment and training and $12,500,000 for each of +fiscal years 2010 through 2014 for the Ready Reserve Corps.''. + + Subtitle D--Enhancing Health Care Workforce Education and Training + +SEC. 5301. TRAINING IN FAMILY MEDICINE, GENERAL INTERNAL MEDICINE, + GENERAL PEDIATRICS, AND PHYSICIAN ASSISTANTSHIP. + + Part C of title VII (42 U.S.C. 293k et seq.) is amended by striking +section 747 and inserting the following: + +``SEC. 747. <<NOTE: 42 USC 293k.>> PRIMARY CARE TRAINING AND + ENHANCEMENT. + + ``(a) Support and Development of Primary Care Training Programs.-- + ``(1) In general.--The Secretary may make grants to, or + enter into contracts with, an accredited public or nonprofit + private hospital, school of medicine or osteopathic medicine, + academically affiliated physician assistant training program, or + a public or private nonprofit entity which the Secretary has + determined is capable of carrying out such grant or contract-- + ``(A) to plan, develop, operate, or participate in + an accredited professional training program, including + an accredited residency or internship program in the + field of family medicine, general internal medicine, or + general pediatrics for medical students, interns, + residents, or practicing physicians as defined by the + Secretary; + ``(B) to provide need-based financial assistance in + the form of traineeships and fellowships to medical + students, interns, residents, practicing physicians, or + other medical personnel, who are participants in any + such program, and who plan to specialize or work in the + practice of the fields defined in subparagraph (A); + ``(C) to plan, develop, and operate a program for + the training of physicians who plan to teach in family + medicine, general internal medicine, or general + pediatrics training programs; + ``(D) to plan, develop, and operate a program for + the training of physicians teaching in community-based + settings; + ``(E) to provide financial assistance in the form of + traineeships and fellowships to physicians who are + participants in any such programs and who plan to teach + or conduct research in a family medicine, general + internal medicine, or general pediatrics training + program; + ``(F) to plan, develop, and operate a physician + assistant education program, and for the training of + individuals who will teach in programs to provide such + training; + ``(G) to plan, develop, and operate a demonstration + program that provides training in new competencies, as + recommended by the Advisory Committee on Training in + +[[Page 124 STAT. 616]] + + Primary Care Medicine and Dentistry and the National + Health Care Workforce Commission established in section + 5101 of the Patient Protection and Affordable Care Act, + which may include-- + ``(i) providing training to primary care + physicians relevant to providing care through + patient-centered medical homes (as defined by the + Secretary for purposes of this section); + ``(ii) developing tools and curricula relevant + to patient-centered medical homes; and + ``(iii) providing continuing education to + primary care physicians relevant to patient- + centered medical homes; and + ``(H) to plan, develop, and operate joint degree + programs to provide interdisciplinary and + interprofessional graduate training in public health and + other health professions to provide training in + environmental health, infectious disease control, + disease prevention and health promotion, epidemiological + studies and injury control. + ``(2) Duration of awards.--The period during which payments + are made to an entity from an award of a grant or contract under + this subsection shall be 5 years. + + ``(b) Capacity Building in Primary Care.-- + ``(1) In general.--The Secretary may make grants to or enter + into contracts with accredited schools of medicine or + osteopathic medicine to establish, maintain, or improve-- + ``(A) academic units or programs that improve + clinical teaching and research in fields defined in + subsection (a)(1)(A); or + ``(B) programs that integrate academic + administrative units in fields defined in subsection + (a)(1)(A) to enhance interdisciplinary recruitment, + training, and faculty development. + ``(2) Preference in making awards under this subsection.--In + making awards of grants and contracts under paragraph (1), the + Secretary shall give preference to any qualified applicant for + such an award that agrees to expend the award for the purpose + of-- + ``(A) establishing academic units or programs in + fields defined in subsection (a)(1)(A); or + ``(B) substantially expanding such units or + programs. + ``(3) Priorities in making awards.--In awarding grants or + contracts under paragraph (1), the Secretary shall give priority + to qualified applicants that-- + ``(A) proposes a collaborative project between + academic administrative units of primary care; + ``(B) proposes innovative approaches to clinical + teaching using models of primary care, such as the + patient centered medical home, team management of + chronic disease, and interprofessional integrated models + of health care that incorporate transitions in health + care settings and integration physical and mental health + provision; + ``(C) have a record of training the greatest + percentage of providers, or that have demonstrated + significant improvements in the percentage of providers + trained, who enter and remain in primary care practice; + +[[Page 124 STAT. 617]] + + ``(D) have a record of training individuals who are + from underrepresented minority groups or from a rural or + disadvantaged background; + ``(E) provide training in the care of vulnerable + populations such as children, older adults, homeless + individuals, victims of abuse or trauma, individuals + with mental health or substance-related disorders, + individuals with HIV/AIDS, and individuals with + disabilities; + ``(F) establish formal relationships and submit + joint applications with federally qualified health + centers, rural health clinics, area health education + centers, or clinics located in underserved areas or that + serve underserved populations; + ``(G) teach trainees the skills to provide + interprofessional, integrated care through collaboration + among health professionals; + ``(H) provide training in enhanced communication + with patients, evidence-based practice, chronic disease + management, preventive care, health information + technology, or other competencies as recommended by the + Advisory Committee on Training in Primary Care Medicine + and Dentistry and the National Health Care Workforce + Commission established in section 5101 of the Patient + Protection and Affordable Care Act; or + ``(I) provide training in cultural competency and + health literacy. + ``(4) Duration of awards.--The period during which payments + are made to an entity from an award of a grant or contract under + this subsection shall be 5 years. + + ``(c) Authorization of Appropriations.-- + ``(1) In general.--For purposes of carrying out this section + (other than subsection (b)(1)(B)), there are authorized to be + appropriated $125,000,000 for fiscal year 2010, and such sums as + may be necessary for each of fiscal years 2011 through 2014. + ``(2) Training programs.--Fifteen percent of the amount + appropriated pursuant to paragraph (1) in each such fiscal year + shall be allocated to the physician assistant training programs + described in subsection (a)(1)(F), which prepare students for + practice in primary care. + ``(3) Integrating academic administrative units.--For + purposes of carrying out subsection (b)(1)(B), there are + authorized to be appropriated $750,000 for each of fiscal years + 2010 through 2014.''. + +SEC. 5302. TRAINING OPPORTUNITIES FOR DIRECT CARE WORKERS. + + Part C of title VII of the Public Health Service Act (42 U.S.C. 293k +et seq.) is amended by inserting after section 747, as amended by +section 5301, the following: + +``SEC. 747A. TRAINING <<NOTE: 42 USC 293k-1.>> OPPORTUNITIES FOR DIRECT + CARE WORKERS. + + ``(a) In General.--The <<NOTE: Grants.>> Secretary shall award +grants to eligible entities to enable such entities to provide new +training opportunities for direct care workers who are employed in long- +term care settings such as nursing homes (as defined in section +1908(e)(1) of the Social Security Act (42 U.S.C. 1396g(e)(1)), assisted +living facilities + +[[Page 124 STAT. 618]] + +and skilled nursing facilities, intermediate care facilities for +individuals with mental retardation, home and community based settings, +and any other setting the Secretary determines to be appropriate. + + ``(b) Eligibility.--To be eligible to receive a grant under this +section, an entity shall-- + ``(1) be an institution of higher education (as defined in + section 102 of the Higher Education Act of 1965 (20 U.S.C. + 1002)) that-- + ``(A) is accredited by a nationally recognized + accrediting agency or association listed under section + 101(c) of the Higher Education Act of 1965 (20 U.S.C. + 1001(c)); and + ``(B) has established a public-private educational + partnership with a nursing home or skilled nursing + facility, agency or entity providing home and community + based services to individuals with disabilities, or + other long-term care provider; and + ``(2) submit to the Secretary an application at such time, + in such manner, and containing such information as the Secretary + may require. + + ``(c) Use of Funds.--An eligible entity shall use amounts awarded +under a grant under this section to provide assistance to eligible +individuals to offset the cost of tuition and required fees for +enrollment in academic programs provided by such entity. + ``(d) Eligible Individual.-- + ``(1) Eligibility.--To be eligible for assistance under this + section, an individual shall be enrolled in courses provided by + a grantee under this subsection and maintain satisfactory + academic progress in such courses. + ``(2) Condition of assistance.--As a condition of receiving + assistance under this section, an individual shall agree that, + following completion of the assistance period, the individual + will work in the field of geriatrics, disability services, long + term services and supports, or chronic care management for a + minimum of 2 years under guidelines set by the Secretary. + + ``(e) Authorization of Appropriations.--There is authorized to be +appropriated to carry out this section, $10,000,000 for the period of +fiscal years 2011 through 2013.''. + +SEC. 5303. TRAINING IN GENERAL, PEDIATRIC, AND PUBLIC HEALTH DENTISTRY. + + Part C of Title VII of the Public Health Service Act (42 U.S.C. 293k +et seq.) is amended by-- + (1) redesignating section 748, <<NOTE: 42 USC 293l.>> as + amended by section 5103 of this Act, as section 749; and + (2) inserting after section 747A, as added by section 5302, + the following: + +``SEC. 748. <<NOTE: 42 USC 293k-2.>> TRAINING IN GENERAL, PEDIATRIC, AND + PUBLIC HEALTH DENTISTRY. + + ``(a) Support and Development of Dental Training Programs.-- + ``(1) In general.--The Secretary may make grants to, or + enter into contracts with, a school of dentistry, public or + nonprofit private hospital, or a public or private nonprofit + entity which the Secretary has determined is capable of carrying + out such grant or contract-- + ``(A) to plan, develop, and operate, or participate + in, an approved professional training program in the + field + +[[Page 124 STAT. 619]] + + of general dentistry, pediatric dentistry, or public + health dentistry for dental students, residents, + practicing dentists, dental hygienists, or other + approved primary care dental trainees, that emphasizes + training for general, pediatric, or public health + dentistry; + ``(B) to provide financial assistance to dental + students, residents, practicing dentists, and dental + hygiene students who are in need thereof, who are + participants in any such program, and who plan to work + in the practice of general, pediatric, public heath + dentistry, or dental hygiene; + ``(C) to plan, develop, and operate a program for + the training of oral health care providers who plan to + teach in general, pediatric, public health dentistry, or + dental hygiene; + ``(D) to provide financial assistance in the form of + traineeships and fellowships to dentists who plan to + teach or are teaching in general, pediatric, or public + health dentistry; + ``(E) to meet the costs of projects to establish, + maintain, or improve dental faculty development programs + in primary care (which may be departments, divisions or + other units); + ``(F) to meet the costs of projects to establish, + maintain, or improve predoctoral and postdoctoral + training in primary care programs; + ``(G) to create a loan repayment program for faculty + in dental programs; and + ``(H) to provide technical assistance to pediatric + training programs in developing and implementing + instruction regarding the oral health status, dental + care needs, and risk-based clinical disease management + of all pediatric populations with an emphasis on + underserved children. + ``(2) Faculty loan repayment.-- + ``(A) In general.--A grant or contract under + subsection (a)(1)(G) may be awarded to a program of + general, pediatric, or public health dentistry described + in such subsection to plan, develop, and operate a loan + repayment program under which-- + ``(i) individuals agree to serve full-time as + faculty members; and + ``(ii) the program of general, pediatric or + public health dentistry agrees to pay the + principal and interest on the outstanding student + loans of the individuals. + ``(B) Manner of payments.--With respect to the + payments described in subparagraph (A)(ii), upon + completion by an individual of each of the first, + second, third, fourth, and fifth years of service, the + program shall pay an amount equal to 10, 15, 20, 25, and + 30 percent, respectively, of the individual's student + loan balance as calculated based on principal and + interest owed at the initiation of the agreement. + + ``(b) Eligible Entity.--For purposes of this subsection, entities +eligible for such grants or contracts in general, pediatric, or public +health dentistry shall include entities that have programs in dental or +dental hygiene schools, or approved residency or advanced education +programs in the practice of general, pediatric, or public health +dentistry. Eligible entities may partner with schools of public + +[[Page 124 STAT. 620]] + +health to permit the education of dental students, residents, and dental +hygiene students for a master's year in public health at a school of +public health. + ``(c) Priorities in Making Awards.--With respect to training +provided for under this section, the Secretary shall give priority in +awarding grants or contracts to the following: + ``(1) Qualified applicants that propose collaborative + projects between departments of primary care medicine and + departments of general, pediatric, or public health dentistry. + ``(2) Qualified applicants that have a record of training + the greatest percentage of providers, or that have demonstrated + significant improvements in the percentage of providers, who + enter and remain in general, pediatric, or public health + dentistry. + ``(3) Qualified applicants that have a record of training + individuals who are from a rural or disadvantaged background, or + from underrepresented minorities. + ``(4) Qualified applicants that establish formal + relationships with Federally qualified health centers, rural + health centers, or accredited teaching facilities and that + conduct training of students, residents, fellows, or faculty at + the center or facility. + ``(5) Qualified applicants that conduct teaching programs + targeting vulnerable populations such as older adults, homeless + individuals, victims of abuse or trauma, individuals with mental + health or substance-related disorders, individuals with + disabilities, and individuals with HIV/AIDS, and in the risk- + based clinical disease management of all populations. + ``(6) Qualified applicants that include educational + activities in cultural competency and health literacy. + ``(7) Qualified applicants that have a high rate for placing + graduates in practice settings that serve underserved areas or + health disparity populations, or who achieve a significant + increase in the rate of placing graduates in such settings. + ``(8) Qualified applicants that intend to establish a + special populations oral health care education center or + training program for the didactic and clinical education of + dentists, dental health professionals, and dental hygienists who + plan to teach oral health care for people with developmental + disabilities, cognitive impairment, complex medical problems, + significant physical limitations, and vulnerable elderly. + + ``(d) Application.--An eligible entity desiring a grant under this +section shall submit to the Secretary an application at such time, in +such manner, and containing such information as the Secretary may +require. + ``(e) Duration of Award.--The period during which payments are made +to an entity from an award of a grant or contract under subsection (a) +shall be 5 years. The provision of such payments shall be subject to +annual approval by the Secretary and subject to the availability of +appropriations for the fiscal year involved to make the payments. + ``(f) Authorizations of Appropriations.--For the purpose of carrying +out subsections (a) and (b), there is authorized to be appropriated +$30,000,000 for fiscal year 2010 and such sums as may be necessary for +each of fiscal years 2011 through 2015. + ``(g) Carryover Funds.--An entity that receives an award under this +section may carry over funds from 1 fiscal year to another without +obtaining approval from the Secretary. In no case + +[[Page 124 STAT. 621]] + +may any funds be carried over pursuant to the preceding sentence for +more than 3 years.''. + +SEC. 5304. ALTERNATIVE DENTAL HEALTH CARE PROVIDERS DEMONSTRATION + PROJECT. + + Subpart X of part D of title III of the Public Health Service Act +(42 U.S.C. 256f et seq.) is amended by adding at the end the following: + +``SEC. 340G-1. <<NOTE: 42 USC 256g-1.>> DEMONSTRATION PROGRAM. + + ``(a) In General. <<NOTE: Grants.>> -- + ``(1) Authorization.--The Secretary is authorized to award + grants to 15 eligible entities to enable such entities to + establish a demonstration program to establish training programs + to train, or to employ, alternative dental health care providers + in order to increase access to dental health care services in + rural and other underserved communities. + ``(2) Definition.--The term `alternative dental health care + providers' includes community dental health coordinators, + advance practice dental hygienists, independent dental + hygienists, supervised dental hygienists, primary care + physicians, dental therapists, dental health aides, and any + other health professional that the Secretary determines + appropriate. + + ``(b) Timeframe.--The demonstration projects funded under this +section shall begin not later than 2 years after the date of enactment +of this section, and shall conclude not later than 7 years after such +date of enactment. + ``(c) Eligible Entities.--To be eligible to receive a grant under +subsection (a), an entity shall-- + ``(1) be-- + ``(A) an institution of higher education, including + a community college; + ``(B) a public-private partnership; + ``(C) a federally qualified health center; + ``(D) an Indian Health Service facility or a tribe + or tribal organization (as such terms are defined in + section 4 of the Indian Self-Determination and Education + Assistance Act); + ``(E) a State or county public health clinic, a + health facility operated by an Indian tribe or tribal + organization, or urban Indian organization providing + dental services; or + ``(F) a public hospital or health system; + ``(2) be within a program accredited by the Commission on + Dental Accreditation or within a dental education program in an + accredited institution; and + ``(3) shall submit an application to the Secretary at such + time, in such manner, and containing such information as the + Secretary may require. + + ``(d) Administrative Provisions.-- + ``(1) Amount of grant.--Each grant under this section shall + be in an amount that is not less than $4,000,000 for the 5-year + period during which the demonstration project being conducted. + ``(2) Disbursement of funds.-- + ``(A) Preliminary disbursements. <<NOTE: Effective + date.>> --Beginning 1 year after the enactment of this + section, the Secretary may disperse to any entity + receiving a grant under this section + +[[Page 124 STAT. 622]] + + not more than 20 percent of the total funding awarded to + such entity under such grant, for the purpose of + enabling the entity to plan the demonstration project to + be conducted under such grant. + ``(B) Subsequent disbursements.--The remaining + amount of grant funds not dispersed under subparagraph + (A) shall be dispersed such that not less than 15 + percent of such remaining amount is dispersed each + subsequent year. + + ``(e) Compliance With State Requirements.--Each entity receiving a +grant under this section shall certify that it is in compliance with all +applicable State licensing requirements. + ``(f) <<NOTE: Contracts.>> Evaluation.--The Secretary shall contract +with the Director of the Institute of Medicine to conduct a study of the +demonstration programs conducted under this section that shall provide +analysis, based upon quantitative and qualitative data, regarding access +to dental health care in the United States. + + ``(g) Clarification Regarding Dental Health Aide Program.--Nothing +in this section shall prohibit a dental health aide training program +approved by the Indian Health Service from being eligible for a grant +under this section. + ``(h) Authorization of Appropriations.--There is authorized to be +appropriated such sums as may be necessary to carry out this section.''. + +SEC. 5305. GERIATRIC EDUCATION AND TRAINING; CAREER AWARDS; + COMPREHENSIVE GERIATRIC EDUCATION. + + (a) Workforce Development; Career Awards.--Section 753 of the Public +Health Service Act (42 U.S.C. 294c) is amended by adding at the end the +following: + ``(d) Geriatric Workforce Development.-- + ``(1) In general. <<NOTE: Grants. Contracts.>> --The + Secretary shall award grants or contracts under this subsection + to entities that operate a geriatric education center pursuant + to subsection (a)(1). + ``(2) Application.--To be eligible for an award under + paragraph (1), an entity described in such paragraph shall + submit to the Secretary an application at such time, in such + manner, and containing such information as the Secretary may + require. + ``(3) Use of funds.--Amounts awarded under a grant or + contract under paragraph (1) shall be used to-- + ``(A) carry out the fellowship program described in + paragraph (4); and + ``(B) carry out 1 of the 2 activities described in + paragraph (5). + ``(4) Fellowship program.-- + ``(A) In general.--Pursuant to paragraph (3), a + geriatric education center that receives an award under + this subsection shall use such funds to offer short-term + intensive courses (referred to in this subsection as a + `fellowship') that focus on geriatrics, chronic care + management, and long-term care that provide supplemental + training for faculty members in medical schools and + other health professions schools with programs in + psychology, pharmacy, nursing, social work, dentistry, + public health, allied health, or other health + disciplines, as approved by the Secretary. Such a + fellowship shall be open to current faculty, and + +[[Page 124 STAT. 623]] + + appropriately credentialed volunteer faculty and + practitioners, who do not have formal training in + geriatrics, to upgrade their knowledge and clinical + skills for the care of older adults and adults with + functional limitations and to enhance their + interdisciplinary teaching skills. + ``(B) Location.--A fellowship shall be offered + either at the geriatric education center that is + sponsoring the course, in collaboration with other + geriatric education centers, or at medical schools, + schools of dentistry, schools of nursing, schools of + pharmacy, schools of social work, graduate programs in + psychology, or allied health and other health + professions schools approved by the Secretary with which + the geriatric education centers are affiliated. + ``(C) CME credit.--Participation in a fellowship + under this paragraph shall be accepted with respect to + complying with continuing health profession education + requirements. As a condition of such acceptance, the + recipient shall agree to subsequently provide a minimum + of 18 hours of voluntary instructional support through a + geriatric education center that is providing clinical + training to students or trainees in long-term care + settings. + ``(5) Additional required activities described.--Pursuant to + paragraph (3), a geriatric education center that receives an + award under this subsection shall use such funds to carry out 1 + of the following 2 activities. + ``(A) Family caregiver and direct care provider + training.--A geriatric education center that receives an + award under this subsection shall offer at least 2 + courses each year, at no charge or nominal cost, to + family caregivers and direct care providers that are + designed to provide practical training for supporting + frail elders and individuals with + disabilities. <<NOTE: Requirements.>> The Secretary + shall require such Centers to work with appropriate + community partners to develop training program content + and to publicize the availability of training courses in + their service areas. All family caregiver and direct + care provider training programs shall include + instruction on the management of psychological and + behavioral aspects of dementia, communication techniques + for working with individuals who have dementia, and the + appropriate, safe, and effective use of medications for + older adults. + ``(B) Incorporation of best practices.--A geriatric + education center that receives an award under this + subsection shall develop and include material on + depression and other mental disorders common among older + adults, medication safety issues for older adults, and + management of the psychological and behavioral aspects + of dementia and communication techniques with + individuals who have dementia in all training courses, + where appropriate. + ``(6) Targets.--A geriatric education center that receives + an award under this subsection shall meet targets approved by + the Secretary for providing geriatric training to a certain + number of faculty or practitioners during the term of the award, + as well as other parameters established by the Secretary. + ``(7) Amount of award.--An award under this subsection shall + be in an amount of $150,000. Not more than 24 geriatric + education centers may receive an award under this subsection. + +[[Page 124 STAT. 624]] + + ``(8) Maintenance of effort.--A geriatric education center + that receives an award under this subsection shall provide + assurances to the Secretary that funds provided to the geriatric + education center under this subsection will be used only to + supplement, not to supplant, the amount of Federal, State, and + local funds otherwise expended by the geriatric education + center. + ``(9) Authorization of appropriations.--In addition to any + other funding available to carry out this section, there is + authorized to be appropriated to carry out this subsection, + $10,800,000 for the period of fiscal year 2011 through 2014. + + ``(e) Geriatric Career Incentive Awards.-- + ``(1) In general. <<NOTE: Grants. Contracts.>> --The + Secretary shall award grants or contracts under this section to + individuals described in paragraph (2) to foster greater + interest among a variety of health professionals in entering the + field of geriatrics, long-term care, and chronic care + management. + ``(2) Eligible individuals.--To be eligible to received an + award under paragraph (1), an individual shall-- + ``(A) be an advanced practice nurse, a clinical + social worker, a pharmacist, or student of psychology + who is pursuing a doctorate or other advanced degree in + geriatrics or related fields in an accredited health + professions school; and + ``(B) submit to the Secretary an application at such + time, in such manner, and containing such information as + the Secretary may require. + ``(3) Condition of award.--As a condition of receiving an + award under this subsection, an individual shall agree that, + following completion of the award period, the individual will + teach or practice in the field of geriatrics, long-term care, or + chronic care management for a minimum of 5 years under + guidelines set by the Secretary. + ``(4) Authorization of appropriations.--There is authorized + to be appropriated to carry out this subsection, $10,000,000 for + the period of fiscal years 2011 through 2013.''. + + (b) Expansion of Eligibility for Geriatric Academic Career Awards; +Payment to Institution.--Section 753(c) of the Public Health Service Act +294(c)) <<NOTE: 42 USC 294c.>> is amended-- + (1) by redesignating paragraphs (4) and (5) as paragraphs + (5) and (6), respectively; + (2) by striking paragraph (2) through paragraph (3) and + inserting the following: + ``(2) Eligible individuals.--To be eligible to receive an + Award under paragraph (1), an individual shall-- + ``(A) be board certified or board eligible in + internal medicine, family practice, psychiatry, or + licensed dentistry, or have completed any required + training in a discipline and employed in an accredited + health professions school that is approved by the + Secretary; + ``(B) have completed an approved fellowship program + in geriatrics or have completed specialty training in + geriatrics as required by the discipline and any + addition geriatrics training as required by the + Secretary; and + ``(C) have a junior (non-tenured) faculty + appointment at an accredited (as determined by the + Secretary) school of medicine, osteopathic medicine, + nursing, social work, + +[[Page 124 STAT. 625]] + + psychology, dentistry, pharmacy, or other allied health + disciplines in an accredited health professions school + that is approved by the Secretary. + ``(3) Limitations.--No Award under paragraph (1) may be made + to an eligible individual unless the individual-- + ``(A) has submitted to the Secretary an application, + at such time, in such manner, and containing such + information as the Secretary may require, and the + Secretary has approved such application; + ``(B) provides, in such form and manner as the + Secretary may require, assurances that the individual + will meet the service requirement described in paragraph + (6); and + ``(C) provides, in such form and manner as the + Secretary may require, assurances that the individual + has a full-time faculty appointment in a health + professions institution and documented commitment from + such institution to spend 75 percent of the total time + of such individual on teaching and developing skills in + interdisciplinary education in geriatrics. + ``(4) Maintenance of effort.--An eligible individual that + receives an Award under paragraph (1) shall provide assurances + to the Secretary that funds provided to the eligible individual + under this subsection will be used only to supplement, not to + supplant, the amount of Federal, State, and local funds + otherwise expended by the eligible individual.''; and + (3) in paragraph (5), as so designated-- + (A) in subparagraph (A)-- + (i) by inserting ``for individuals who are + physicians'' after ``this section''; and + (ii) <<NOTE: Determination.>> by inserting + after the period at the end the following: ``The + Secretary shall determine the amount of an Award + under this section for individuals who are not + physicians.''; and + (B) by adding at the end the following: + ``(C) Payment to institution.--The Secretary shall + make payments to institutions which include schools of + medicine, osteopathic medicine, nursing, social work, + psychology, dentistry, and pharmacy, or other allied + health discipline in an accredited health professions + school that is approved by the Secretary.''. + + (c) Comprehensive Geriatric Education.--Section 855 of the Public +Health Service Act (42 U.S.C. 298) is amended-- + (1) in subsection (b)-- + (A) in paragraph (3), by striking ``or'' at the end; + (B) in paragraph (4), by striking the period and + inserting ``; or''; and + (C) by adding at the end the following: + ``(5) establish traineeships for individuals who are + preparing for advanced education nursing degrees in geriatric + nursing, long-term care, gero-psychiatric nursing or other + nursing areas that specialize in the care of the elderly + population.''; and + (2) in subsection (e), by striking ``2003 through 2007'' and + inserting ``2010 through 2014''. + +[[Page 124 STAT. 626]] + +SEC. 5306. MENTAL AND BEHAVIORAL HEALTH EDUCATION AND TRAINING GRANTS. + + (a) In General.--Part D of title VII (42 U.S.C. 294 et seq.) is +amended by-- + (1) <<NOTE: 42 USC 294g.>> striking section 757; + (2) <<NOTE: 42 USC 294f.>> redesignating section 756 (as + amended by section 5103) as section 757; and + (3) inserting after section 755 the following: + +``SEC. 756. <<NOTE: 42 USC 294e-1.>> MENTAL AND BEHAVIORAL HEALTH + EDUCATION AND TRAINING GRANTS. + + ``(a) Grants Authorized.--The Secretary may award grants to eligible +institutions of higher education to support the recruitment of students +for, and education and clinical experience of the students in-- + ``(1) baccalaureate, master's, and doctoral degree programs + of social work, as well as the development of faculty in social + work; + ``(2) accredited master's, doctoral, internship, and post- + doctoral residency programs of psychology for the development + and implementation of interdisciplinary training of psychology + graduate students for providing behavioral and mental health + services, including substance abuse prevention and treatment + services; + ``(3) accredited institutions of higher education or + accredited professional training programs that are establishing + or expanding internships or other field placement programs in + child and adolescent mental health in psychiatry, psychology, + school psychology, behavioral pediatrics, psychiatric nursing, + social work, school social work, substance abuse prevention and + treatment, marriage and family therapy, school counseling, or + professional counseling; and + ``(4) State-licensed mental health nonprofit and for-profit + organizations to enable such organizations to pay for programs + for preservice or in-service training of paraprofessional child + and adolescent mental health workers. + + ``(b) Eligibility Requirements.--To be eligible for a grant under +this section, an institution shall demonstrate-- + ``(1) participation in the institutions' programs of + individuals and groups from different racial, ethnic, cultural, + geographic, religious, linguistic, and class backgrounds, and + different genders and sexual orientations; + ``(2) knowledge and understanding of the concerns of the + individuals and groups described in subsection (a); + ``(3) any internship or other field placement program + assisted under the grant will prioritize cultural and linguistic + competency; + ``(4) the institution will provide to the Secretary such + data, assurances, and information as the Secretary may require; + and + ``(5) with respect to any violation of the agreement between + the Secretary and the institution, the institution will pay such + liquidated damages as prescribed by the Secretary by regulation. + + ``(c) Institutional Requirement.--For grants authorized under +subsection (a)(1), at least 4 of the grant recipients shall + +[[Page 124 STAT. 627]] + +be historically black colleges or universities or other minority-serving +institutions. + ``(d) Priority.-- + ``(1) In selecting the grant recipients in social work under + subsection (a)(1), the Secretary shall give priority to + applicants that-- + ``(A) are accredited by the Council on Social Work + Education; + ``(B) have a graduation rate of not less than 80 + percent for social work students; and + ``(C) exhibit an ability to recruit social workers + from and place social workers in areas with a high need + and high demand population. + ``(2) In selecting the grant recipients in graduate + psychology under subsection (a)(2), the Secretary shall give + priority to institutions in which training focuses on the needs + of vulnerable groups such as older adults and children, + individuals with mental health or substance-related disorders, + victims of abuse or trauma and of combat stress disorders such + as posttraumatic stress disorder and traumatic brain injuries, + homeless individuals, chronically ill persons, and their + families. + ``(3) In selecting the grant recipients in training programs + in child and adolescent mental health under subsections (a)(3) + and (a)(4), the Secretary shall give priority to applicants + that-- + ``(A) have demonstrated the ability to collect data + on the number of students trained in child and + adolescent mental health and the populations served by + such students after graduation or completion of + preservice or in-service training; + ``(B) have demonstrated familiarity with evidence- + based methods in child and adolescent mental health + services, including substance abuse prevention and + treatment services; + ``(C) have programs designed to increase the number + of professionals and paraprofessionals serving high- + priority populations and to applicants who come from + high-priority communities and plan to serve medically + underserved populations, in health professional shortage + areas, or in medically underserved areas; + ``(D) offer curriculum taught collaboratively with a + family on the consumer and family lived experience or + the importance of family-professional or family- + paraprofessional partnerships; and + ``(E) provide services through a community mental + health program described in section 1913(b)(1). + + ``(e) Authorization of Appropriation.--For the fiscal years 2010 +through 2013, there is authorized to be appropriated to carry out this +section-- + ``(1) $8,000,000 for training in social work in subsection + (a)(1); + ``(2) $12,000,000 for training in graduate psychology in + subsection (a)(2), of which not less than $10,000,000 shall be + allocated for doctoral, postdoctoral, and internship level + training; + ``(3) $10,000,000 for training in professional child and + adolescent mental health in subsection (a)(3); and + +[[Page 124 STAT. 628]] + + ``(4) $5,000,000 for training in paraprofessional child and + adolescent work in subsection (a)(4).''. + + (b) Conforming Amendments.--Section 757(b)(2) of the Public Health +Service Act, as redesignated by subsection (a) <<NOTE: 42 USC 294f.>> , +is amended by striking ``sections 751(a)(1)(A), 751(a)(1)(B), 753(b), +754(3)(A), and 755(b)'' and inserting ``sections 751(b)(1)(A), 753(b), +and 755(b)''. + +SEC. 5307. CULTURAL COMPETENCY, PREVENTION, AND PUBLIC HEALTH AND + INDIVIDUALS WITH DISABILITIES TRAINING. + + (a) Title VII.--Section 741 of the Public Health Service Act (42 +U.S.C. 293e) is amended-- + (1) in subsection (a)-- + (A) by striking the subsection heading and inserting + ``Cultural Competency, Prevention, and Public Health and + Individuals With Disability Grants''; and + (B) in paragraph (1), by striking ``for the purpose + of'' and all that follows through the period at the end + and inserting ``for the development, evaluation, and + dissemination of research, demonstration projects, and + model curricula for cultural competency, prevention, + public health proficiency, reducing health disparities, + and aptitude for working with individuals with + disabilities training for use in health professions + schools and continuing education programs, and for other + purposes determined as appropriate by the Secretary.''; + and + (2) by striking subsection (b) and inserting the following: + + ``(b) Collaboration.--In carrying out subsection (a), the Secretary +shall collaborate with health professional societies, licensing and +accreditation entities, health professions schools, and experts in +minority health and cultural competency, prevention, and public health +and disability groups, community-based organizations, and other +organizations as determined appropriate by the Secretary. The Secretary +shall coordinate with curricula and research and demonstration projects +developed under section 807. + ``(c) Dissemination.-- + ``(1) In general.--Model curricula developed under this + section shall be disseminated through the Internet Clearinghouse + under section 270 and such other means as determined appropriate + by the Secretary. + ``(2) Evaluation.--The Secretary shall evaluate the adoption + and the implementation of cultural competency, prevention, and + public health, and working with individuals with a disability + training curricula, and the facilitate inclusion of these + competency measures in quality measurement systems as + appropriate. + + ``(d) Authorization of Appropriations.--There is authorized to be +appropriated to carry out this section such sums as may be necessary for +each of fiscal years 2010 through 2015.''. + (b) Title VIII.--Section 807 of the Public Health Service Act (42 +U.S.C. 296e-1) is amended-- + (1) in subsection (a)-- + (A) by striking the subsection heading and inserting + ``Cultural Competency, Prevention, and Public Health and + Individuals With Disability Grants''; and + (B) by striking ``for the purpose of'' and all that + follows through ``health care.'' and inserting ``for the + development, + +[[Page 124 STAT. 629]] + + evaluation, and dissemination of research, demonstration + projects, and model curricula for cultural competency, + prevention, public health proficiency, reducing health + disparities, and aptitude for working with individuals + with disabilities training for use in health professions + schools and continuing education programs, and for other + purposes determined as appropriate by the Secretary.''; + and + (2) by redesignating subsection (b) as subsection (d); + (3) by inserting after subsection (a) the following: + + ``(b) Collaboration.--In carrying out subsection (a), the Secretary +shall collaborate with the entities described in section 741(b). The +Secretary shall coordinate with curricula and research and demonstration +projects developed under such section 741. + ``(c) Dissemination.--Model curricula developed under this section +shall be disseminated and evaluated in the same manner as model +curricula developed under section 741, as described in subsection (c) of +such section.''; and + (4) in subsection (d), as so redesignated-- + (A) by striking ``subsection (a)'' and inserting + ``this section''; and + (B) by striking ``2001 through 2004'' and inserting + ``2010 through 2015''. + +SEC. 5308. ADVANCED NURSING EDUCATION GRANTS. + + Section 811 of the Public Health Service Act (42 U.S.C. 296j) is +amended-- + (1) in subsection (c)-- + (A) in the subsection heading, by striking ``and + Nurse Midwifery Programs''; and + (B) by striking ``and nurse midwifery''; + (2) in subsection (f)-- + (A) by striking paragraph (2); and + (B) by redesignating paragraph (3) as paragraph (2); + and + (3) by redesignating subsections (d), (e), and (f) as + subsections (e), (f), and (g), respectively; and + (4) by inserting after subsection (c), the following: + + ``(d) Authorized Nurse-midwifery Programs.--Midwifery programs that +are eligible for support under this section are educational programs +that-- + ``(1) have as their objective the education of midwives; and + ``(2) are accredited by the American College of Nurse- + Midwives Accreditation Commission for Midwifery Education.''. + +SEC. 5309. NURSE EDUCATION, PRACTICE, AND RETENTION GRANTS. + + (a) In General.--Section 831 of the Public Health Service Act (42 +U.S.C. 296p) is amended-- + (1) in the section heading, by striking ``retention'' and + inserting ``quality''; + (2) in subsection (a)-- + (A) in paragraph (1), by adding ``or'' after the + semicolon; + (B) by striking paragraph (2); and + (C) by redesignating paragraph (3) as paragraph (2); + (3) in subsection (b)(3), by striking ``managed care, + quality improvement'' and inserting ``coordinated care''; + (4) in subsection (g), by inserting ``, as defined in + section 801(2),'' after ``school of nursing''; and + +[[Page 124 STAT. 630]] + + (5) in subsection (h), by striking ``2003 through 2007'' and + inserting ``2010 through 2014''. + + (b) Nurse Retention Grants.--Title VIII of the Public Health Service +Act is amended by inserting after section 831 (42 U.S.C. 296b) the +following: + +``SEC. 831A. <<NOTE: 42 USC 296p-1.>> NURSE RETENTION GRANTS. + + ``(a) Retention Priority Areas.--The Secretary may award grants to, +and enter into contracts with, eligible entities to enhance the nursing +workforce by initiating and maintaining nurse retention programs +pursuant to subsection (b) or (c). + ``(b) Grants for Career Ladder Program.--The Secretary may award +grants to, and enter into contracts with, eligible entities for +programs-- + ``(1) to promote career advancement for individuals + including licensed practical nurses, licensed vocational nurses, + certified nurse assistants, home health aides, diploma degree or + associate degree nurses, to become baccalaureate prepared + registered nurses or advanced education nurses in order to meet + the needs of the registered nurse workforce; + ``(2) developing and implementing internships and residency + programs in collaboration with an accredited school of nursing, + as defined by section 801(2), to encourage mentoring and the + development of specialties; or + ``(3) to assist individuals in obtaining education and + training required to enter the nursing profession and advance + within such profession. + + ``(c) Enhancing Patient Care Delivery Systems.-- + ``(1) Grants.--The Secretary may award grants to eligible + entities to improve the retention of nurses and enhance patient + care that is directly related to nursing activities by enhancing + collaboration and communication among nurses and other health + care professionals, and by promoting nurse involvement in the + organizational and clinical decision-making processes of a + health care facility. + ``(2) Priority.--In making awards of grants under this + subsection, the Secretary shall give preference to applicants + that have not previously received an award under this subsection + (or section 831(c) as such section existed on the day before the + date of enactment of this section). + ``(3) Continuation of an award.--The Secretary shall make + continuation of any award under this subsection beyond the + second year of such award contingent on the recipient of such + award having demonstrated to the Secretary measurable and + substantive improvement in nurse retention or patient care. + + ``(d) Other Priority Areas.--The Secretary may award grants to, or +enter into contracts with, eligible entities to address other areas that +are of high priority to nurse retention, as determined by the Secretary. + ``(e) Report.--The Secretary shall submit to the Congress before the +end of each fiscal year a report on the grants awarded and the contracts +entered into under this section. Each such report shall identify the +overall number of such grants and contracts and provide an explanation +of why each such grant or contract will meet the priority need of the +nursing workforce. + +[[Page 124 STAT. 631]] + + ``(f) Eligible Entity.--For purposes of this section, the term +`eligible entity' includes an accredited school of nursing, as defined +by section 801(2), a health care facility, or a partnership of such a +school and facility. + ``(g) Authorization of Appropriations.--There are authorized to be +appropriated to carry out this section such sums as may be necessary for +each of fiscal years 2010 through 2012.''. + +SEC. 5310. LOAN REPAYMENT AND SCHOLARSHIP PROGRAM. + + (a) Loan Repayments and Scholarships.--Section 846(a)(3) of the +Public Health Service Act (42 U.S.C. 297n(a)(3)) is amended by inserting +before the semicolon the following: ``, or in a accredited school of +nursing, as defined by section 801(2), as nurse faculty''. + (b) Technical and Conforming Amendments.--Title VIII (42 U.S.C. 296 +et seq.) is amended-- + (1) by redesignating section 810 <<NOTE: 42 USC + 296g.>> (relating to prohibition against discrimination by + schools on the basis of sex) as section 809 and moving such + section so that it follows section 808; + (2) in sections 835, 836, 838, 840, and 842, <<NOTE: 42 USC + 297a, 297b, 297d, 297g, 297i.>> by striking the term ``this + subpart'' each place it appears and inserting ``this part''; + (3) in section 836(h), <<NOTE: 42 USC 297b.>> by striking + the last sentence; + (4) in section 836, by redesignating subsection (l) as + subsection (k); + (5) in section 839, <<NOTE: 42 USC 297e.>> by striking + ``839'' and all that follows through ``(a)'' and inserting + ``839. (a)''; + (6) in section 835(b), <<NOTE: 42 USC 297a.>> by striking + ``841'' each place it appears and inserting ``871''; + (7) by redesignating section 841 <<NOTE: 42 USC 298d.>> as + section 871, moving part F to the end of the title, and + redesignating such part as part I; + (8) in part G-- + (A) by redesignating section 845 <<NOTE: 42 USC + 297t.>> as section 851; and + (B) by redesignating part G as part F; + (9) in part H-- + (A) by redesignating sections 851 and 852 <<NOTE: 42 + USC 297w, 297x.>> as sections 861 and 862, respectively; + and + (B) by redesignating part H as part G; and + (10) in part I-- + (A) by redesignating section 855, <<NOTE: 42 USC + 298.>> as amended by section 5305, as section 865; and + (B) by redesignating part I as part H. + +SEC. 5311. NURSE FACULTY LOAN PROGRAM. + + (a) In General.--Section 846A of the Public Health Service Act (42 +U.S.C. 297n-1) is amended-- + (1) in subsection (a)-- + (A) in the subsection heading, by striking + ``Establishment'' and inserting ``School of Nursing + Student Loan Fund''; and + (B) by inserting ``accredited'' after ``agreement + with any''; + (2) in subsection (c)-- + (A) in paragraph (2), by striking ``$30,000'' and + all that follows through the semicolon and inserting + ``$35,500, during fiscal years 2010 and 2011 fiscal + years (after fiscal year 2011, such amounts shall be + adjusted to provide for + +[[Page 124 STAT. 632]] + + a cost-of-attendance increase for the yearly loan rate + and the aggregate loan;''; and + (B) in paragraph (3)(A), by inserting ``an + accredited'' after ``faculty member in''; + (3) in subsection (e), by striking ``a school'' and + inserting ``an accredited school''; and + (4) in subsection (f), by striking ``2003 through 2007'' and + inserting ``2010 through 2014''. + + (b) Eligible Individual Student Loan Repayment.--Title VIII of the +Public Health Service Act is amended by inserting after section 846A (42 +U.S.C. 297n-1) the following: + +``SEC. 847. <<NOTE: 42 USC 297o.>> ELIGIBLE INDIVIDUAL STUDENT LOAN + REPAYMENT. + + ``(a) In General.--The Secretary, acting through the Administrator +of the Health Resources and Services Administration, may enter into an +agreement with eligible individuals for the repayment of education +loans, in accordance with this section, to increase the number of +qualified nursing faculty. + ``(b) Agreements.--Each agreement entered into under this subsection +shall require that the eligible individual shall serve as a full-time +member of the faculty of an accredited school of nursing, for a total +period, in the aggregate, of at least 4 years during the 6-year period +beginning on the later of-- + ``(1) the date on which the individual receives a master's + or doctorate nursing degree from an accredited school of + nursing; or + ``(2) the date on which the individual enters into an + agreement under this subsection. + + ``(c) Agreement Provisions.--Agreements entered into pursuant to +subsection (b) shall be entered into on such terms and conditions as the +Secretary may determine, except that-- + ``(1) <<NOTE: Deadline.>> not more than 10 months after the + date on which the 6-year period described under subsection (b) + begins, but in no case before the individual starts as a full- + time member of the faculty of an accredited school of nursing + the Secretary shall begin making payments, for and on behalf of + that individual, on the outstanding principal of, and interest + on, any loan of that individual obtained to pay for such degree; + ``(2) for an individual who has completed a master's in + nursing or equivalent degree in nursing-- + ``(A) payments may not exceed $10,000 per calendar + year; and + ``(B) total payments may not exceed $40,000 during + the 2010 and 2011 fiscal years (after fiscal year 2011, + such amounts shall be adjusted to provide for a cost-of- + attendance increase for the yearly loan rate and the + aggregate loan); and + ``(3) for an individual who has completed a doctorate or + equivalent degree in nursing-- + ``(A) payments may not exceed $20,000 per calendar + year; and + ``(B) total payments may not exceed $80,000 during + the 2010 and 2011 fiscal years (adjusted for subsequent + fiscal years as provided for in the same manner as in + paragraph (2)(B)). + + ``(d) Breach of Agreement.-- + +[[Page 124 STAT. 633]] + + ``(1) In general.--In the case of any agreement made under + subsection (b), the individual is liable to the Federal + Government for the total amount paid by the Secretary under such + agreement, and for interest on such amount at the maximum legal + prevailing rate, if the individual fails to meet the agreement + terms required under such subsection. + ``(2) Waiver or suspension of liability.--In the case of an + individual making an agreement for purposes of paragraph (1), + the Secretary shall provide for the waiver or suspension of + liability under such paragraph if compliance by the individual + with the agreement involved is impossible or would involve + extreme hardship to the individual or if enforcement of the + agreement with respect to the individual would be + unconscionable. + ``(3) Date certain for recovery.--Subject to paragraph (2), + any amount that the Federal Government is entitled to recover + under paragraph (1) shall be paid to the United States not later + than the expiration of the 3-year period beginning on the date + the United States becomes so entitled. + ``(4) Availability.--Amounts recovered under paragraph (1) + shall be available to the Secretary for making loan repayments + under this section and shall remain available for such purpose + until expended. + + ``(e) Eligible Individual Defined.--For purposes of this section, +the term `eligible individual' means an individual who-- + ``(1) is a United States citizen, national, or lawful + permanent resident; + ``(2) holds an unencumbered license as a registered nurse; + and + ``(3) has either already completed a master's or doctorate + nursing program at an accredited school of nursing or is + currently enrolled on a full-time or part-time basis in such a + program. + + ``(f) Priority.--For the purposes of this section and section 846A, +funding priority will be awarded to School of Nursing Student Loans that +support doctoral nursing students or Individual Student Loan Repayment +that support doctoral nursing students. + ``(g) Authorization of Appropriations.--There are authorized to be +appropriated to carry out this section such sums as may be necessary for +each of fiscal years 2010 through 2014.''. + +SEC. 5312. AUTHORIZATION OF APPROPRIATIONS FOR PARTS B THROUGH D OF + TITLE VIII. + + Section 871 of the Public Health Service Act, as redesignated and +moved by section 5310, is amended to read as follows: + +``SEC. 871. <<NOTE: 42 USC 298d.>> AUTHORIZATION OF APPROPRIATIONS. + + ``For the purpose of carrying out parts B, C, and D (subject to +section 851(g)), there are authorized to be appropriated $338,000,000 +for fiscal year 2010, and such sums as may be necessary for each of the +fiscal years 2011 through 2016.''. + +SEC. 5313. GRANTS TO PROMOTE THE COMMUNITY HEALTH WORKFORCE. + + (a) In General.--Part P of title III of the Public Health Service +Act (42 U.S.C. 280g et seq.) is amended by adding at the end the +following: + +[[Page 124 STAT. 634]] + +``SEC. 399V. <<NOTE: 42 USC 280g-11.>> GRANTS TO PROMOTE POSITIVE HEALTH + BEHAVIORS AND OUTCOMES. + + ``(a) Grants Authorized.--The Director of the Centers for Disease +Control and Prevention, in collaboration with the Secretary, shall award +grants to eligible entities to promote positive health behaviors and +outcomes for populations in medically underserved communities through +the use of community health workers. + ``(b) Use of Funds.--Grants awarded under subsection (a) shall be +used to support community health workers-- + ``(1) to educate, guide, and provide outreach in a community + setting regarding health problems prevalent in medically + underserved communities, particularly racial and ethnic minority + populations; + ``(2) to educate and provide guidance regarding effective + strategies to promote positive health behaviors and discourage + risky health behaviors; + ``(3) to educate and provide outreach regarding enrollment + in health insurance including the Children's Health Insurance + Program under title XXI of the Social Security Act, Medicare + under title XVIII of such Act and Medicaid under title XIX of + such Act; + ``(4) to identify, educate, refer, and enroll underserved + populations to appropriate healthcare agencies and community- + based programs and organizations in order to increase access to + quality healthcare services and to eliminate duplicative care; + or + ``(5) to educate, guide, and provide home visitation + services regarding maternal health and prenatal care. + + ``(c) Application.--Each eligible entity that desires to receive a +grant under subsection (a) shall submit an application to the Secretary, +at such time, in such manner, and accompanied by such information as the +Secretary may require. + ``(d) Priority.--In awarding grants under subsection (a), the +Secretary shall give priority to applicants that-- + ``(1) propose to target geographic areas-- + ``(A) with a high percentage of residents who are + eligible for health insurance but are uninsured or + underinsured; + ``(B) with a high percentage of residents who suffer + from chronic diseases; or + ``(C) with a high infant mortality rate; + ``(2) have experience in providing health or health-related + social services to individuals who are underserved with respect + to such services; and + ``(3) have documented community activity and experience with + community health workers. + + ``(e) Collaboration With Academic Institutions and the One-stop +Delivery System.--The Secretary shall encourage community health worker +programs receiving funds under this section to collaborate with academic +institutions and one-stop delivery systems under section 134(c) of the +Workforce Investment Act of 1998. Nothing in this section shall be +construed to require such collaboration. + ``(f) Evidence-based Interventions.--The Secretary shall encourage +community health worker programs receiving funding under this section to +implement a process or an outcome-based + +[[Page 124 STAT. 635]] + +payment system that rewards community health workers for connecting +underserved populations with the most appropriate services at the most +appropriate time. Nothing in this section shall be construed to require +such a payment. + ``(g) Quality Assurance and Cost +Effectiveness. <<NOTE: Guidelines.>> --The Secretary shall establish +guidelines for assuring the quality of the training and supervision of +community health workers under the programs funded under this section +and for assuring the cost-effectiveness of such programs. + + ``(h) Monitoring.--The Secretary shall monitor community health +worker programs identified in approved applications under this section +and shall determine whether such programs are in compliance with the +guidelines established under subsection (g). + ``(i) Technical Assistance.--The Secretary may provide technical +assistance to community health worker programs identified in approved +applications under this section with respect to planning, developing, +and operating programs under the grant. + ``(j) Authorization of Appropriations.--There are authorized to be +appropriated, such sums as may be necessary to carry out this section +for each of fiscal years 2010 through 2014. + ``(k) Definitions.--In this section: + ``(1) Community health worker.--The term `community health + worker', as defined by the Department of Labor as Standard + Occupational Classification [21-1094] means an individual who + promotes health or nutrition within the community in which the + individual resides-- + ``(A) by serving as a liaison between communities + and healthcare agencies; + ``(B) by providing guidance and social assistance to + community residents; + ``(C) by enhancing community residents' ability to + effectively communicate with healthcare providers; + ``(D) by providing culturally and linguistically + appropriate health or nutrition education; + ``(E) by advocating for individual and community + health; + ``(F) by providing referral and follow-up services + or otherwise coordinating care; and + ``(G) by proactively identifying and enrolling + eligible individuals in Federal, State, local, private + or nonprofit health and human services programs. + ``(2) Community setting.--The term `community setting' means + a home or a community organization located in the neighborhood + in which a participant in the program under this section + resides. + ``(3) Eligible entity.--The term `eligible entity' means a + public or nonprofit private entity (including a State or public + subdivision of a State, a public health department, a free + health clinic, a hospital, or a Federally-qualified health + center (as defined in section 1861(aa) of the Social Security + Act)), or a consortium of any such entities. + ``(4) Medically underserved community.--The term `medically + underserved community' means a community identified by a State-- + ``(A) that has a substantial number of individuals + who are members of a medically underserved population, + as defined by section 330(b)(3); and + +[[Page 124 STAT. 636]] + + ``(B) a significant portion of which is a health + professional shortage area as designated under section + 332.''. + +SEC. 5314. FELLOWSHIP TRAINING IN PUBLIC HEALTH. + + Part E of title VII of the Public Health Service Act (42 U.S.C. 294n +et seq.), as amended by section 5206, is further amended by adding at +the end the following: + +``SEC. 778. <<NOTE: 42 USC 295f-3.>> FELLOWSHIP TRAINING IN APPLIED + PUBLIC HEALTH EPIDEMIOLOGY, PUBLIC HEALTH LABORATORY + SCIENCE, PUBLIC HEALTH INFORMATICS, AND EXPANSION OF THE + EPIDEMIC INTELLIGENCE SERVICE. + + ``(a) In General.--The Secretary may carry out activities to address +documented workforce shortages in State and local health departments in +the critical areas of applied public health epidemiology and public +health laboratory science and informatics and may expand the Epidemic +Intelligence Service. + ``(b) Specific Uses.--In carrying out subsection (a), the Secretary +shall provide for the expansion of existing fellowship programs operated +through the Centers for Disease Control and Prevention in a manner that +is designed to alleviate shortages of the type described in subsection +(a). + ``(c) Other Programs.--The Secretary may provide for the expansion +of other applied epidemiology training programs that meet objectives +similar to the objectives of the programs described in subsection (b). + ``(d) Work Obligation.--Participation in fellowship training +programs under this section shall be deemed to be service for purposes +of satisfying work obligations stipulated in contracts under section +338I(j). + ``(e) General Support.--Amounts may be used from grants awarded +under this section to expand the Public Health Informatics Fellowship +Program at the Centers for Disease Control and Prevention to better +support all public health systems at all levels of government. + ``(f) Authorization of Appropriations.--There are authorized to be +appropriated to carry out this section $39,500,000 for each of fiscal +years 2010 through 2013, of which-- + ``(1) $5,000,000 shall be made available in each such fiscal + year for epidemiology fellowship training program activities + under subsections (b) and (c); + ``(2) $5,000,000 shall be made available in each such fiscal + year for laboratory fellowship training programs under + subsection (b); + ``(3) $5,000,000 shall be made available in each such fiscal + year for the Public Health Informatics Fellowship Program under + subsection (e); and + ``(4) $24,500,000 shall be made available for expanding the + Epidemic Intelligence Service under subsection (a).''. + +SEC. 5315. UNITED STATES PUBLIC HEALTH SCIENCES TRACK. + + Title II of the Public Health Service Act (42 U.S.C. 202 et seq.) is +amended by adding at the end the following: + +[[Page 124 STAT. 637]] + + ``PART D--UNITED STATES PUBLIC HEALTH SCIENCES TRACK + +``SEC. 271. <<NOTE: 42 USC 239l.>> ESTABLISHMENT. + + ``(a) United States Public Health Services Track.-- + ``(1) In general.--There is hereby authorized to be + established a United States Public Health Sciences Track + (referred to in this part as the `Track'), at sites to be + selected by the Secretary, with authority to grant appropriate + advanced degrees in a manner that uniquely emphasizes team-based + service, public health, epidemiology, and emergency preparedness + and response. It shall be so organized as to graduate not less + than-- + ``(A) 150 medical students annually, 10 of whom + shall be awarded studentships to the Uniformed Services + University of Health Sciences; + ``(B) 100 dental students annually; + ``(C) 250 nursing students annually; + ``(D) 100 public health students annually; + ``(E) 100 behavioral and mental health professional + students annually; + ``(F) 100 physician assistant or nurse practitioner + students annually; and + ``(G) 50 pharmacy students annually. + ``(2) Locations.--The Track shall be located at existing and + accredited, affiliated health professions education training + programs at academic health centers located in regions of the + United States determined appropriate by the Surgeon General, in + consultation with the National Health Care Workforce Commission + established in section 5101 of the Patient Protection and + Affordable Care Act. + + ``(b) Number of Graduates.--Except as provided in subsection (a), +the number of persons to be graduated from the Track shall be prescribed +by the Secretary. In so prescribing the number of persons to be +graduated from the Track, the Secretary shall institute actions +necessary to ensure the maximum number of first-year enrollments in the +Track consistent with the academic capacity of the affiliated sites and +the needs of the United States for medical, dental, and nursing +personnel. + ``(c) Development.--The development of the Track may be by such +phases as the Secretary may prescribe subject to the requirements of +subsection (a). + ``(d) Integrated Longitudinal Plan.--The Surgeon General shall +develop an integrated longitudinal plan for health professions +continuing education throughout the continuum of health-related +education, training, and practice. Training under such plan shall +emphasize patient-centered, interdisciplinary, and care coordination +skills. Experience with deployment of emergency response teams shall be +included during the clinical experiences. + ``(e) Faculty Development.--The Surgeon General shall develop +faculty development programs and curricula in decentralized venues of +health care, to balance urban, tertiary, and inpatient venues. + +``SEC. 272. <<NOTE: 42 USC 239l-1.>> ADMINISTRATION. + + ``(a) In General.--The business of the Track shall be conducted by +the Surgeon General with funds appropriated for and provided + +[[Page 124 STAT. 638]] + +by the Department of Health and Human Services. The National Health Care +Workforce Commission shall assist the Surgeon General in an advisory +capacity. + ``(b) Faculty.-- + ``(1) In general.--The Surgeon General, after considering + the recommendations of the National Health Care Workforce + Commission, shall obtain the services of such professors, + instructors, and administrative and other employees as may be + necessary to operate the Track, but utilize when possible, + existing affiliated health professions training institutions. + Members of the faculty and staff shall be employed under salary + schedules and granted retirement and other related benefits + prescribed by the Secretary so as to place the employees of the + Track faculty on a comparable basis with the employees of fully + accredited schools of the health professions within the United + States. + ``(2) Titles.--The Surgeon General may confer academic + titles, as appropriate, upon the members of the faculty. + ``(3) Nonapplication of provisions.--The limitations in + section 5373 of title 5, United States Code, shall not apply to + the authority of the Surgeon General under paragraph (1) to + prescribe salary schedules and other related benefits. + + ``(c) Agreements.--The Surgeon General may negotiate agreements with +agencies of the Federal Government to utilize on a reimbursable basis +appropriate existing Federal medical resources located in the United +States (or locations selected in accordance with section 271(a)(2)). +Under such agreements the facilities concerned will retain their +identities and basic missions. The Surgeon General may negotiate +affiliation agreements with accredited universities and health +professions training institutions in the United States. Such agreements +may include provisions for payments for educational services provided +students participating in Department of Health and Human Services +educational programs. + ``(d) Programs.--The Surgeon General may establish the following +educational programs for Track students: + ``(1) Postdoctoral, postgraduate, and technological + programs. + ``(2) A cooperative program for medical, dental, physician + assistant, pharmacy, behavioral and mental health, public + health, and nursing students. + ``(3) Other programs that the Surgeon General determines + necessary in order to operate the Track in a cost-effective + manner. + + ``(e) Continuing Medical Education.--The Surgeon General shall +establish programs in continuing medical education for members of the +health professions to the end that high standards of health care may be +maintained within the United States. + ``(f) Authority of the Surgeon General.-- + ``(1) <<NOTE: Contracts. Grants.>> In general.--The Surgeon + General is authorized-- + ``(A) to enter into contracts with, accept grants + from, and make grants to any nonprofit entity for the + purpose of carrying out cooperative enterprises in + medical, dental, physician assistant, pharmacy, + behavioral and mental health, public health, and nursing + research, consultation, and education; + ``(B) to enter into contracts with entities under + which the Surgeon General may furnish the services of + such + +[[Page 124 STAT. 639]] + + professional, technical, or clerical personnel as may be + necessary to fulfill cooperative enterprises undertaken + by the Track; + ``(C) to accept, hold, administer, invest, and spend + any gift, devise, or bequest of personal property made + to the Track, including any gift, devise, or bequest for + the support of an academic chair, teaching, research, or + demonstration project; + ``(D) to enter into agreements with entities that + may be utilized by the Track for the purpose of + enhancing the activities of the Track in education, + research, and technological applications of knowledge; + and + ``(E) to accept the voluntary services of guest + scholars and other persons. + ``(2) Limitation.--The Surgeon General may not enter into + any contract with an entity if the contract would obligate the + Track to make outlays in advance of the enactment of budget + authority for such outlays. + ``(3) Scientists.--Scientists or other medical, dental, or + nursing personnel utilized by the Track under an agreement + described in paragraph (1) may be appointed to any position + within the Track and may be permitted to perform such duties + within the Track as the Surgeon General may approve. + ``(4) Volunteer services.--A person who provides voluntary + services under the authority of subparagraph (E) of paragraph + (1) shall be considered to be an employee of the Federal + Government for the purposes of chapter 81 of title 5, relating + to compensation for work-related injuries, and to be an employee + of the Federal Government for the purposes of chapter 171 of + title 28, relating to tort claims. Such a person who is not + otherwise employed by the Federal Government shall not be + considered to be a Federal employee for any other purpose by + reason of the provision of such services. + +``SEC. 273. <<NOTE: 42 USC 239l-2.>> STUDENTS; SELECTION; OBLIGATION. + + ``(a) Student Selection.-- + ``(1) In general.--Medical, dental, physician assistant, + pharmacy, behavioral and mental health, public health, and + nursing students at the Track shall be selected under procedures + prescribed by the Surgeon General. In so prescribing, the + Surgeon General shall consider the recommendations of the + National Health Care Workforce Commission. + ``(2) Priority.--In developing admissions procedures under + paragraph (1), the Surgeon General shall ensure that such + procedures give priority to applicant medical, dental, physician + assistant, pharmacy, behavioral and mental health, public + health, and nursing students from rural communities and + underrepresented minorities. + + ``(b) Contract and Service Obligation.-- + ``(1) Contract.--Upon being admitted to the Track, a + medical, dental, physician assistant, pharmacy, behavioral and + mental health, public health, or nursing student shall enter + into a written contract with the Surgeon General that shall + contain-- + ``(A) an agreement under which-- + ``(i) subject to subparagraph (B), the Surgeon + General agrees to provide the student with tuition + (or + +[[Page 124 STAT. 640]] + + tuition remission) and a student stipend + (described in paragraph (2)) in each school year + for a period of years (not to exceed 4 school + years) determined by the student, during which + period the student is enrolled in the Track at an + affiliated or other participating health + professions institution pursuant to an agreement + between the Track and such institution; and + ``(ii) subject to subparagraph (B), the + student agrees-- + ``(I) to accept the provision of + such tuition and student stipend to the + student; + ``(II) to maintain enrollment at the + Track until the student completes the + course of study involved; + ``(III) while enrolled in such + course of study, to maintain an + acceptable level of academic standing + (as determined by the Surgeon General); + ``(IV) if pursuing a degree from a + school of medicine or osteopathic + medicine, dental, public health, or + nursing school or a physician assistant, + pharmacy, or behavioral and mental + health professional program, to complete + a residency or internship in a specialty + that the Surgeon General determines is + appropriate; and + ``(V) to serve for a period of time + (referred to in this part as the `period + of obligated service') within the + Commissioned Corps of the Public Health + Service equal to 2 years for each school + year during which such individual was + enrolled at the College, reduced as + provided for in paragraph (3); + ``(B) a provision that any financial obligation of + the United States arising out of a contract entered into + under this part and any obligation of the student which + is conditioned thereon, is contingent upon funds being + appropriated to carry out this part; + ``(C) a statement of the damages to which the United + States is entitled for the student's breach of the + contract; and + ``(D) such other statements of the rights and + liabilities of the Secretary and of the individual, not + inconsistent with the provisions of this part. + ``(2) Tuition and student stipend.-- + ``(A) Tuition remission rates.--The Surgeon General, + based on the recommendations of the National Health Care + Workforce Commission, shall establish Federal tuition + remission rates to be used by the Track to provide + reimbursement to affiliated and other participating + health professions institutions for the cost of + educational services provided by such institutions to + Track students. The agreement entered into by such + participating institutions under paragraph (1)(A)(i) + shall contain an agreement to accept as payment in full + the established remission rate under this subparagraph. + ``(B) Stipend.--The Surgeon General, based on the + recommendations of the National Health Care Workforce + +[[Page 124 STAT. 641]] + + Commission, shall establish and update Federal stipend + rates for payment to students under this part. + ``(3) Reductions in the period of obligated service.--The + period of obligated service under paragraph (1)(A)(ii)(V) shall + be reduced-- + ``(A) in the case of a student who elects to + participate in a high-needs speciality residency (as + determined by the National Health Care Workforce + Commission), by 3 months for each year of such + participation (not to exceed a total of 12 months); and + ``(B) in the case of a student who, upon completion + of their residency, elects to practice in a Federal + medical facility (as defined in section 781(e)) that is + located in a health professional shortage area (as + defined in section 332), by 3 months for year of full- + time practice in such a facility (not to exceed a total + of 12 months). + + ``(c) Second 2 Years of Service.--During the third and fourth years +in which a medical, dental, physician assistant, pharmacy, behavioral +and mental health, public health, or nursing student is enrolled in the +Track, training should be designed to prioritize clinical rotations in +Federal medical facilities in health professional shortage areas, and +emphasize a balance of hospital and community-based experiences, and +training within interdisciplinary teams. + ``(d) Dentist, Physician Assistant, Pharmacist, Behavioral and +Mental Health Professional, Public Health Professional, and Nurse +Training.--The Surgeon General shall establish provisions applicable +with respect to dental, physician assistant, pharmacy, behavioral and +mental health, public health, and nursing students that are comparable +to those for medical students under this section, including service +obligations, tuition support, and stipend support. The Surgeon General +shall give priority to health professions training institutions that +train medical, dental, physician assistant, pharmacy, behavioral and +mental health, public health, and nursing students for some significant +period of time together, but at a minimum have a discrete and shared +core curriculum. + ``(e) <<NOTE: Criteria.>> Elite Federal Disaster Teams.--The Surgeon +General, in consultation with the Secretary, the Director of the Centers +for Disease Control and Prevention, and other appropriate military and +Federal government agencies, shall develop criteria for the appointment +of highly qualified Track faculty, medical, dental, physician assistant, +pharmacy, behavioral and mental health, public health, and nursing +students, and graduates to elite Federal disaster preparedness teams to +train and to respond to public health emergencies, natural disasters, +bioterrorism events, and other emergencies. + + ``(f) <<NOTE: Regulations.>> Student Dropped From Track in Affiliate +School.--A medical, dental, physician assistant, pharmacy, behavioral +and mental health, public health, or nursing student who, under +regulations prescribed by the Surgeon General, is dropped from the Track +in an affiliated school for deficiency in conduct or studies, or for +other reasons, shall be liable to the United States for all tuition and +stipend support provided to the student. + +[[Page 124 STAT. 642]] + +``SEC. 274. <<NOTE: 42 USC 239l-3.>> FUNDING. + + ``Beginning <<NOTE: Effective date.>> with fiscal year 2010, the +Secretary shall transfer from the Public Health and Social Services +Emergency Fund such sums as may be necessary to carry out this part.''. + + Subtitle E--Supporting the Existing Health Care Workforce + +SEC. 5401. CENTERS OF EXCELLENCE. + + Section 736 of the Public Health Service Act (42 U.S.C. 293) is +amended by striking subsection (h) and inserting the following: + ``(h) <<NOTE: Grants.>> Formula for Allocations.-- + ``(1) <<NOTE: Applicability.>> Allocations.--Based on the + amount appropriated under subsection (i) for a fiscal year, the + following subparagraphs shall apply as appropriate: + ``(A) In general.--If the amounts appropriated under + subsection (i) for a fiscal year are $24,000,000 or + less-- + ``(i) the Secretary shall make available + $12,000,000 for grants under subsection (a) to + health professions schools that meet the + conditions described in subsection (c)(2)(A); and + ``(ii) and available after grants are made + with funds under clause (i), the Secretary shall + make available-- + ``(I) 60 percent of such amount for + grants under subsection (a) to health + professions schools that meet the + conditions described in paragraph (3) or + (4) of subsection (c) (including meeting + the conditions under subsection (e)); + and + ``(II) 40 percent of such amount for + grants under subsection (a) to health + professions schools that meet the + conditions described in subsection + (c)(5). + ``(B) Funding in excess of $24,000,000.--If amounts + appropriated under subsection (i) for a fiscal year + exceed $24,000,000 but are less than $30,000,000-- + ``(i) 80 percent of such excess amounts shall + be made available for grants under subsection (a) + to health professions schools that meet the + requirements described in paragraph (3) or (4) of + subsection (c) (including meeting conditions + pursuant to subsection (e)); and + ``(ii) 20 percent of such excess amount shall + be made available for grants under subsection (a) + to health professions schools that meet the + conditions described in subsection (c)(5). + ``(C) Funding in excess of $30,000,000.--If amounts + appropriated under subsection (i) for a fiscal year + exceed $30,000,000 but are less than $40,000,000, the + Secretary shall make available-- + ``(i) not less than $12,000,000 for grants + under subsection (a) to health professions schools + that meet the conditions described in subsection + (c)(2)(A); + ``(ii) not less than $12,000,000 for grants + under subsection (a) to health professions schools + that meet the conditions described in paragraph + (3) or (4) of + +[[Page 124 STAT. 643]] + + subsection (c) (including meeting conditions + pursuant to subsection (e)); + ``(iii) not less than $6,000,000 for grants + under subsection (a) to health professions schools + that meet the conditions described in subsection + (c)(5); and + ``(iv) after grants are made with funds under + clauses (i) through (iii), any remaining excess + amount for grants under subsection (a) to health + professions schools that meet the conditions + described in paragraph (2)(A), (3), (4), or (5) of + subsection (c). + ``(D) Funding in excess of $40,000,000.--If amounts + appropriated under subsection (i) for a fiscal year are + $40,000,000 or more, the Secretary shall make + available-- + ``(i) not less than $16,000,000 for grants + under subsection (a) to health professions schools + that meet the conditions described in subsection + (c)(2)(A); + ``(ii) not less than $16,000,000 for grants + under subsection (a) to health professions schools + that meet the conditions described in paragraph + (3) or (4) of subsection (c) (including meeting + conditions pursuant to subsection (e)); + ``(iii) not less than $8,000,000 for grants + under subsection (a) to health professions schools + that meet the conditions described in subsection + (c)(5); and + ``(iv) after grants are made with funds under + clauses (i) through (iii), any remaining funds for + grants under subsection (a) to health professions + schools that meet the conditions described in + paragraph (2)(A), (3), (4), or (5) of subsection + (c). + ``(2) No limitation.--Nothing in this subsection shall be + construed as limiting the centers of excellence referred to in + this section to the designated amount, or to preclude such + entities from competing for grants under this section. + ``(3) Maintenance of effort.-- + ``(A) In general.--With respect to activities for + which a grant made under this part are authorized to be + expended, the Secretary may not make such a grant to a + center of excellence for any fiscal year unless the + center agrees to maintain expenditures of non-Federal + amounts for such activities at a level that is not less + than the level of such expenditures maintained by the + center for the fiscal year preceding the fiscal year for + which the school receives such a grant. + ``(B) Use of federal funds.--With respect to any + Federal amounts received by a center of excellence and + available for carrying out activities for which a grant + under this part is authorized to be expended, the center + shall, before expending the grant, expend the Federal + amounts obtained from sources other than the grant, + unless given prior approval from the Secretary. + + ``(i) Authorization of Appropriations.--There are authorized to be +appropriated to carry out this section-- + ``(1) $50,000,000 for each of the fiscal years 2010 through + 2015; and + ``(2) and such sums as are necessary for each subsequent + fiscal year.''. + +[[Page 124 STAT. 644]] + +SEC. 5402. HEALTH CARE PROFESSIONALS TRAINING FOR DIVERSITY. + + (a) Loan Repayments and Fellowships Regarding Faculty Positions.-- +Section 738(a)(1) of the Public Health Service Act (42 U.S.C. +293b(a)(1)) is amended by striking ``$20,000 of the principal and +interest of the educational loans of such individuals.'' and inserting +``$30,000 of the principal and interest of the educational loans of such +individuals.''. + (b) Scholarships for Disadvantaged Students.--Section 740(a) of such +Act (42 U.S.C. 293d(a)) is amended by striking ``$37,000,000'' and all +that follows through ``2002'' and inserting ``$51,000,000 for fiscal +year 2010, and such sums as may be necessary for each of the fiscal +years 2011 through 2014''. + (c) Reauthorization for Loan Repayments and Fellowships Regarding +Faculty Positions.--Section 740(b) of such Act (42 U.S.C. 293d(b)) is +amended by striking ``appropriated'' and all that follows through the +period at the end and inserting ``appropriated, $5,000,000 for each of +the fiscal years 2010 through 2014.''. + (d) Reauthorization for Educational Assistance in the Health +Professions Regarding Individuals From a Disadvantaged Background.-- +Section 740(c) of such Act (42 U.S.C. 293d(c)) is amended by striking +the first sentence and inserting the following: ``For the purpose of +grants and contracts under section 739(a)(1), there is authorized to be +appropriated $60,000,000 for fiscal year 2010 and such sums as may be +necessary for each of the fiscal years 2011 through 2014.'' + +SEC. 5403. INTERDISCIPLINARY, COMMUNITY-BASED LINKAGES. + + (a) Area Health Education Centers.--Section 751 of the Public Health +Service Act (42 U.S.C. 294a) is amended to read as follows: + +``SEC. 751. AREA HEALTH EDUCATION CENTERS. + + ``(a) Establishment of Awards.--The Secretary shall make the +following 2 types of awards in accordance with this section: + ``(1) Infrastructure development award.--The Secretary shall + make awards to eligible entities to enable such entities to + initiate health care workforce educational programs or to + continue to carry out comparable programs that are operating at + the time the award is made by planning, developing, operating, + and evaluating an area health education center program. + ``(2) Point of service maintenance and enhancement award.-- + The Secretary shall make awards to eligible entities to maintain + and improve the effectiveness and capabilities of an existing + area health education center program, and make other + modifications to the program that are appropriate due to changes + in demographics, needs of the populations served, or other + similar issues affecting the area health education center + program. For the purposes of this section, the term `Program' + refers to the area health education center program. + + ``(b) Eligible Entities; Application.-- + ``(1) <<NOTE: Definitions.>> Eligible entities.-- + ``(A) Infrastructure development.--For purposes of + subsection (a)(1), the term `eligible entity' means a + school of medicine or osteopathic medicine, an + incorporated consortium of such schools, or the parent + institutions of such a school. With respect to a State + in which no area + +[[Page 124 STAT. 645]] + + health education center program is in operation, the + Secretary may award a grant or contract under subsection + (a)(1) to a school of nursing. + ``(B) Point of service maintenance and + enhancement.--For purposes of subsection (a)(2), the + term `eligible entity' means an entity that has received + funds under this section, is operating an area health + education center program, including an area health + education center or centers, and has a center or centers + that are no longer eligible to receive financial + assistance under subsection (a)(1). + ``(2) Application.--An eligible entity desiring to receive + an award under this section shall submit to the Secretary an + application at such time, in such manner, and containing such + information as the Secretary may require. + + ``(c) Use of Funds.-- + ``(1) Required activities. <<NOTE: Grants.>> --An eligible + entity shall use amounts awarded under a grant under subsection + (a)(1) or (a)(2) to carry out the following activities: + ``(A) Develop and implement strategies, in + coordination with the applicable one-stop delivery + system under section 134(c) of the Workforce Investment + Act of 1998, to recruit individuals from + underrepresented minority populations or from + disadvantaged or rural backgrounds into health + professions, and support such individuals in attaining + such careers. + ``(B) Develop and implement strategies to foster and + provide community-based training and education to + individuals seeking careers in health professions within + underserved areas for the purpose of developing and + maintaining a diverse health care workforce that is + prepared to deliver high-quality care, with an emphasis + on primary care, in underserved areas or for health + disparity populations, in collaboration with other + Federal and State health care workforce development + programs, the State workforce agency, and local + workforce investment boards, and in health care safety + net sites. + ``(C) Prepare individuals to more effectively + provide health services to underserved areas and health + disparity populations through field placements or + preceptorships in conjunction with community-based + organizations, accredited primary care residency + training programs, Federally qualified health centers, + rural health clinics, public health departments, or + other appropriate facilities. + ``(D) Conduct and participate in interdisciplinary + training that involves physicians, physician assistants, + nurse practitioners, nurse midwives, dentists, + psychologists, pharmacists, optometrists, community + health workers, public and allied health professionals, + or other health professionals, as practicable. + ``(E) Deliver or facilitate continuing education and + information dissemination programs for health care + professionals, with an emphasis on individuals providing + care in underserved areas and for health disparity + populations. + ``(F) Propose and implement effective program and + outcomes measurement and evaluation strategies. + +[[Page 124 STAT. 646]] + + ``(G) Establish a youth public health program to + expose and recruit high school students into health + careers, with a focus on careers in public health. + ``(2) Innovative opportunities.--An eligible entity may use + amounts awarded under a grant under subsection (a)(1) or + subsection (a)(2) to carry out any of the following activities: + ``(A) Develop and implement innovative curricula in + collaboration with community-based accredited primary + care residency training programs, Federally qualified + health centers, rural health clinics, behavioral and + mental health facilities, public health departments, or + other appropriate facilities, with the goal of + increasing the number of primary care physicians and + other primary care providers prepared to serve in + underserved areas and health disparity populations. + ``(B) Coordinate community-based participatory + research with academic health centers, and facilitate + rapid flow and dissemination of evidence-based health + care information, research results, and best practices + to improve quality, efficiency, and effectiveness of + health care and health care systems within community + settings. + ``(C) Develop and implement other strategies to + address identified workforce needs and increase and + enhance the health care workforce in the area served by + the area health education center program. + + ``(d) Requirements.-- + ``(1) Area health education center program.--In carrying out + this section, the Secretary shall ensure the following: + ``(A) An entity that receives an award under this + section shall conduct at least 10 percent of clinical + education required for medical students in community + settings that are removed from the primary teaching + facility of the contracting institution for grantees + that operate a school of medicine or osteopathic + medicine. In States in which an entity that receives an + award under this section is a nursing school or its + parent institution, the Secretary shall alternatively + ensure that-- + ``(i) the nursing school conducts at least 10 + percent of clinical education required for nursing + students in community settings that are remote + from the primary teaching facility of the school; + and + ``(ii) the entity receiving the award + maintains a written agreement with a school of + medicine or osteopathic medicine to place students + from that school in training sites in the area + health education center program area. + ``(B) An entity receiving funds under subsection + (a)(2) does not distribute such funding to a center that + is eligible to receive funding under subsection (a)(1). + ``(2) Area health education center.--The Secretary shall + ensure that each area health education center program includes + at least 1 area health education center, and that each such + center-- + ``(A) is a public or private organization whose + structure, governance, and operation is independent from + the awardee and the parent institution of the awardee; + +[[Page 124 STAT. 647]] + + ``(B) is not a school of medicine or osteopathic + medicine, the parent institution of such a school, or a + branch campus or other subunit of a school of medicine + or osteopathic medicine or its parent institution, or a + consortium of such entities; + ``(C) designates an underserved area or population + to be served by the center which is in a location + removed from the main location of the teaching + facilities of the schools participating in the program + with such center and does not duplicate, in whole or in + part, the geographic area or population served by any + other center; + ``(D) fosters networking and collaboration among + communities and between academic health centers and + community-based centers; + ``(E) serves communities with a demonstrated need of + health professionals in partnership with academic + medical centers; + ``(F) addresses the health care workforce needs of + the communities served in coordination with the public + workforce investment system; and + ``(G) has a community-based governing or advisory + board that reflects the diversity of the communities + involved. + + ``(e) Matching Funds.--With respect to the costs of operating a +program through a grant under this section, to be eligible for financial +assistance under this section, an entity shall make available (directly +or through contributions from State, county or municipal governments, or +the private sector) recurring non-Federal contributions in cash or in +kind, toward such costs in an amount that is equal to not less than 50 +percent of such costs. At least 25 percent of the total required non- +Federal contributions shall be in cash. An entity may apply to the +Secretary for a waiver of not more than 75 percent of the matching fund +amount required by the entity for each of the first 3 years the entity +is funded through a grant under subsection (a)(1). + ``(f) Limitation.--Not less than 75 percent of the total amount +provided to an area health education center program under subsection +(a)(1) or (a)(2) shall be allocated to the area health education centers +participating in the program under this section. <<NOTE: Waiver +authority.>> To provide needed flexibility to newly funded area health +education center programs, the Secretary may waive the requirement in +the sentence for the first 2 years of a new area health education center +program funded under subsection (a)(1). + + ``(g) Award.--An award to an entity under this section shall be not +less than $250,000 annually per area health education center included in +the program involved. If amounts appropriated to carry out this section +are not sufficient to comply with the preceding sentence, the Secretary +may reduce the per center amount provided for in such sentence as +necessary, provided the distribution established in subsection (j)(2) is +maintained. + ``(h) Project Terms.-- + ``(1) In general.--Except as provided in paragraph (2), the + period during which payments may be made under an award under + subsection (a)(1) may not exceed-- + ``(A) in the case of a program, 12 years; or + ``(B) in the case of a center within a program, 6 + years. + +[[Page 124 STAT. 648]] + + ``(2) Exception.--The periods described in paragraph (1) + shall not apply to programs receiving point of service + maintenance and enhancement awards under subsection (a)(2) to + maintain existing centers and activities. + + ``(i) Inapplicability of Provision.--Notwithstanding any other +provision of this title, section 791(a) shall not apply to an area +health education center funded under this section. + ``(j) Authorization of Appropriations.-- + ``(1) In general.--There is authorized to be appropriated to + carry out this section $125,000,000 for each of the fiscal years + 2010 through 2014. + ``(2) Requirements.--Of the amounts appropriated for a + fiscal year under paragraph (1)-- + ``(A) not more than 35 percent shall be used for + awards under subsection (a)(1); + ``(B) not less than 60 percent shall be used for + awards under subsection (a)(2); + ``(C) not more than 1 percent shall be used for + grants and contracts to implement outcomes evaluation + for the area health education centers; and + ``(D) not more than 4 percent shall be used for + grants and contracts to provide technical assistance to + entities receiving awards under this section. + ``(3) Carryover funds.--An entity that receives an award + under this section may carry over funds from 1 fiscal year to + another without obtaining approval from the Secretary. In no + case may any funds be carried over pursuant to the preceding + sentence for more than 3 years. + + ``(k) Sense of Congress.--It is the sense of the Congress that every +State have an area health education center program in effect under this +section.''. + (b) Continuing Educational Support for Health Professionals Serving +in Underserved Communities.--Part D of title VII of the Public Health +Service Act (42 U.S.C. 294 et seq.) is amended by striking section +752 <<NOTE: 42 USC 294b.>> and inserting the following: + +``SEC. 752. CONTINUING EDUCATIONAL SUPPORT FOR HEALTH PROFESSIONALS + SERVING IN UNDERSERVED COMMUNITIES. + + ``(a) In General. <<NOTE: Grants. Contracts.>> --The Secretary shall +make grants to, and enter into contracts with, eligible entities to +improve health care, increase retention, increase representation of +minority faculty members, enhance the practice environment, and provide +information dissemination and educational support to reduce professional +isolation through the timely dissemination of research findings using +relevant resources. + + ``(b) Eligible Entities. <<NOTE: Definition.>> --For purposes of +this section, the term `eligible entity' means an entity described in +section 799(b). + + ``(c) Application.--An eligible entity desiring to receive an award +under this section shall submit to the Secretary an application at such +time, in such manner, and containing such information as the Secretary +may require. + ``(d) Use of Funds.--An eligible entity shall use amounts awarded +under a grant or contract under this section to provide + +[[Page 124 STAT. 649]] + +innovative supportive activities to enhance education through distance +learning, continuing educational activities, collaborative conferences, +and electronic and telelearning activities, with priority for primary +care. + ``(e) Authorization.--There is authorized to be appropriated to +carry out this section $5,000,000 for each of the fiscal years 2010 +through 2014, and such sums as may be necessary for each subsequent +fiscal year.''. + +SEC. 5404. WORKFORCE DIVERSITY GRANTS. + + Section 821 of the Public Health Service Act (42 U.S.C. 296m) is +amended-- + (1) in subsection (a)-- + (A) by striking ``The Secretary may'' and inserting + the following: + ``(1) Authority.--The Secretary may''; + (B) by striking ``pre-entry preparation, and + retention activities'' and inserting the following: + ``stipends for diploma or associate degree nurses to + enter a bridge or degree completion program, student + scholarships or stipends for accelerated nursing degree + programs, pre-entry preparation, advanced education + preparation, and retention activities''; and + (2) in subsection (b)-- + (A) by striking ``First'' and all that follows + through ``including the'' and inserting ``National + Advisory Council on Nurse Education and Practice and + consult with nursing associations including the National + Coalition of Ethnic Minority Nurse Associations,''; and + (B) by inserting before the period the following: + ``, and other organizations determined appropriate by + the Secretary''. + +SEC. 5405. PRIMARY CARE EXTENSION PROGRAM. + + Part P of title III of the Public Health Service Act (42 U.S.C. 280g +et seq.), as amended by section 5313, is further amended by adding at +the end the following: + +``SEC. 399W. <<NOTE: 42 USC 280g-12.>> PRIMARY CARE EXTENSION PROGRAM. + + ``(a) Establishment, Purpose and Definition.-- + ``(1) In general.--The Secretary, acting through the + Director of the Agency for Healthcare Research and Quality, + shall establish a Primary Care Extension Program. + ``(2) Purpose.--The Primary Care Extension Program shall + provide support and assistance to primary care providers to + educate providers about preventive medicine, health promotion, + chronic disease management, mental and behavioral health + services (including substance abuse prevention and treatment + services), and evidence-based and evidence-informed therapies + and techniques, in order to enable providers to incorporate such + matters into their practice and to improve community health by + working with community-based health connectors (referred to in + this section as `Health Extension Agents'). + ``(3) Definitions.--In this section: + ``(A) Health extension agent.--The term `Health + Extension Agent' means any local, community-based health + worker who facilitates and provides assistance to + primary care practices by implementing quality + improvement or + +[[Page 124 STAT. 650]] + + system redesign, incorporating the principles of the + patient-centered medical home to provide high-quality, + effective, efficient, and safe primary care and to + provide guidance to patients in culturally and + linguistically appropriate ways, and linking practices + to diverse health system resources. + ``(B) Primary care provider.--The term `primary care + provider' means a clinician who provides integrated, + accessible health care services and who is accountable + for addressing a large majority of personal health care + needs, including providing preventive and health + promotion services for men, women, and children of all + ages, developing a sustained partnership with patients, + and practicing in the context of family and community, + as recognized by a State licensing or regulatory + authority, unless otherwise specified in this section. + + ``(b) Grants To Establish State Hubs and Local Primary Care +Extension Agencies.-- + ``(1) Grants.--The Secretary shall award competitive grants + to States for the establishment of State- or multistate-level + primary care Primary Care Extension Program State Hubs (referred + to in this section as `Hubs'). + ``(2) Composition of hubs.--A Hub established by a State + pursuant to paragraph (1)-- + ``(A) shall consist of, at a minimum, the State + health department, the entity responsible for + administering the State Medicaid program (if other than + the State health department), the State-level entity + administering the Medicare program, and the departments + of 1 or more health professions schools in the State + that train providers in primary care; and + ``(B) may include entities such as hospital + associations, primary care practice-based research + networks, health professional societies, State primary + care associations, State licensing boards, organizations + with a contract with the Secretary under section 1153 of + the Social Security Act, consumer groups, and other + appropriate entities. + + ``(c) State and Local Activities.-- + ``(1) Hub activities.--Hubs established under a grant under + subsection (b) shall-- + ``(A) <<NOTE: Plan.>> submit to the Secretary a plan + to coordinate functions with quality improvement + organizations and area health education centers if such + entities are members of the Hub not described in + subsection (b)(2)(A); + ``(B) <<NOTE: Contracts.>> contract with a county- + or local-level entity that shall serve as the Primary + Care Extension Agency to administer the services + described in paragraph (2); + ``(C) organize and administer grant funds to county- + or local-level Primary Care Extension Agencies that + serve a catchment area, as determined by the State; and + ``(D) organize State-wide or multistate networks of + local-level Primary Care Extension Agencies to share and + disseminate information and practices. + ``(2) Local primary care extension agency activities.-- + ``(A) Required activities.--Primary Care Extension + Agencies established by a Hub under paragraph (1) + shall-- + +[[Page 124 STAT. 651]] + + ``(i) assist primary care providers to + implement a patient-centered medical home to + improve the accessibility, quality, and efficiency + of primary care services, including health homes; + ``(ii) develop and support primary care + learning communities to enhance the dissemination + of research findings for evidence-based practice, + assess implementation of practice improvement, + share best practices, and involve community + clinicians in the generation of new knowledge and + identification of important questions for + research; + ``(iii) participate in a national network of + Primary Care Extension Hubs and propose how the + Primary Care Extension Agency will share and + disseminate lessons learned and best practices; + and + ``(iv) <<NOTE: Plan.>> develop a plan for + financial sustainability involving State, local, + and private contributions, to provide for the + reduction in Federal funds that is expected after + an initial 6-year period of program establishment, + infrastructure development, and planning. + ``(B) Discretionary activities.--Primary Care + Extension Agencies established by a Hub under paragraph + (1) may-- + ``(i) provide technical assistance, training, + and organizational support for community health + teams established under section 3602 of the + Patient Protection and Affordable Care Act; + ``(ii) collect data and provision of primary + care provider feedback from standardized + measurements of processes and outcomes to aid in + continuous performance improvement; + ``(iii) collaborate with local health + departments, community health centers, tribes and + tribal entities, and other community agencies to + identify community health priorities and local + health workforce needs, and participate in + community-based efforts to address the social and + primary determinants of health, strengthen the + local primary care workforce, and eliminate health + disparities; + ``(iv) develop measures to monitor the impact + of the proposed program on the health of practice + enrollees and of the wider community served; and + ``(v) participate in other activities, as + determined appropriate by the Secretary. + + ``(d) Federal Program Administration.-- + ``(1) Grants; types.--Grants awarded under subsection (b) + shall be-- + ``(A) program grants, that are awarded to State or + multistate entities that submit fully-developed plans + for the implementation of a Hub, for a period of 6 + years; or + ``(B) planning grants, that are awarded to State or + multistate entities with the goal of developing a plan + for a Hub, for a period of 2 years. + ``(2) Applications.--To be eligible for a grant under + subsection (b), a State or multistate entity shall submit to the + +[[Page 124 STAT. 652]] + + Secretary an application, at such time, in such manner, and + containing such information as the Secretary may require. + ``(3) <<NOTE: Appointment.>> Evaluation.--A State that + receives a grant under subsection (b) shall be evaluated at the + end of the grant period by an evaluation panel appointed by the + Secretary. + ``(4) Continuing support.--After the sixth year in which + assistance is provided to a State under a grant awarded under + subsection (b), the State may receive additional support under + this section if the State program has received satisfactory + evaluations with respect to program performance and the merits + of the State sustainability plan, as determined by the + Secretary. + ``(5) Limitation.--A State shall not use in excess of 10 + percent of the amount received under a grant to carry out + administrative activities under this section. Funds awarded + pursuant to this section shall not be used for funding direct + patient care. + + ``(e) Requirements on the Secretary. <<NOTE: Consultation.>> --In +carrying out this section, the Secretary shall consult with the heads of +other Federal agencies with demonstrated experience and expertise in +health care and preventive medicine, such as the Centers for Disease +Control and Prevention, the Substance Abuse and Mental Health +Administration, the Health Resources and Services Administration, the +National Institutes of Health, the Office of the National Coordinator +for Health Information Technology, the Indian Health Service, the +Agricultural Cooperative Extension Service of the Department of +Agriculture, and other entities, as the Secretary determines +appropriate. + + ``(f) Authorization of Appropriations.--To awards grants as provided +in subsection (d), there are authorized to be appropriated $120,000,000 +for each of fiscal years 2011 and 2012, and such sums as may be +necessary to carry out this section for each of fiscal years 2013 +through 2014.''. + + Subtitle F--Strengthening Primary Care and Other Workforce Improvements + +SEC. 5501. EXPANDING ACCESS TO PRIMARY CARE SERVICES AND GENERAL SURGERY + SERVICES. + + (a) Incentive Payment Program for Primary Care Services.-- + (1) In general.--Section 1833 of the Social Security Act (42 + U.S.C. 1395l) is amended by adding at the end the following new + subsection: + + ``(x) Incentive Payments for Primary Care Services.-- + ``(1) In general. <<NOTE: Time period.>> --In the case of + primary care services furnished on or after January 1, 2011, and + before January 1, 2016, by a primary care practitioner, in + addition to the amount of payment that would otherwise be made + for such services under this part, there also shall be paid (on + a monthly or quarterly basis) an amount equal to 10 percent of + the payment amount for the service under this part. + ``(2) Definitions.--In this subsection: + ``(A) Primary care practitioner.--The term `primary + care practitioner' means an individual-- + ``(i) who-- + +[[Page 124 STAT. 653]] + + ``(I) is a physician (as described + in section 1861(r)(1)) who has a primary + specialty designation of family + medicine, internal medicine, geriatric + medicine, or pediatric medicine; or + ``(II) is a nurse practitioner, + clinical nurse specialist, or physician + assistant (as those terms are defined in + section 1861(aa)(5)); and + ``(ii) for whom primary care services + accounted for at least 60 percent of the allowed + charges under this part for such physician or + practitioner in a prior period as determined + appropriate by the Secretary. + ``(B) Primary care services.--The term `primary care + services' means services identified, as of January 1, + 2009, by the following HCPCS codes (and as subsequently + modified by the Secretary): + ``(i) 99201 through 99215. + ``(ii) 99304 through 99340. + ``(iii) 99341 through 99350. + ``(3) <<NOTE: Determination.>> Coordination with other + payments.--The amount of the additional payment for a service + under this subsection and subsection (m) shall be determined + without regard to any additional payment for the service under + subsection (m) and this subsection, respectively. + ``(4) Limitation on review.--There shall be no + administrative or judicial review under section 1869, 1878, or + otherwise, respecting the identification of primary care + practitioners under this subsection.''. + (2) Conforming amendment.--Section 1834(g)(2)(B) of the + Social Security Act (42 U.S.C. 1395m(g)(2)(B)) is amended by + adding at the end the following sentence: ``Section 1833(x) + shall not be taken into account in determining the amounts that + would otherwise be paid pursuant to the preceding sentence.''. + + (b) Incentive Payment Program for Major Surgical Procedures +Furnished in Health Professional Shortage Areas.-- + (1) In general. <<NOTE: Time period.>> --Section 1833 of the + Social Security Act (42 U.S.C. 1395l), as amended by subsection + (a)(1), is amended by adding at the end the following new + subsection: + + ``(y) Incentive Payments for Major Surgical Procedures Furnished in +Health Professional Shortage Areas.-- + ``(1) In general.--In the case of major surgical procedures + furnished on or after January 1, 2011, and before January 1, + 2016, by a general surgeon in an area that is designated (under + section 332(a)(1)(A) of the Public Health Service Act) as a + health professional shortage area as identified by the Secretary + prior to the beginning of the year involved, in addition to the + amount of payment that would otherwise be made for such services + under this part, there also shall be paid (on a monthly or + quarterly basis) an amount equal to 10 percent of the payment + amount for the service under this part. + ``(2) Definitions.--In this subsection: + ``(A) General surgeon.--In this subsection, the term + `general surgeon' means a physician (as described in + section 1861(r)(1)) who has designated CMS specialty + code 02-General Surgery as their primary specialty code + in the physician's enrollment under section 1866(j). + ``(B) Major surgical procedures.--The term `major + surgical procedures' means physicians' services which + are + +[[Page 124 STAT. 654]] + + surgical procedures for which a 10-day or 90-day global + period is used for payment under the fee schedule under + section 1848(b). + ``(3) Coordination with other payments.--The amount of the + additional payment for a service under this subsection and + subsection (m) shall be determined without regard to any + additional payment for the service under subsection (m) and this + subsection, respectively. + ``(4) Application.--The provisions of paragraph (2) and (4) + of subsection (m) shall apply to the determination of additional + payments under this subsection in the same manner as such + provisions apply to the determination of additional payments + under subsection (m).''. + (2) Conforming amendment.--Section 1834(g)(2)(B) of the + Social Security Act (42 U.S.C. 1395m(g)(2)(B)), as amended by + subsection (a)(2), is amended by striking ``Section 1833(x)'' + and inserting ``Subsections (x) and (y) of section 1833'' in the + last sentence. + + (c) Budget-neutrality Adjustment.--Section 1848(c)(2)(B) of the +Social Security Act (42 U.S.C. 1395w-4(c)(2)(B)) is amended by adding at +the end the following new clause: + ``(vii) Adjustment for certain physician + incentive payments. <<NOTE: Applicability.>> -- + Fifty percent of the additional expenditures under + this part attributable to subsections (x) and (y) + of section 1833 for a year (as estimated by the + Secretary) shall be taken into account in applying + clause (ii)(II) for 2011 and subsequent years. In + lieu of applying the budget-neutrality adjustments + required under clause (ii)(II) to relative value + units to account for such costs for the year, the + Secretary shall apply such budget-neutrality + adjustments to the conversion factor otherwise + determined for the year. For 2011 and subsequent + years, the Secretary shall increase the incentive + payment otherwise applicable under section 1833(m) + by a percent estimated to be equal to the + additional expenditures estimated under the first + sentence of this clause for such year that is + applicable to physicians who primarily furnish + services in areas designated (under section + 332(a)(1)(A) of the Public Health Service Act) as + health professional shortage areas.''. + +SEC. 5502. MEDICARE FEDERALLY QUALIFIED HEALTH CENTER IMPROVEMENTS. + + (a) Expansion of Medicare-Covered Preventive Services at Federally +Qualified Health Centers.-- + (1) In general.--Section 1861(aa)(3)(A) of the Social + Security Act <<NOTE: 42 USC 1395x.>> (42 U.S.C. 1395w + (aa)(3)(A)) is amended to read as follows: + ``(A) services of the type described subparagraphs + (A) through (C) of paragraph (1) and preventive services + (as defined in section 1861(ddd)(3)); and''. + (2) Effective date. <<NOTE: Applicability. 42 USC 1395x + note.>> --The amendment made by paragraph (1) shall apply to + services furnished on or after January 1, 2011. + + (b) Prospective Payment System for Federally Qualified Health +Centers.--Section 1834 of the Social Security Act (42 + +[[Page 124 STAT. 655]] + +U.S.C. 1395m) is amended by adding at the end the following new +subsection: + ``(n) Development and Implementation of Prospective Payment +System.-- + ``(1) Development.-- + ``(A) In general.--The Secretary shall develop a + prospective payment system for payment for Federally + qualified health services furnished by Federally + qualified health centers under this title. Such system + shall include a process for appropriately describing the + services furnished by Federally qualified health + centers. + ``(B) Collection of data and evaluation.--The + Secretary shall require Federally qualified health + centers to submit to the Secretary such information as + the Secretary may require in order to develop and + implement the prospective payment system under this + paragraph and paragraph (2), respectively, including the + reporting of services using HCPCS codes. + ``(2) Implementation.-- + ``(A) In general. <<NOTE: Effective date.>> -- + Notwithstanding section 1833(a)(3)(B), the Secretary + shall provide, for cost reporting periods beginning on + or after October 1, 2014, for payments for Federally + qualified health services furnished by Federally + qualified health centers under this title in accordance + with the prospective payment system developed by the + Secretary under paragraph (1). + ``(B) Payments.-- + ``(i) Initial payments.--The Secretary shall + implement such prospective payment system so that + the estimated amount of expenditures under this + title for Federally qualified health services in + the first year that the prospective payment system + is implemented is equal to 103 percent of the + estimated amount of expenditures under this title + that would have occurred for such services in such + year if the system had not been implemented. + ``(ii) Payments in subsequent years.--In the + year after the first year of implementation of + such system, and in each subsequent year, the + payment rate for Federally qualified health + services furnished in the year shall be equal to + the payment rate established for such services + furnished in the preceding year under this + subparagraph increased by the percentage increase + in the MEI (as defined in 1842(i)(3)) for the year + involved.''. + +SEC. 5503. DISTRIBUTION OF ADDITIONAL RESIDENCY POSITIONS. + + (a) In General.--Section 1886(h) of the Social Security Act (42 +U.S.C. 1395ww(h)) is amended-- + (1) in paragraph (4)(F)(i), by striking ``paragraph (7)'' + and inserting ``paragraphs (7) and (8)''; + (2) in paragraph (4)(H)(i), by striking ``paragraph (7)'' + and inserting ``paragraphs (7) and (8)''; + (3) in paragraph (7)(E), by inserting ``or paragraph (8)'' + before the period at the end; and + (4) by adding at the end the following new paragraph: + ``(8) Distribution of additional residency positions.-- + +[[Page 124 STAT. 656]] + + ``(A) Reductions in limit based on unused + positions.-- + ``(i) <<NOTE: Effective date.>> In general.-- + Except as provided in clause (ii), if a hospital's + reference resident level (as defined in + subparagraph (H)(i)) is less than the otherwise + applicable resident limit (as defined in + subparagraph (H)(iii)), effective for portions of + cost reporting periods occurring on or after July + 1, 2011, the otherwise applicable resident limit + shall be reduced by 65 percent of the difference + between such otherwise applicable resident limit + and such reference resident level. + ``(ii) Exceptions.--This subparagraph shall + not apply to-- + ``(I) a hospital located in a rural + area (as defined in subsection + (d)(2)(D)(ii)) with fewer than 250 acute + care inpatient beds; + ``(II) <<NOTE: Deadline.>> a + hospital that was part of a qualifying + entity which had a voluntary residency + reduction plan approved under paragraph + (6)(B) or under the authority of section + 402 of Public Law 90-248, if the + hospital demonstrates to the Secretary + that it has a specified plan in place + for filling the unused positions by not + later than 2 years after the date of + enactment of this paragraph; or + ``(III) a hospital described in + paragraph (4)(H)(v). + ``(B) Distribution.-- + ``(i) In general.--The Secretary shall + increase the otherwise applicable resident limit + for each qualifying hospital that submits an + application under this subparagraph by such number + as the Secretary may approve for portions of cost + reporting periods occurring on or after July 1, + 2011. The aggregate number of increases in the + otherwise applicable resident limit under this + subparagraph shall be equal to the aggregate + reduction in such limits attributable to + subparagraph (A) (as estimated by the Secretary). + ``(ii) Requirements.--Subject to clause (iii), + a hospital that receives an increase in the + otherwise applicable resident limit under this + subparagraph shall ensure, during the 5-year + period beginning on the date of such increase, + that-- + ``(I) the number of full-time + equivalent primary care residents, as + defined in paragraph (5)(H) (as + determined by the Secretary), excluding + any additional positions under subclause + (II), is not less than the average + number of full-time equivalent primary + care residents (as so determined) during + the 3 most recent cost reporting periods + ending prior to the date of enactment of + this paragraph; and + ``(II) not less than 75 percent of + the positions attributable to such + increase are in a primary care or + general surgery residency (as determined + by the Secretary). + +[[Page 124 STAT. 657]] + + The Secretary may determine whether a hospital has + met the requirements under this clause during such + 5-year period in such manner and at such time as + the Secretary determines appropriate, including at + the end of such 5-year period. + ``(iii) Redistribution of positions if + hospital no longer meets certain requirements.--In + the case where the Secretary determines that a + hospital described in clause (ii) does not meet + either of the requirements under subclause (I) or + (II) of such clause, the Secretary shall-- + ``(I) reduce the otherwise + applicable resident limit of the + hospital by the amount by which such + limit was increased under this + paragraph; and + ``(II) provide for the distribution + of positions attributable to such + reduction in accordance with the + requirements of this paragraph. + ``(C) Considerations in redistribution.--In + determining for which hospitals the increase in the + otherwise applicable resident limit is provided under + subparagraph (B), the Secretary shall take into + account-- + ``(i) <<NOTE: Effective date.>> the + demonstration likelihood of the hospital filling + the positions made available under this paragraph + within the first 3 cost reporting periods + beginning on or after July 1, 2011, as determined + by the Secretary; and + ``(ii) whether the hospital has an accredited + rural training track (as described in paragraph + (4)(H)(iv)). + ``(D) Priority for certain areas.--In determining + for which hospitals the increase in the otherwise + applicable resident limit is provided under subparagraph + (B), subject to subparagraph (E), the Secretary shall + distribute the increase to hospitals based on the + following factors: + ``(i) Whether the hospital is located in a + State with a resident-to-population ratio in the + lowest quartile (as determined by the Secretary). + ``(ii) Whether the hospital is located in a + State, a territory of the United States, or the + District of Columbia that is among the top 10 + States, territories, or Districts in terms of the + ratio of-- + ``(I) the total population of the + State, territory, or District living in + an area designated (under such section + 332(a)(1)(A)) as a health professional + shortage area (as of the date of + enactment of this paragraph); to + ``(II) the total population of the + State, territory, or District (as + determined by the Secretary based on the + most recent available population data + published by the Bureau of the Census). + ``(iii) Whether the hospital is located in a + rural area (as defined in subsection + (d)(2)(D)(ii)). + ``(E) Reservation of positions for certain + hospitals.-- + ``(i) In general.--Subject to clause (ii), the + Secretary shall reserve the positions available + for distribution under this paragraph as follows: + +[[Page 124 STAT. 658]] + + ``(I) 70 percent of such positions + for distribution to hospitals described + in clause (i) of subparagraph (D). + ``(II) 30 percent of such positions + for distribution to hospitals described + in clause (ii) and (iii) of such + subparagraph. + ``(ii) Exception if positions not + redistributed by july 1, + 2011. <<NOTE: Deadline.>> --In the case where the + Secretary does not distribute positions to + hospitals in accordance with clause (i) by July 1, + 2011, the Secretary shall distribute such + positions to other hospitals in accordance with + the considerations described in subparagraph (C) + and the priority described in subparagraph (D). + ``(F) Limitation.--A hospital may not receive more + than 75 full-time equivalent additional residency + positions under this paragraph. + ``(G) Application of per resident amounts for + primary care and nonprimary care.--With respect to + additional residency positions in a hospital + attributable to the increase provided under this + paragraph, the approved FTE per resident amounts are + deemed to be equal to the hospital per resident amounts + for primary care and nonprimary care computed under + paragraph (2)(D) for that hospital. + ``(H) Definitions.--In this paragraph: + ``(i) Reference resident level.--The term + `reference resident level' means, with respect to + a hospital, the highest resident level for any of + the 3 most recent cost reporting periods (ending + before the date of the enactment of this + paragraph) of the hospital for which a cost report + has been settled (or, if not, submitted (subject + to audit)), as determined by the Secretary. + ``(ii) Resident level.--The term `resident + level' has the meaning given such term in + paragraph (7)(C)(i). + ``(iii) Otherwise applicable resident limit.-- + The term `otherwise applicable resident limit' + means, with respect to a hospital, the limit + otherwise applicable under subparagraphs (F)(i) + and (H) of paragraph (4) on the resident level for + the hospital determined without regard to this + paragraph but taking into account paragraph + (7)(A).''. + + (b) IME.-- + (1) In general.--Section 1886(d)(5)(B)(v) of the Social + Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the second + sentence, is amended-- + (A) by striking ``subsection (h)(7)'' and inserting + ``subsections (h)(7) and (h)(8)''; and + (B) by striking ``it applies'' and inserting ``they + apply''. + (2) Conforming amendment.--Section 1886(d)(5)(B) of the + Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by + adding at the end the following clause: + ``(x) <<NOTE: Effective date.>> For discharges occurring on + or after July 1, 2011, insofar as an additional payment amount + under this subparagraph is attributable to resident positions + distributed to a hospital under subsection (h)(8)(B), the + indirect teaching adjustment factor shall be computed in the + same manner as provided under clause (ii) with respect to such + resident positions.''. + +[[Page 124 STAT. 659]] + + (c) Conforming Amendment.--Section 422(b)(2) of the Medicare +Prescription Drug, Improvement, and Modernization Act of 2003 (Public +Law 108-173) <<NOTE: 42 USC 1395ww note.>> is amended by striking +``section 1886(h)(7)'' and all that follows and inserting ``paragraphs +(7) and (8) of subsection (h) of section 1886 of the Social Security +Act''. + +SEC. 5504. <<NOTE: Effective dates.>> COUNTING RESIDENT TIME IN + NONPROVIDER SETTINGS. + + (a) GME.--Section 1886(h)(4)(E) of the Social Security Act (42 +U.S.C. 1395ww(h)(4)(E)) is amended-- + (1) by striking ``shall be counted and that all the time'' + and inserting ``shall be counted and that-- + ``(i) effective for cost reporting periods + beginning before July 1, 2010, all the time;''; + (2) in clause (i), as inserted by paragraph (1), by striking + the period at the end and inserting ``; and''; + (3) by inserting after clause (i), as so inserted, the + following new clause: + ``(ii) effective for cost reporting periods + beginning on or after July 1, 2010, all the time + so spent by a resident shall be counted towards + the determination of full-time equivalency, + without regard to the setting in which the + activities are performed, if a hospital incurs the + costs of the stipends and fringe benefits of the + resident during the time the resident spends in + that setting. If more than one hospital incurs + these costs, either directly or through a third + party, such hospitals shall count a proportional + share of the time, as determined by written + agreement between the hospitals, that a resident + spends training in that setting.''; and + (4) <<NOTE: Records.>> by adding at the end the following + flush sentence: + ``Any hospital claiming under this subparagraph for time + spent in a nonprovider setting shall maintain and make + available to the Secretary records regarding the amount + of such time and such amount in comparison with amounts + of such time in such base year as the Secretary shall + specify.''. + + (b) IME.--Section 1886(d)(5)(B)(iv) of the Social Security Act (42 +U.S.C. 1395ww(d)(5)) is amended-- + (1) by striking ``(iv) Effective for discharges occurring on + or after October 1, 1997'' and inserting <<NOTE: Time + period.>> ``(iv)(I) Effective for discharges occurring on or + after October 1, 1997, and before July 1, 2010''; and + (2) by inserting after clause (I), as inserted by paragraph + (1), the following new subparagraph: + ``(II) Effective for discharges occurring on or after July + 1, 2010, all the time spent by an intern or resident in patient + care activities in a nonprovider setting shall be counted + towards the determination of full-time equivalency if a hospital + incurs the costs of the stipends and fringe benefits of the + intern or resident during the time the intern or resident spends + in that setting. If more than one hospital incurs these costs, + either directly or through a third party, such hospitals shall + count a proportional share of the time, as determined by written + agreement between the hospitals, that a resident spends training + in that setting.''. + +[[Page 124 STAT. 660]] + + (c) Application. <<NOTE: 42 USC 1395ww note.>> --The amendments made +by this section shall not be applied in a manner that requires reopening +of any settled hospital cost reports as to which there is not a +jurisdictionally proper appeal pending as of the date of the enactment +of this Act on the issue of payment for indirect costs of medical +education under section 1886(d)(5)(B) of the Social Security Act (42 +U.S.C. 1395ww(d)(5)(B)) or for direct graduate medical education costs +under section 1886(h) of such Act (42 U.S.C. 1395ww(h)). + +SEC. 5505. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC AND SCHOLARLY + ACTIVITIES AND OTHER ACTIVITIES. + + (a) GME.--Section 1886(h) of the Social Security Act (42 U.S.C. +1395ww(h)), as amended by section 5504, is amended-- + (1) in paragraph (4)-- + (A) in subparagraph (E), by striking ``Such rules'' + and inserting ``Subject to subparagraphs (J) and (K), + such rules''; and + (B) by adding at the end the following new + subparagraphs: + ``(J) Treatment of certain nonprovider and didactic + activities.--Such rules shall provide that all time + spent by an intern or resident in an approved medical + residency training program in a nonprovider setting that + is primarily engaged in furnishing patient care (as + defined in paragraph (5)(K)) in non-patient care + activities, such as didactic conferences and seminars, + but not including research not associated with the + treatment or diagnosis of a particular patient, as such + time and activities are defined by the Secretary, shall + be counted toward the determination of full-time + equivalency. + ``(K) <<NOTE: Definition.>> Treatment of certain + other activities.--In determining the hospital's number + of full-time equivalent residents for purposes of this + subsection, all the time that is spent by an intern or + resident in an approved medical residency training + program on vacation, sick leave, or other approved + leave, as such time is defined by the Secretary, and + that does not prolong the total time the resident is + participating in the approved program beyond the normal + duration of the program shall be counted toward the + determination of full-time equivalency.''; and + (2) in paragraph (5), by adding at the end the following new + subparagraph: + ``(K) Nonprovider setting that is primarily engaged + in furnishing patient care.--The term `nonprovider + setting that is primarily engaged in furnishing patient + care' means a nonprovider setting in which the primary + activity is the care and treatment of patients, as + defined by the Secretary.''. + + (b) IME Determinations.--Section 1886(d)(5)(B) of such Act (42 +U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end the following +new clause: + ``(x)(I) <<NOTE: Applicability.>> The + provisions of subparagraph (K) of subsection + (h)(4) shall apply under this subparagraph in the + same manner as they apply under such subsection. + ``(II) In determining the hospital's number of + full-time equivalent residents for purposes of + this subparagraph, all the time spent by an intern + or resident + +[[Page 124 STAT. 661]] + + in an approved medical residency training program + in non-patient care activities, such as didactic + conferences and seminars, as such time and + activities are defined by the Secretary, that + occurs in the hospital shall be counted toward the + determination of full-time equivalency if the + hospital-- + ``(aa) is recognized as a subsection + (d) hospital; + ``(bb) is recognized as a subsection + (d) Puerto Rico hospital; + ``(cc) is reimbursed under a + reimbursement system authorized under + section 1814(b)(3); or + ``(dd) is a provider-based hospital + outpatient department. + ``(III) In determining the hospital's number + of full-time equivalent residents for purposes of + this subparagraph, all the time spent by an intern + or resident in an approved medical residency + training program in research activities that are + not associated with the treatment or diagnosis of + a particular patient, as such time and activities + are defined by the Secretary, shall not be counted + toward the determination of full-time + equivalency.''. + + (c) <<NOTE: Applicability. 42 USC 1395ww note.>> Effective Dates.-- + (1) In general.--Except as otherwise provided, the Secretary + of Health and Human Services shall implement the amendments made + by this section in a manner so as to apply to cost reporting + periods beginning on or after January 1, 1983. + (2) GME.--Section 1886(h)(4)(J) of the Social Security Act, + as added by subsection (a)(1)(B), shall apply to cost reporting + periods beginning on or after July 1, 2009. + (3) IME.--Section 1886(d)(5)(B)(x)(III) of the Social + Security Act, as added by subsection (b), shall apply to cost + reporting periods beginning on or after October 1, 2001. Such + section, as so added, shall not give rise to any inference as to + how the law in effect prior to such date should be interpreted. + +SEC. 5506. PRESERVATION OF RESIDENT CAP POSITIONS FROM CLOSED HOSPITALS. + + (a) GME.--Section 1886(h)(4)(H) of the Social Security Act (42 +U.S.C. Section 1395ww(h)(4)(H)) is amended by adding at the end the +following new clause: + ``(vi) Redistribution of residency slots after + a hospital closes.-- + ``(I) <<NOTE: Regulations.>> In + general.--Subject to the succeeding + provisions of this clause, the Secretary + shall, by regulation, establish a + process under which, in the case where a + hospital (other than a hospital + described in clause (v)) with an + approved medical residency program + closes on or after a date that is 2 + years before the date of enactment of + this clause, the Secretary shall + increase the otherwise applicable + resident limit under this paragraph for + other hospitals in accordance with this + clause. + ``(II) Priority for hospitals in + certain areas.--Subject to the + succeeding provisions of this clause, in + determining for which hospitals the + +[[Page 124 STAT. 662]] + + increase in the otherwise applicable + resident limit is provided under such + process, the Secretary shall distribute + the increase to hospitals in the + following priority order (with + preference given within each category to + hospitals that are members of the same + affiliated group (as defined by the + Secretary under clause (ii)) as the + closed hospital): + ``(aa) First, to hospitals + located in the same core-based + statistical area as, or a core- + based statistical area + contiguous to, the hospital that + closed. + ``(bb) Second, to hospitals + located in the same State as the + hospital that closed. + ``(cc) Third, to hospitals + located in the same region of + the country as the hospital that + closed. + ``(dd) Fourth, only if the + Secretary is not able to + distribute the increase to + hospitals described in item + (cc), to qualifying hospitals in + accordance with the provisions + of paragraph (8). + ``(III) Requirement hospital likely + to fill position within certain time + period. <<NOTE: Determination.>> --The + Secretary may only increase the + otherwise applicable resident limit of a + hospital under such process if the + Secretary determines the hospital has + demonstrated a likelihood of filling the + positions made available under this + clause within 3 years. + ``(IV) Limitation.--The aggregate + number of increases in the otherwise + applicable resident limits for hospitals + under this clause shall be equal to the + number of resident positions in the + approved medical residency programs that + closed on or after the date described in + subclause (I). + ``(V) Administration.--Chapter 35 of + title 44, United States Code, shall not + apply to the implementation of this + clause.''. + + (b) IME.--Section 1886(d)(5)(B)(v) of the Social Security Act (42 +U.S.C. 1395ww(d)(5)(B)(v)), in the second sentence, as amended by +section 5503, is amended by striking ``subsections (h)(7) and (h)(8)'' +and inserting ``subsections (h)(4)(H)(vi), (h)(7), and (h)(8)''. + (c) <<NOTE: 42 USC 1395ww note.>> Application.--The amendments made +by this section shall not be applied in a manner that requires reopening +of any settled hospital cost reports as to which there is not a +jurisdictionally proper appeal pending as of the date of the enactment +of this Act on the issue of payment for indirect costs of medical +education under section 1886(d)(5)(B) of the Social Security Act (42 +U.S.C. 1395ww(d)(5)(B)) or for direct graduate medical education costs +under section 1886(h) of such Act (42 U.S.C. Section 1395ww(h)). + + (d) <<NOTE: 42 USC 1395ww note.>> Effect on Temporary FTE Cap +Adjustments.--The Secretary of Health and Human Services shall give +consideration to the effect of the amendments made by this section on +any temporary adjustment to a hospital's FTE cap under section 413.79(h) +of title 42, Code of Federal Regulations (as in effect on the date of +enactment of this Act) in order to ensure that there is no duplication +of FTE slots. Such amendments shall not affect the + +[[Page 124 STAT. 663]] + +application of section 1886(h)(4)(H)(v) of the Social Security Act (42 +U.S.C. 1395ww(h)(4)(H)(v)). + + (e) Conforming Amendment.--Section 1886(h)(7)(E) of the Social +Security Act (42 U.S.C. 1395ww(h)(7)(E)), as amended by section 5503(a), +is amended by striking ``paragraph or paragraph (8)'' and inserting +``this paragraph, paragraph (8), or paragraph (4)(H)(vi)''. + +SEC. 5507. DEMONSTRATION PROJECTS TO ADDRESS HEALTH PROFESSIONS + WORKFORCE NEEDS; EXTENSION OF FAMILY-TO-FAMILY HEALTH + INFORMATION CENTERS. + + (a) Authority To Conduct Demonstration Projects.--Title XX of the +Social Security Act (42 U.S.C. 1397 et seq.) is amended by adding at the +end the following: + +``SEC. 2008. <<NOTE: 42 USC 1397g.>> DEMONSTRATION PROJECTS TO ADDRESS + HEALTH PROFESSIONS WORKFORCE NEEDS. + + ``(a) Demonstration Projects To Provide Low-Income Individuals With +Opportunities for Education, Training, and Career Advancement To Address +Health Professions Workforce Needs.-- + ``(1) Authority to award grants.--The Secretary, in + consultation with the Secretary of Labor, shall award grants to + eligible entities to conduct demonstration projects that are + designed to provide eligible individuals with the opportunity to + obtain education and training for occupations in the health care + field that pay well and are expected to either experience labor + shortages or be in high demand. + ``(2) Requirements.-- + ``(A) Aid and supportive services.-- + ``(i) In general.--A demonstration project + conducted by an eligible entity awarded a grant + under this section shall, if appropriate, provide + eligible individuals participating in the project + with financial aid, child care, case management, + and other supportive services. + ``(ii) Treatment.--Any aid, services, or + incentives provided to an eligible beneficiary + participating in a demonstration project under + this section shall not be considered income, and + shall not be taken into account for purposes of + determining the individual's eligibility for, or + amount of, benefits under any means-tested + program. + ``(B) Consultation and coordination.--An eligible + entity applying for a grant to carry out a demonstration + project under this section shall demonstrate in the + application that the entity has consulted with the State + agency responsible for administering the State TANF + program, the local workforce investment board in the + area in which the project is to be conducted (unless the + applicant is such board), the State workforce investment + board established under section 111 of the Workforce + Investment Act of 1998, and the State Apprenticeship + Agency recognized under the Act of August 16, 1937 + (commonly known as the `National Apprenticeship Act') + (or if no agency has been recognized in the State, the + Office of Apprenticeship of the Department of Labor) and + that the project will be carried out in coordination + with such entities. + +[[Page 124 STAT. 664]] + + ``(C) Assurance of opportunities for indian + populations. <<NOTE: Grants.>> --The Secretary shall + award at least 3 grants under this subsection to an + eligible entity that is an Indian tribe, tribal + organization, or Tribal College or University. + ``(3) Reports and evaluation.-- + ``(A) Eligible entities.--An eligible entity awarded + a grant to conduct a demonstration project under this + subsection shall submit interim reports to the Secretary + on the activities carried out under the project and a + final report on such activities upon the conclusion of + the entities' participation in the project. Such reports + shall include assessments of the effectiveness of such + activities with respect to improving outcomes for the + eligible individuals participating in the project and + with respect to addressing health professions workforce + needs in the areas in which the project is conducted. + ``(B) <<NOTE: Grants. Contracts.>> Evaluation.--The + Secretary shall, by grant, contract, or interagency + agreement, evaluate the demonstration projects conducted + under this subsection. Such evaluation shall include + identification of successful activities for creating + opportunities for developing and sustaining, + particularly with respect to low-income individuals and + other entry-level workers, a health professions + workforce that has accessible entry points, that meets + high standards for education, training, certification, + and professional development, and that provides + increased wages and affordable benefits, including + health care coverage, that are responsive to the + workforce's needs. + ``(C) Report to congress.--The Secretary shall + submit interim reports and, based on the evaluation + conducted under subparagraph (B), a final report to + Congress on the demonstration projects conducted under + this subsection. + ``(4) Definitions.--In this subsection: + ``(A) Eligible entity.--The term `eligible entity' + means a State, an Indian tribe or tribal organization, + an institution of higher education, a local workforce + investment board established under section 117 of the + Workforce Investment Act of 1998, a sponsor of an + apprenticeship program registered under the National + Apprenticeship Act or a community-based organization. + ``(B) Eligible individual.-- + ``(i) In general.--The term `eligible + individual' means a individual receiving + assistance under the State TANF program. + ``(ii) Other low-income individuals.--Such + term may include other low-income individuals + described by the eligible entity in its + application for a grant under this section. + ``(C) Indian tribe; tribal organization.--The terms + `Indian tribe' and `tribal organization' have the + meaning given such terms in section 4 of the Indian + Self-Determination and Education Assistance Act (25 + U.S.C. 450b). + ``(D) Institution of higher education.--The term + `institution of higher education' has the meaning given + that term in section 101 of the Higher Education Act of + 1965 (20 U.S.C. 1001). + +[[Page 124 STAT. 665]] + + ``(E) State.--The term `State' means each of the 50 + States, the District of Columbia, the Commonwealth of + Puerto Rico, the United States Virgin Islands, Guam, and + American Samoa. + ``(F) State tanf program.--The term `State TANF + program' means the temporary assistance for needy + families program funded under part A of title IV. + ``(G) Tribal college or university.--The term + `Tribal College or University' has the meaning given + that term in section 316(b) of the Higher Education Act + of 1965 (20 U.S.C. 1059c(b)). + + ``(b) Demonstration Project To Develop Training and Certification +Programs for Personal or Home Care Aides.-- + ``(1) Authority to award grants. <<NOTE: Deadline.>> --Not + later than 18 months after the date of enactment of this + section, the Secretary shall award grants to eligible entities + that are States to conduct demonstration projects for purposes + of developing core training competencies and certification + programs for personal or home care aides. The Secretary shall-- + ``(A) <<NOTE: Evaluation.>> evaluate the efficacy of + the core training competencies described in paragraph + (3)(A) for newly hired personal or home care aides and + the methods used by States to implement such core + training competencies in accordance with the issues + specified in paragraph (3)(B); and + ``(B) ensure that the number of hours of training + provided by States under the demonstration project with + respect to such core training competencies are not less + than the number of hours of training required under any + applicable State or Federal law or regulation. + ``(2) Duration.--A demonstration project shall be conducted + under this subsection for not less than 3 years. + ``(3) Core training competencies for personal or home care + aides.-- + ``(A) In general.--The core training competencies + for personal or home care aides described in this + subparagraph include competencies with respect to the + following areas: + ``(i) The role of the personal or home care + aide (including differences between a personal or + home care aide employed by an agency and a + personal or home care aide employed directly by + the health care consumer or an independent + provider). + ``(ii) Consumer rights, ethics, and + confidentiality (including the role of proxy + decision-makers in the case where a health care + consumer has impaired decision-making capacity). + ``(iii) Communication, cultural and linguistic + competence and sensitivity, problem solving, + behavior management, and relationship skills. + ``(iv) Personal care skills. + ``(v) Health care support. + ``(vi) Nutritional support. + ``(vii) Infection control. + ``(viii) Safety and emergency training. + ``(ix) Training specific to an individual + consumer's needs (including older individuals, + younger individuals with disabilities, individuals + with developmental + +[[Page 124 STAT. 666]] + + disabilities, individuals with dementia, and + individuals with mental and behavioral health + needs). + ``(x) Self-Care. + ``(B) Implementation.--The implementation issues + specified in this subparagraph include the following: + ``(i) The length of the training. + ``(ii) The appropriate trainer to student + ratio. + ``(iii) The amount of instruction time spent + in the classroom as compared to on-site in the + home or a facility. + ``(iv) Trainer qualifications. + ``(v) Content for a `hands-on' and written + certification exam. + ``(vi) Continuing education requirements. + ``(4) Application and selection criteria.-- + ``(A) In general.-- + ``(i) Number of + states. <<NOTE: Contracts.>> --The Secretary shall + enter into agreements with not more than 6 States + to conduct demonstration projects under this + subsection. + ``(ii) Requirements for states.--An agreement + entered into under clause (i) shall require that a + participating State-- + ``(I) implement the core training + competencies described in paragraph + (3)(A); and + ``(II) develop written materials and + protocols for such core training + competencies, including the development + of a certification test for personal or + home care aides who have completed such + training competencies. + ``(iii) Consultation and collaboration with + community and vocational colleges.--The Secretary + shall encourage participating States to consult + with community and vocational colleges regarding + the development of curricula to implement the + project with respect to activities, as applicable, + which may include consideration of such colleges + as partners in such implementation. + ``(B) Application and eligibility.--A State seeking + to participate in the project shall-- + ``(i) submit an application to the Secretary + containing such information and at such time as + the Secretary may specify; + ``(ii) meet the selection criteria established + under subparagraph (C); and + ``(iii) meet such additional criteria as the + Secretary may specify. + ``(C) Selection criteria.--In selecting States to + participate in the program, the Secretary shall + establish criteria to ensure (if applicable with respect + to the activities involved)-- + ``(i) geographic and demographic diversity; + ``(ii) that participating States offer medical + assistance for personal care services under the + State Medicaid plan; + ``(iii) that the existing training standards + for personal or home care aides in each + participating State-- + +[[Page 124 STAT. 667]] + + ``(I) are different from such + standards in the other participating + States; and + ``(II) are different from the core + training competencies described in + paragraph (3)(A); + ``(iv) that participating States do not reduce + the number of hours of training required under + applicable State law or regulation after being + selected to participate in the project; and + ``(v) that participating States recruit a + minimum number of eligible health and long-term + care providers to participate in the project. + ``(D) Technical assistance.--The Secretary shall + provide technical assistance to States in developing + written materials and protocols for such core training + competencies. + ``(5) Evaluation and report.-- + ``(A) <<NOTE: Contracts.>> Evaluation.--The + Secretary shall develop an experimental or control group + testing protocol in consultation with an independent + evaluation contractor selected by the Secretary. Such + contractor shall evaluate-- + ``(i) the impact of core training competencies + described in paragraph (3)(A), including curricula + developed to implement such core training + competencies, for personal or home care aides + within each participating State on job + satisfaction, mastery of job skills, beneficiary + and family caregiver satisfaction with services, + and additional measures determined by the + Secretary in consultation with the expert panel; + ``(ii) the impact of providing such core + training competencies on the existing training + infrastructure and resources of States; and + ``(iii) whether a minimum number of hours of + initial training should be required for personal + or home care aides and, if so, what minimum number + of hours should be required. + ``(B) Reports.-- + ``(i) Report on initial implementation.--Not + later than 2 years after the date of enactment of + this section, the Secretary shall submit to + Congress a report on the initial implementation of + activities conducted under the demonstration + project, including any available results of the + evaluation conducted under subparagraph (A) with + respect to such activities, together with such + recommendations for legislation or administrative + action as the Secretary determines appropriate. + ``(ii) Final report.--Not later than 1 year + after the completion of the demonstration project, + the Secretary shall submit to Congress a report + containing the results of the evaluation conducted + under subparagraph (A), together with such + recommendations for legislation or administrative + action as the Secretary determines appropriate. + ``(6) Definitions.--In this subsection: + ``(A) Eligible health and long-term care provider.-- + The term `eligible health and long-term care provider' + means a personal or home care agency (including personal + or home care public authorities), a nursing home, a home + health agency (as defined in section 1861(o)), or + +[[Page 124 STAT. 668]] + + any other health care provider the Secretary determines + appropriate which-- + ``(i) is licensed or authorized to provide + services in a participating State; and + ``(ii) receives payment for services under + title XIX. + ``(B) Personal care services.--The term `personal + care services' has the meaning given such term for + purposes of title XIX. + ``(C) Personal or home care aide.--The term + `personal or home care aide' means an individual who + helps individuals who are elderly, disabled, ill, or + mentally disabled (including an individual with + Alzheimer's disease or other dementia) to live in their + own home or a residential care facility (such as a + nursing home, assisted living facility, or any other + facility the Secretary determines appropriate) by + providing routine personal care services and other + appropriate services to the individual. + ``(D) State.--The term `State' has the meaning given + that term for purposes of title XIX. + + ``(c) Funding.-- + ``(1) In general.--Subject to paragraph (2), out of any + funds in the Treasury not otherwise appropriated, there are + appropriated to the Secretary to carry out subsections (a) and + (b), $85,000,000 for each of fiscal years 2010 through 2014. + ``(2) Training and certification programs for personal and + home care aides.--With respect to the demonstration projects + under subsection (b), the Secretary shall use $5,000,000 of the + amount appropriated under paragraph (1) for each of fiscal years + 2010 through 2012 to carry out such projects. No funds + appropriated under paragraph (1) shall be used to carry out + demonstration projects under subsection (b) after fiscal year + 2012. + + ``(d) Nonapplication.-- + ``(1) In general.--Except as provided in paragraph (2), the + preceding sections of this title shall not apply to grant + awarded under this section. + ``(2) Limitations on use of + grants. <<NOTE: Applicability.>> --Section 2005(a) (other than + paragraph (6)) shall apply to a grant awarded under this section + to the same extent and in the same manner as such section + applies to payments to States under this title.''. + + (b) Extension of Family-To-Family Health Information Centers.-- +Section 501(c)(1)(A)(iii) of the Social Security Act (42 U.S.C. +701(c)(1)(A)(iii)) is amended by striking ``fiscal year 2009'' and +inserting ``each of fiscal years 2009 through 2012''. + +SEC. 5508. INCREASING TEACHING CAPACITY. + + (a) Teaching Health Centers Training and Enhancement.--Part C of +title VII of the Public Health Service Act (42 U.S.C. 293k et. seq.), as +amended by section 5303, is further amended by inserting after section +749 the following: + +``SEC. 749A. <<NOTE: 42 USC 239l-1.>> TEACHING HEALTH CENTERS + DEVELOPMENT GRANTS. + + ``(a) Program Authorized.--The Secretary may award grants under this +section to teaching health centers for the purpose of establishing new +accredited or expanded primary care residency programs. + +[[Page 124 STAT. 669]] + + ``(b) Amount and Duration.--Grants awarded under this section shall +be for a term of not more than 3 years and the maximum award may not be +more than $500,000. + ``(c) Use of Funds.--Amounts provided under a grant under this +section shall be used to cover the costs of-- + ``(1) establishing or expanding a primary care residency + training program described in subsection (a), including costs + associated with-- + ``(A) curriculum development; + ``(B) recruitment, training and retention of + residents and faculty: + ``(C) accreditation by the Accreditation Council for + Graduate Medical Education (ACGME), the American Dental + Association (ADA), or the American Osteopathic + Association (AOA); and + ``(D) faculty salaries during the development phase; + and + ``(2) technical assistance provided by an eligible entity. + + ``(d) Application.--A teaching health center seeking a grant under +this section shall submit an application to the Secretary at such time, +in such manner, and containing such information as the Secretary may +require. + ``(e) Preference for Certain Applications.--In selecting recipients +for grants under this section, the Secretary shall give preference to +any such application that documents an existing affiliation agreement +with an area health education center program as defined in sections 751 +and 799B. + ``(f) Definitions.--In this section: + ``(1) Eligible entity.--The term `eligible entity' means an + organization capable of providing technical assistance including + an area health education center program as defined in sections + 751 and 799B. + ``(2) Primary care residency program.--The term `primary + care residency program' means an approved graduate medical + residency training program (as defined in section 340H) in + family medicine, internal medicine, pediatrics, internal + medicine-pediatrics, obstetrics and gynecology, psychiatry, + general dentistry, pediatric dentistry, and geriatrics. + ``(3) Teaching health center.-- + ``(A) In general.--The term `teaching health center' + means an entity that-- + ``(i) is a community based, ambulatory patient + care center; and + ``(ii) operates a primary care residency + program. + ``(B) Inclusion of certain entities.--Such term + includes the following: + ``(i) A Federally qualified health center (as + defined in section 1905(l)(2)(B), of the Social + Security Act). + ``(ii) A community mental health center (as + defined in section 1861(ff)(3)(B) of the Social + Security Act). + ``(iii) A rural health clinic, as defined in + section 1861(aa) of the Social Security Act. + ``(iv) A health center operated by the Indian + Health Service, an Indian tribe or tribal + organization, or an urban Indian organization (as + defined in section 4 of the Indian Health Care + Improvement Act). + +[[Page 124 STAT. 670]] + + ``(v) An entity receiving funds under title X + of the Public Health Service Act. + + ``(g) Authorization of Appropriations.--There is authorized to be +appropriated, $25,000,000 for fiscal year 2010, $50,000,000 for fiscal +year 2011, $50,000,000 for fiscal year 2012, and such sums as may be +necessary for each fiscal year thereafter to carry out this section. Not +to exceed $5,000,000 annually may be used for technical assistance +program grants.''. + (b) National Health Service Corps Teaching Capacity.--Section +338C(a) of the Public Health Service Act (42 U.S.C. 254m(a)) is amended +to read as follows: + ``(a) <<NOTE: Contracts.>> Service in Full-time Clinical Practice.-- +Except as provided in section 338D, each individual who has entered into +a written contract with the Secretary under section 338A or 338B shall +provide service in the full-time clinical practice of such individual's +profession as a member of the Corps for the period of obligated service +provided in such contract. For the purpose of calculating time spent in +full-time clinical practice under this subsection, up to 50 percent of +time spent teaching by a member of the Corps may be counted toward his +or her service obligation.''. + + (c) Payments to Qualified Teaching Health Centers.--Part D of title +III of the Public Health Service Act (42 U.S.C. 254b et seq.) is amended +by adding at the end the following: + + ``Subpart XI--Support of Graduate Medical Education in Qualified + Teaching Health Centers + +``SEC. 340H. <<NOTE: 42 USC 256h.>> PROGRAM OF PAYMENTS TO TEACHING + HEALTH CENTERS THAT OPERATE GRADUATE MEDICAL EDUCATION + PROGRAMS. + + ``(a) Payments.--Subject to subsection (h)(2), the Secretary shall +make payments under this section for direct expenses and for indirect +expenses to qualified teaching health centers that are listed as +sponsoring institutions by the relevant accrediting body for expansion +of existing or establishment of new approved graduate medical residency +training programs. + ``(b) Amount of Payments.-- + ``(1) In general.--Subject to paragraph (2), the amounts + payable under this section to qualified teaching health centers + for an approved graduate medical residency training program for + a fiscal year are each of the following amounts: + ``(A) Direct expense amount.--The amount determined + under subsection (c) for direct expenses associated with + sponsoring approved graduate medical residency training + programs. + ``(B) Indirect expense amount.--The amount + determined under subsection (d) for indirect expenses + associated with the additional costs relating to + teaching residents in such programs. + ``(2) Capped amount.-- + ``(A) In general.--The total of the payments made to + qualified teaching health centers under paragraph (1)(A) + or paragraph (1)(B) in a fiscal year shall not exceed + the amount of funds appropriated under subsection (g) + for such payments for that fiscal year. + ``(B) Limitation.--The Secretary shall limit the + funding of full-time equivalent residents in order to + ensure + +[[Page 124 STAT. 671]] + + the direct and indirect payments as determined under + subsection (c) and (d) do not exceed the total amount of + funds appropriated in a fiscal year under subsection + (g). + + ``(c) Amount of Payment for Direct Graduate Medical Education.-- + ``(1) In general.--The amount determined under this + subsection for payments to qualified teaching health centers for + direct graduate expenses relating to approved graduate medical + residency training programs for a fiscal year is equal to the + product of-- + ``(A) the updated national per resident amount for + direct graduate medical education, as determined under + paragraph (2); and + ``(B) the average number of full-time equivalent + residents in the teaching health center's graduate + approved medical residency training programs as + determined under section 1886(h)(4) of the Social + Security Act (without regard to the limitation under + subparagraph (F) of such section) during the fiscal + year. + ``(2) Updated national per resident amount for direct + graduate medical education.--The updated per resident amount for + direct graduate medical education for a qualified teaching + health center for a fiscal year is an amount determined as + follows: + ``(A) Determination of qualified teaching health + center per resident amount.--The Secretary shall compute + for each individual qualified teaching health center a + per resident amount-- + ``(i) by dividing the national average per + resident amount computed under section + 340E(c)(2)(D) into a wage-related portion and a + non-wage related portion by applying the + proportion determined under subparagraph (B); + ``(ii) by multiplying the wage-related portion + by the factor applied under section 1886(d)(3)(E) + of the Social Security Act (but without + application of section 4410 of the Balanced Budget + Act of 1997 (42 U.S.C. 1395ww note)) during the + preceding fiscal year for the teaching health + center's area; and + ``(iii) by adding the non-wage-related portion + to the amount computed under clause (ii). + ``(B) Updating rate.--The Secretary shall update + such per resident amount for each such qualified + teaching health center as determined appropriate by the + Secretary. + + ``(d) Amount of Payment for Indirect Medical Education.-- + ``(1) <<NOTE: Determination.>> In general.--The amount + determined under this subsection for payments to qualified + teaching health centers for indirect expenses associated with + the additional costs of teaching residents for a fiscal year is + equal to an amount determined appropriate by the Secretary. + ``(2) Factors.--In determining the amount under paragraph + (1), the Secretary shall-- + ``(A) evaluate indirect training costs relative to + supporting a primary care residency program in qualified + teaching health centers; and + ``(B) based on this evaluation, assure that the + aggregate of the payments for indirect expenses under + this section + +[[Page 124 STAT. 672]] + + and the payments for direct graduate medical education + as determined under subsection (c) in a fiscal year do + not exceed the amount appropriated for such expenses as + determined in subsection (g). + ``(3) Interim payment.--Before the Secretary makes a payment + under this subsection pursuant to a determination of indirect + expenses under paragraph (1), the Secretary may provide to + qualified teaching health centers a payment, in addition to any + payment made under subsection (c), for expected indirect + expenses associated with the additional costs of teaching + residents for a fiscal year, based on an estimate by the + Secretary. + + ``(e) Clarification Regarding Relationship to Other Payments for +Graduate Medical Education.--Payments under this section-- + ``(1) shall be in addition to any payments-- + ``(A) for the indirect costs of medical education + under section 1886(d)(5)(B) of the Social Security Act; + ``(B) for direct graduate medical education costs + under section 1886(h) of such Act; and + ``(C) for direct costs of medical education under + section 1886(k) of such Act; + ``(2) shall not be taken into account in applying the + limitation on the number of total full-time equivalent residents + under subparagraphs (F) and (G) of section 1886(h)(4) of such + Act and clauses (v), (vi)(I), and (vi)(II) of section + 1886(d)(5)(B) of such Act for the portion of time that a + resident rotates to a hospital; and + ``(3) shall not include the time in which a resident is + counted toward full-time equivalency by a hospital under + paragraph (2) or under section 1886(d)(5)(B)(iv) of the Social + Security Act, section 1886(h)(4)(E) of such Act, or section 340E + of this Act. + + ``(f) <<NOTE: Determination.>> Reconciliation.--The Secretary shall +determine any changes to the number of residents reported by a hospital +in the application of the hospital for the current fiscal year to +determine the final amount payable to the hospital for the current +fiscal year for both direct expense and indirect expense amounts. Based +on such determination, the Secretary shall recoup any overpayments made +to pay any balance due to the extent possible. The final amount so +determined shall be considered a final intermediary determination for +the purposes of section 1878 of the Social Security Act and shall be +subject to administrative and judicial review under that section in the +same manner as the amount of payment under section 1186(d) of such Act +is subject to review under such section. + + ``(g) Funding.--To carry out this section, there are appropriated +such sums as may be necessary, not to exceed $230,000,000, for the +period of fiscal years 2011 through 2015. + ``(h) Annual Reporting Required.-- + ``(1) Annual report.--The report required under this + paragraph for a qualified teaching health center for a fiscal + year is a report that includes (in a form and manner specified + by the Secretary) the following information for the residency + academic year completed immediately prior to such fiscal year: + ``(A) The types of primary care resident approved + training programs that the qualified teaching health + center provided for residents. + +[[Page 124 STAT. 673]] + + ``(B) The number of approved training positions for + residents described in paragraph (4). + ``(C) The number of residents described in paragraph + (4) who completed their residency training at the end of + such residency academic year and care for vulnerable + populations living in underserved areas. + ``(D) Other information as deemed appropriate by the + Secretary. + ``(2) Audit authority; limitation on payment.-- + ``(A) Audit authority.--The Secretary may audit a + qualified teaching health center to ensure the accuracy + and completeness of the information submitted in a + report under paragraph (1). + ``(B) Limitation on payment.--A teaching health + center may only receive payment in a cost reporting + period for a number of such resident positions that is + greater than the base level of primary care resident + positions, as determined by the Secretary. For purposes + of this subparagraph, the `base level of primary care + residents' for a teaching health center is the level of + such residents as of a base period. + ``(3) Reduction in payment for failure to report.-- + ``(A) <<NOTE: Determination.>> In general.--The + amount payable under this section to a qualified + teaching health center for a fiscal year shall be + reduced by at least 25 percent if the Secretary + determines that-- + ``(i) the qualified teaching health center has + failed to provide the Secretary, as an addendum to + the qualified teaching health center's application + under this section for such fiscal year, the + report required under paragraph (1) for the + previous fiscal year; or + ``(ii) such report fails to provide complete + and accurate information required under any + subparagraph of such paragraph. + ``(B) Notice and opportunity to provide accurate and + missing information. <<NOTE: Deadline.>> --Before + imposing a reduction under subparagraph (A) on the basis + of a qualified teaching health center's failure to + provide complete and accurate information described in + subparagraph (A)(ii), the Secretary shall provide notice + to the teaching health center of such failure and the + Secretary's intention to impose such reduction and shall + provide the teaching health center with the opportunity + to provide the required information within the period of + 30 days beginning on the date of such notice. If the + teaching health center provides such information within + such period, no reduction shall be made under + subparagraph (A) on the basis of the previous failure to + provide such information. + ``(4) Residents.--The residents described in this paragraph + are those who are in part-time or full-time equivalent resident + training positions at a qualified teaching health center in any + approved graduate medical residency training program. + + ``(i) Regulations.--The Secretary shall promulgate regulations to +carry out this section. + ``(j) Definitions.--In this section: + ``(1) Approved graduate medical residency training + program.--The term `approved graduate medical residency + +[[Page 124 STAT. 674]] + + training program' means a residency or other postgraduate + medical training program-- + ``(A) participation in which may be counted toward + certification in a specialty or subspecialty and + includes formal postgraduate training programs in + geriatric medicine approved by the Secretary; and + ``(B) that meets criteria for accreditation (as + established by the Accreditation Council for Graduate + Medical Education, the American Osteopathic Association, + or the American Dental Association). + ``(2) Primary care residency program.--The term `primary + care residency program' has the meaning given that term in + section 749A. + ``(3) Qualified teaching health center.--The term `qualified + teaching health center' has the meaning given the term `teaching + health center' in section 749A.''. + +SEC. 5509. <<NOTE: 42 USC 1395ww note.>> GRADUATE NURSE EDUCATION + DEMONSTRATION. + + (a) In General.-- + (1) Establishment.-- + (A) In general.--The Secretary shall establish a + graduate nurse education demonstration under title XVIII + of the Social Security Act (42 U.S.C. 1395 et seq.) + under which an eligible hospital may receive payment for + the hospital's reasonable costs (described in paragraph + (2)) for the provision of qualified clinical training to + advance practice nurses. + (B) Number.--The demonstration shall include up to 5 + eligible hospitals. + (C) Written agreements.--Eligible hospitals selected + to participate in the demonstration shall enter into + written agreements pursuant to subsection (b) in order + to reimburse the eligible partners of the hospital the + share of the costs attributable to each partner. + (2) Costs described.-- + (A) In general.--Subject to subparagraph (B) and + subsection (d), the costs described in this paragraph + are the reasonable costs (as described in section + 1861(v) of the Social Security Act (42 U.S.C. 1395x(v))) + of each eligible hospital for the clinical training + costs (as determined by the Secretary) that are + attributable to providing advanced practice registered + nurses with qualified training. + (B) <<NOTE: Time period.>> Limitation.--With respect + to a year, the amount reimbursed under subparagraph (A) + may not exceed the amount of costs described in + subparagraph (A) that are attributable to an increase in + the number of advanced practice registered nurses + enrolled in a program that provides qualified training + during the year and for which the hospital is being + reimbursed under the demonstration, as compared to the + average number of advanced practice registered nurses + who graduated in each year during the period beginning + on January 1, 2006, and ending on December 31, 2010 (as + determined by the Secretary) from the graduate nursing + education program operated by the applicable school of + nursing that is an eligible partner of the hospital for + purposes of the demonstration. + +[[Page 124 STAT. 675]] + + (3) Waiver authority.--The Secretary may waive such + requirements of titles XI and XVIII of the Social Security Act + as may be necessary to carry out the demonstration. + (4) Administration.--Chapter 35 of title 44, United States + Code, shall not apply to the implementation of this section. + + (b) Written Agreements With Eligible Partners.--No payment shall be +made under this section to an eligible hospital unless such hospital has +in effect a written agreement with the eligible partners of the +hospital. Such written agreement shall describe, at a minimum-- + (1) the obligations of the eligible partners with respect to + the provision of qualified training; and + (2) the obligation of the eligible hospital to reimburse + such eligible partners applicable (in a timely manner) for the + costs of such qualified training attributable to partner. + + (c) <<NOTE: Deadline. Reports.>> Evaluation.--Not later than October +17, 2017, the Secretary shall submit to Congress a report on the +demonstration. Such report shall include an analysis of the following: + (1) The growth in the number of advanced practice registered + nurses with respect to a specific base year as a result of the + demonstration. + (2) The growth for each of the specialties described in + subparagraphs (A) through (D) of subsection (e)(1). + (3) The costs to the Medicare program under title XVIII of + the Social Security Act as a result of the demonstration. + (4) Other items the Secretary determines appropriate and + relevant. + + (d) Funding.-- + (1) In general.--There is hereby appropriated to the + Secretary, out of any funds in the Treasury not otherwise + appropriated, $50,000,000 for each of fiscal years 2012 through + 2015 to carry out this section, including the design, + implementation, monitoring, and evaluation of the demonstration. + (2) Proration.--If the aggregate payments to eligible + hospitals under the demonstration exceed $50,000,000 for a + fiscal year described in paragraph (1), the Secretary shall + prorate the payment amounts to each eligible hospital in order + to ensure that the aggregate payments do not exceed such amount. + (3) Without fiscal year limitation.--Amounts appropriated + under this subsection shall remain available without fiscal year + limitation. + + (e) Definitions.--In this section: + (1) Advanced practice registered nurse.--The term ``advanced + practice registered nurse'' includes the following: + (A) A clinical nurse specialist (as defined in + subsection (aa)(5) of section 1861 of the Social + Security Act (42 U.S.C. 1395x)). + (B) A nurse practitioner (as defined in such + subsection). + (C) A certified registered nurse anesthetist (as + defined in subsection (bb)(2) of such section). + (D) A certified nurse-midwife (as defined in + subsection (gg)(2) of such section). + (2) Applicable non-hospital community-based care setting.-- + The term ``applicable non-hospital community-based care + setting'' means a non-hospital community-based care setting + which has entered into a written agreement (as described in + subsection (b)) with the eligible hospital participating in the + +[[Page 124 STAT. 676]] + + demonstration. Such settings include Federally qualified health + centers, rural health clinics, and other non-hospital settings + as determined appropriate by the Secretary. + (3) Applicable school of nursing.--The term ``applicable + school of nursing'' means an accredited school of nursing (as + defined in section 801 of the Public Health Service Act) which + has entered into a written agreement (as described in subsection + (b)) with the eligible hospital participating in the + demonstration. + (4) Demonstration.--The term ``demonstration'' means the + graduate nurse education demonstration established under + subsection (a). + (5) Eligible hospital.--The term ``eligible hospital'' means + a hospital (as defined in subsection (e) of section 1861 of the + Social Security Act (42 U.S.C. 1395x)) or a critical access + hospital (as defined in subsection (mm)(1) of such section) that + has a written agreement in place with-- + (A) 1 or more applicable schools of nursing; and + (B) 2 or more applicable non-hospital community- + based care settings. + (6) Eligible partners.--The term ``eligible partners'' + includes the following: + (A) An applicable non-hospital community-based care + setting. + (B) An applicable school of nursing. + (7) Qualified training.-- + (A) In general.--The term ``qualified training'' + means training-- + (i) that provides an advanced practice + registered nurse with the clinical skills + necessary to provide primary care, preventive + care, transitional care, chronic care management, + and other services appropriate for individuals + entitled to, or enrolled for, benefits under part + A of title XVIII of the Social Security Act, or + enrolled under part B of such title; and + (ii) subject to subparagraph (B), at least + half of which is provided in a non-hospital + community-based care setting. + (B) Waiver of requirement half of training be + provided in non-hospital community-based care setting in + certain areas.--The Secretary may waive the requirement + under subparagraph (A)(ii) with respect to eligible + hospitals located in rural or medically underserved + areas. + (8) Secretary.--The term ``Secretary'' means the Secretary + of Health and Human Services. + + Subtitle G--Improving Access to Health Care Services + +SEC. 5601. SPENDING FOR FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS). + + (a) In General.--Section 330(r) of the Public Health Service Act (42 +U.S.C. 254b(r)) is amended by striking paragraph (1) and inserting the +following: + +[[Page 124 STAT. 677]] + + ``(1) General amounts for grants.--For the purpose of + carrying out this section, in addition to the amounts authorized + to be appropriated under subsection (d), there is authorized to + be appropriated the following: + ``(A) For fiscal year 2010, $2,988,821,592. + ``(B) For fiscal year 2011, $3,862,107,440. + ``(C) For fiscal year 2012, $4,990,553,440. + ``(D) For fiscal year 2013, $6,448,713,307. + ``(E) For fiscal year 2014, $7,332,924,155. + ``(F) For fiscal year 2015, $8,332,924,155. + ``(G) For fiscal year 2016, and each subsequent + fiscal year, the amount appropriated for the preceding + fiscal year adjusted by the product of-- + ``(i) one plus the average percentage increase + in costs incurred per patient served; and + ``(ii) one plus the average percentage + increase in the total number of patients + served.''. + + (b) Rule of Construction.--Section 330(r) of the Public Health +Service Act (42 U.S.C. 254b(r)) is amended by adding at the end the +following: + ``(4) Rule of construction with respect to rural health + clinics.-- + ``(A) In general.--Nothing in this section shall be + construed to prevent a community health center from + contracting with a Federally certified rural health + clinic (as defined in section 1861(aa)(2) of the Social + Security Act), a low-volume hospital (as defined for + purposes of section 1886 of such Act), a critical access + hospital, a sole community hospital (as defined for + purposes of section 1886(d)(5)(D)(iii) of such Act), or + a medicare-dependent share hospital (as defined for + purposes of section 1886(d)(5)(G)(iv) of such Act) for + the delivery of primary health care services that are + available at the clinic or hospital to individuals who + would otherwise be eligible for free or reduced cost + care if that individual were able to obtain that care at + the community health center. Such services may be + limited in scope to those primary health care services + available in that clinic or hospitals. + ``(B) Assurances.--In order for a clinic or hospital + to receive funds under this section through a contract + with a community health center under subparagraph (A), + such clinic or hospital shall establish policies to + ensure-- + ``(i) nondiscrimination based on the ability + of a patient to pay; and + ``(ii) the establishment of a sliding fee + scale for low-income patients.''. + +SEC. 5602. <<NOTE: Deadlines. 42 USC 254b note.>> NEGOTIATED RULEMAKING + FOR DEVELOPMENT OF METHODOLOGY AND CRITERIA FOR DESIGNATING + MEDICALLY UNDERSERVED POPULATIONS AND HEALTH PROFESSIONS + SHORTAGE AREAS. + + (a) Establishment.-- + (1) In general.--The Secretary of Health and Human Services + (in this section referred to as the ``Secretary'') shall + establish, through a negotiated rulemaking process under + subchapter 3 of chapter 5 of title 5, United States Code, a + comprehensive methodology and criteria for designation of-- + +[[Page 124 STAT. 678]] + + (A) medically underserved populations in accordance + with section 330(b)(3) of the Public Health Service Act + (42 U.S.C. 254b(b)(3)); + (B) health professions shortage areas under section + 332 of the Public Health Service Act (42 U.S.C. 254e). + (2) Factors to consider.--In establishing the methodology + and criteria under paragraph (1), the Secretary-- + (A) shall consult with relevant stakeholders who + will be significantly affected by a rule (such as + national, State and regional organizations representing + affected entities), State health offices, community + organizations, health centers and other affected + entities, and other interested parties; and + (B) shall take into account-- + (i) the timely availability and + appropriateness of data used to determine a + designation to potential applicants for such + designations; + (ii) the impact of the methodology and + criteria on communities of various types and on + health centers and other safety net providers; + (iii) the degree of ease or difficulty that + will face potential applicants for such + designations in securing the necessary data; and + (iv) the extent to which the methodology + accurately measures various barriers that confront + individuals and population groups in seeking + health care services. + + (b) <<NOTE: Deadline.>> Publication of Notice.--In carrying out the +rulemaking process under this subsection, the Secretary shall publish +the notice provided for under section 564(a) of title 5, United States +Code, by not later than 45 days after the date of the enactment of this +Act. + + (c) Target Date for Publication of Rule.--As part of the notice +under subsection (b), and for purposes of this subsection, the ``target +date for publication'', as referred to in section 564(a)(5) of title 5, +United Sates Code, shall be July 1, 2010. + (d) <<NOTE: Deadlines.>> Appointment of Negotiated Rulemaking +Committee and Facilitator.--The Secretary shall provide for-- + (1) the appointment of a negotiated rulemaking committee + under section 565(a) of title 5, United States Code, by not + later than 30 days after the end of the comment period provided + for under section 564(c) of such title; and + (2) the nomination of a facilitator under section 566(c) of + such title 5 by not later than 10 days after the date of + appointment of the committee. + + (e) Preliminary Committee Report.--The negotiated rulemaking +committee appointed under subsection (d) shall report to the Secretary, +by not later than April 1, 2010, regarding the committee's progress on +achieving a consensus with regard to the rulemaking proceeding and +whether such consensus is likely to occur before one month before the +target date for publication of the rule. If the committee reports that +the committee has failed to make significant progress toward such +consensus or is unlikely to reach such consensus by the target date, the +Secretary may terminate such process and provide for the publication of +a rule under this section through such other methods as the Secretary +may provide. + +[[Page 124 STAT. 679]] + + (f) Final Committee Report.--If the committee is not terminated +under subsection (e), the rulemaking committee shall submit a report +containing a proposed rule by not later than one month before the target +publication date. + (g) <<NOTE: Regulations. Federal Register, publication.>> Interim +Final Effect.--The Secretary shall publish a rule under this section in +the Federal Register by not later than the target publication +date. <<NOTE: Effective date. Public information.>> Such rule shall be +effective and final immediately on an interim basis, but is subject to +change and revision after public notice and opportunity for a period (of +not less than 90 days) for public comment. In connection with such rule, +the Secretary shall specify the process for the timely review and +approval of applications for such designations pursuant to such rules +and consistent with this section. + + (h) Publication of Rule After Public Comment.--The Secretary shall +provide for consideration of such comments and republication of such +rule by not later than 1 year after the target publication date. + +SEC. 5603. REAUTHORIZATION OF THE WAKEFIELD EMERGENCY MEDICAL SERVICES + FOR CHILDREN PROGRAM. + + Section 1910 of the Public Health Service Act (42 U.S.C. 300w-9) is +amended-- + (1) in subsection (a), by striking ``3-year period (with an + optional 4th year'' and inserting ``4-year period (with an + optional 5th year''; and + (2) in subsection (d)-- + (A) by striking ``and such sums'' and inserting + ``such sums''; and + (B) by inserting before the period the following: + ``, $25,000,000 for fiscal year 2010, $26,250,000 for + fiscal year 2011, $27,562,500 for fiscal year 2012, + $28,940,625 for fiscal year 2013, and $30,387,656 for + fiscal year 2014''. + +SEC. 5604. CO-LOCATING PRIMARY AND SPECIALTY CARE IN COMMUNITY-BASED + MENTAL HEALTH SETTINGS. + + Subpart 3 of part B of title V of the Public Health Service Act (42 +U.S.C. 290bb-31 et seq.) is amended by adding at the end the following: + +``SEC. 520K. <<NOTE: 42 USC 290bb-42.>> AWARDS FOR CO-LOCATING PRIMARY + AND SPECIALTY CARE IN COMMUNITY-BASED MENTAL HEALTH + SETTINGS. + + ``(a) Definitions.--In this section: + ``(1) Eligible entity.--The term `eligible entity' means a + qualified community mental health program defined under section + 1913(b)(1). + ``(2) Special populations.--The term `special populations' + means adults with mental illnesses who have co-occurring primary + care conditions and chronic diseases. + + ``(b) <<NOTE: Grants. Contracts.>> Program Authorized.--The +Secretary, acting through the Administrator shall award grants and +cooperative agreements to eligible entities to establish demonstration +projects for the provision of coordinated and integrated services to +special populations through the co-location of primary and specialty +care services in community-based mental and behavioral health settings. + + ``(c) Application.--To be eligible to receive a grant or cooperative +agreement under this section, an eligible entity shall submit an +application to the Administrator at such time, in such manner, + +[[Page 124 STAT. 680]] + +and accompanied by such information as the Administrator may require, +including a description of partnerships, or other arrangements with +local primary care providers, including community health centers, to +provide services to special populations. + ``(d) Use of Funds.-- + ``(1) In general.--For the benefit of special populations, + an eligible entity shall use funds awarded under this section + for-- + ``(A) the provision, by qualified primary care + professionals, of on site primary care services; + ``(B) reasonable costs associated with medically + necessary referrals to qualified specialty care + professionals, other coordinators of care or, if + permitted by the terms of the grant or cooperative + agreement, by qualified specialty care professionals on + a reasonable cost basis on site at the eligible entity; + ``(C) information technology required to accommodate + the clinical needs of primary and specialty care + professionals; or + ``(D) facility modifications needed to bring primary + and specialty care professionals on site at the eligible + entity. + ``(2) Limitation.--Not to exceed 15 percent of grant or + cooperative agreement funds may be used for activities described + in subparagraphs (C) and (D) of paragraph (1). + + ``(e) <<NOTE: Deadline.>> Evaluation.--Not later than 90 days after +a grant or cooperative agreement awarded under this section expires, an +eligible entity shall submit to the Secretary the results of an +evaluation to be conducted by the entity concerning the effectiveness of +the activities carried out under the grant or agreement. + + ``(f) Authorization of Appropriations.--There are authorized to be +appropriated to carry out this section, $50,000,000 for fiscal year 2010 +and such sums as may be necessary for each of fiscal years 2011 through +2014.''. + +SEC. 5605. <<NOTE: 36 USC 150303 note.>> KEY NATIONAL INDICATORS. + + (a) Definitions.--In this section: + (1) Academy.--The term ``Academy'' means the National + Academy of Sciences. + (2) Commission.--The term ``Commission'' means the + Commission on Key National Indicators established under + subsection (b). + (3) Institute.--The term ``Institute'' means a Key National + Indicators Institute as designated under subsection (c)(3). + + (b) Commission on Key National Indicators.-- + (1) Establishment.--There is established a ``Commission on + Key National Indicators''. + (2) Membership.-- + (A) Number and appointment.--The Commission shall be + composed of 8 members, to be appointed equally by the + majority and minority leaders of the Senate and the + Speaker and minority leader of the House of + Representatives. + (B) Prohibited appointments.--Members of the + Commission shall not include Members of Congress or + other elected Federal, State, or local government + officials. + (C) Qualifications.--In making appointments under + subparagraph (A), the majority and minority leaders of + +[[Page 124 STAT. 681]] + + the Senate and the Speaker and minority leader of the + House of Representatives shall appoint individuals who + have shown a dedication to improving civic dialogue and + decision-making through the wide use of scientific + evidence and factual information. + (D) Period of appointment.--Each member of the + Commission shall be appointed for a 2-year term, except + that 1 initial appointment shall be for 3 years. Any + vacancies shall not affect the power and duties of the + Commission but shall be filled in the same manner as the + original appointment and shall last only for the + remainder of that term. + (E) Date.--Members of the Commission shall be + appointed by not later than 30 days after the date of + enactment of this Act. + (F) Initial organizing period.---Not later than 60 + days after the date of enactment of this Act, the + Commission shall develop and implement a schedule for + completion of the review and reports required under + subsection (d). + (G) Co-chairpersons.--The Commission shall select 2 + Co-Chairpersons from among its members. + + (c) Duties of the Commission.-- + (1) In general.--The Commission shall-- + (A) conduct comprehensive oversight of a newly + established key national indicators system consistent + with the purpose described in this subsection; + (B) make recommendations on how to improve the key + national indicators system; + (C) coordinate with Federal Government users and + information providers to assure access to relevant and + quality data; and + (D) <<NOTE: Contracts.>> enter into contracts with + the Academy. + (2) Reports.-- + (A) Annual report to congress.--Not later than 1 + year after the selection of the 2 Co-Chairpersons of the + Commission, and each subsequent year thereafter, the + Commission shall prepare and submit to the appropriate + Committees of Congress and the President a report that + contains a detailed statement of the recommendations, + findings, and conclusions of the Commission on the + activities of the Academy and a designated Institute + related to the establishment of a Key National Indicator + System. + (B) Annual report to the academy.-- + (i) In general.--Not later than 6 months after + the selection of the 2 Co-Chairpersons of the + Commission, and each subsequent year thereafter, + the Commission shall prepare and submit to the + Academy and a designated Institute a report making + recommendations concerning potential issue areas + and key indicators to be included in the Key + National Indicators. + (ii) Limitation.--The Commission shall not + have the authority to direct the Academy or, if + established, the Institute, to adopt, modify, or + delete any key indicators. + (3) Contract with the national academy of sciences.-- + (A) In general.---As soon as practicable after the + selection of the 2 Co-Chairpersons of the Commission, + the + +[[Page 124 STAT. 682]] + + Co-Chairpersons shall enter into an arrangement with the + National Academy of Sciences under which the Academy + shall-- + (i) review available public and private sector + research on the selection of a set of key national + indicators; + (ii) determine how best to establish a key + national indicator system for the United States, + by either creating its own institutional + capability or designating an independent private + nonprofit organization as an Institute to + implement a key national indicator system; + (iii) if the Academy designates an independent + Institute under clause (ii), provide scientific + and technical advice to the Institute and create + an appropriate governance mechanism that balances + Academy involvement and the independence of the + Institute; and + (iv) <<NOTE: Reports.>> provide an annual + report to the Commission addressing scientific and + technical issues related to the key national + indicator system and, if established, the + Institute, and governance of the Institute's + budget and operations. + (B) Participation.--In executing the arrangement + under subparagraph (A), the National Academy of Sciences + shall convene a multi-sector, multi-disciplinary process + to define major scientific and technical issues + associated with developing, maintaining, and evolving a + Key National Indicator System and, if an Institute is + established, to provide it with scientific and technical + advice. + (C) Establishment of a key national indicator + system.-- + (i) In general.--In executing the arrangement + under subparagraph (A), the National Academy of + Sciences shall enable the establishment of a key + national indicator system by-- + (I) creating its own institutional + capability; or + (II) partnering with an independent + private nonprofit organization as an + Institute to implement a key national + indicator system. + (ii) Institute.--If the Academy designates an + Institute under clause (i)(II), such Institute + shall be a non-profit entity (as defined for + purposes of section 501(c)(3) of the Internal + Revenue Code of 1986) with an educational mission, + a governance structure that emphasizes + independence, and characteristics that make such + entity appropriate for establishing a key national + indicator system. + (iii) Responsibilities.--Either the Academy or + the Institute designated under clause (i)(II) + shall be responsible for the following: + (I) Identifying and selecting issue + areas to be represented by the key + national indicators. + (II) Identifying and selecting the + measures used for key national + indicators within the issue areas under + subclause (I). + +[[Page 124 STAT. 683]] + + (III) Identifying and selecting data + to populate the key national indicators + described under subclause (II). + (IV) Designing, publishing, and + maintaining a public website that + contains a freely accessible database + allowing public access to the key + national indicators. + (V) Developing a quality assurance + framework to ensure rigorous and + independent processes and the selection + of quality data. + (VI) Developing a budget for the + construction and management of a + sustainable, adaptable, and evolving key + national indicator system that reflects + all Commission funding of Academy and, + if an Institute is established, + Institute activities. + (VII) <<NOTE: Reports.>> Reporting + annually to the Commission regarding its + selection of issue areas, key + indicators, data, and progress toward + establishing a web-accessible database. + (VIII) Responding directly to the + Commission in response to any Commission + recommendations and to the Academy + regarding any inquiries by the Academy. + (iv) Governance.--Upon the establishment of a + key national indicator system, the Academy shall + create an appropriate governance mechanism that + incorporates advisory and control functions. If an + Institute is designated under clause (i)(II), the + governance mechanism shall balance appropriate + Academy involvement and the independence of the + Institute. + (v) Modification and changes.--The Academy + shall retain the sole discretion, at any time, to + alter its approach to the establishment of a key + national indicator system or, if an Institute is + designated under clause (i)(II), to alter any + aspect of its relationship with the Institute or + to designate a different non-profit entity to + serve as the Institute. + (vi) Construction.--Nothing in this section + shall be construed to limit the ability of the + Academy or the Institute designated under clause + (i)(II) to receive private funding for activities + related to the establishment of a key national + indicator system. + (D) Annual report.--As part of the arrangement under + subparagraph (A), the National Academy of Sciences + shall, not later than 270 days after the date of + enactment of this Act, and annually thereafter, submit + to the Co-Chairpersons of the Commission a report that + contains the findings and recommendations of the + Academy. + + (d) Government Accountability Office Study and Report.-- + (1) GAO study.--The Comptroller General of the United States + shall conduct a study of previous work conducted by all public + agencies, private organizations, or foreign countries with + respect to best practices for a key national indicator system. + The study shall be submitted to the appropriate authorizing + committees of Congress. + +[[Page 124 STAT. 684]] + + (2) GAO financial audit.--If an Institute is established + under this section, the Comptroller General shall conduct an + annual audit of the financial statements of the Institute, in + accordance with generally accepted government auditing standards + and submit a report on such audit to the Commission and the + appropriate authorizing committees of Congress. + (3) GAO programmatic review.--The Comptroller General of the + United States shall conduct programmatic assessments of the + Institute established under this section as determined necessary + by the Comptroller General and report the findings to the + Commission and to the appropriate authorizing committees of + Congress. + + (e) Authorization of Appropriations.-- + (1) In general.---There are authorized to be appropriated to + carry out the purposes of this section, $10,000,000 for fiscal + year 2010, and $7,500,000 for each of fiscal year 2011 through + 2018. + (2) Availability.---Amounts appropriated under paragraph (1) + shall remain available until expended. + + Subtitle H--General Provisions + +SEC. 5701. <<NOTE: 42 USC 204 note.>> REPORTS. + + (a) Reports by Secretary of Health and Human Services.--On an annual +basis, the Secretary of Health and Human Services shall submit to the +appropriate Committees of Congress a report on the activities carried +out under the amendments made by this title, and the effectiveness of +such activities. + (b) Reports by Recipients of Funds.--The Secretary of Health and +Human Services may require, as a condition of receiving funds under the +amendments made by this title, that the entity receiving such award +submit to such Secretary such reports as the such Secretary may require +on activities carried out with such award, and the effectiveness of such +activities. + + TITLE VI--TRANSPARENCY AND PROGRAM INTEGRITY + + Subtitle A--Physician Ownership and Other Transparency + +SEC. 6001. LIMITATION ON MEDICARE EXCEPTION TO THE PROHIBITION ON + CERTAIN PHYSICIAN REFERRALS FOR HOSPITALS. + + (a) In General.--Section 1877 of the Social Security Act (42 U.S.C. +1395nn) is amended-- + (1) in subsection (d)(2)-- + (A) in subparagraph (A), by striking ``and'' at the + end; + (B) in subparagraph (B), by striking the period at + the end and inserting ``; and''; and + (C) by adding at the end the following new + subparagraph: + ``(C) in the case where the entity is a hospital, + the hospital meets the requirements of paragraph + (3)(D).''; + +[[Page 124 STAT. 685]] + + (2) in subsection (d)(3)-- + (A) in subparagraph (B), by striking ``and'' at the + end; + (B) in subparagraph (C), by striking the period at + the end and inserting ``; and''; and + (C) by adding at the end the following new + subparagraph: + ``(D) <<NOTE: Deadline.>> the hospital meets the + requirements described in subsection (i)(1) not later + than 18 months after the date of the enactment of this + subparagraph.''; and + (3) by adding at the end the following new subsection: + + ``(i) Requirements for Hospitals To Qualify for Rural Provider and +Hospital Exception to Ownership or Investment Prohibition.-- + ``(1) Requirements described.--For purposes of subsection + (d)(3)(D), the requirements described in this paragraph for a + hospital are as follows: + ``(A) Provider agreement.--The hospital had-- + ``(i) physician ownership or investment on + February 1, 2010; and + ``(ii) a provider agreement under section 1866 + in effect on such date. + ``(B) Limitation on expansion of facility + capacity.--Except as provided in paragraph (3), the + number of operating rooms, procedure rooms, and beds for + which the hospital is licensed at any time on or after + the date of the enactment of this subsection is no + greater than the number of operating rooms, procedure + rooms, and beds for which the hospital is licensed as of + such date. + ``(C) Preventing conflicts of interest.-- + ``(i) <<NOTE: Reports.>> The hospital submits + to the Secretary an annual report containing a + detailed description of-- + ``(I) the identity of each physician + owner or investor and any other owners + or investors of the hospital; and + ``(II) the nature and extent of all + ownership and investment interests in + the hospital. + ``(ii) The hospital has procedures in place to + require that any referring physician owner or + investor discloses to the patient being referred, + by a time that permits the patient to make a + meaningful decision regarding the receipt of care, + as determined by the Secretary-- + ``(I) the ownership or investment + interest, as applicable, of such + referring physician in the hospital; and + ``(II) if applicable, any such + ownership or investment interest of the + treating physician. + ``(iii) The hospital does not condition any + physician ownership or investment interests either + directly or indirectly on the physician owner or + investor making or influencing referrals to the + hospital or otherwise generating business for the + hospital. + ``(iv) The hospital discloses the fact that + the hospital is partially owned or invested in by + physicians-- + ``(I) on any public website for the + hospital; and + ``(II) in any public advertising for + the hospital. + ``(D) Ensuring bona fide investment.-- + +[[Page 124 STAT. 686]] + + ``(i) The percentage of the total value of the + ownership or investment interests held in the + hospital, or in an entity whose assets include the + hospital, by physician owners or investors in the + aggregate does not exceed such percentage as of + the date of enactment of this subsection. + ``(ii) Any ownership or investment interests + that the hospital offers to a physician owner or + investor are not offered on more favorable terms + than the terms offered to a person who is not a + physician owner or investor. + ``(iii) The hospital (or any owner or investor + in the hospital) does not directly or indirectly + provide loans or financing for any investment in + the hospital by a physician owner or investor. + ``(iv) The hospital (or any owner or investor + in the hospital) does not directly or indirectly + guarantee a loan, make a payment toward a loan, or + otherwise subsidize a loan, for any individual + physician owner or investor or group of physician + owners or investors that is related to acquiring + any ownership or investment interest in the + hospital. + ``(v) Ownership or investment returns are + distributed to each owner or investor in the + hospital in an amount that is directly + proportional to the ownership or investment + interest of such owner or investor in the + hospital. + ``(vi) Physician owners and investors do not + receive, directly or indirectly, any guaranteed + receipt of or right to purchase other business + interests related to the hospital, including the + purchase or lease of any property under the + control of other owners or investors in the + hospital or located near the premises of the + hospital. + ``(vii) The hospital does not offer a + physician owner or investor the opportunity to + purchase or lease any property under the control + of the hospital or any other owner or investor in + the hospital on more favorable terms than the + terms offered to an individual who is not a + physician owner or investor. + ``(E) Patient safety.-- + ``(i) Insofar as the hospital admits a patient + and does not have any physician available on the + premises to provide services during all hours in + which the hospital is providing services to such + patient, before admitting the patient-- + ``(I) the hospital discloses such + fact to a patient; and + ``(II) following such disclosure, + the hospital receives from the patient a + signed acknowledgment that the patient + understands such fact. + ``(ii) The hospital has the capacity to-- + ``(I) provide assessment and initial + treatment for patients; and + ``(II) refer and transfer patients + to hospitals with the capability to + treat the needs of the patient involved. + +[[Page 124 STAT. 687]] + + ``(F) Limitation on application to certain converted + facilities.--The hospital was not converted from an + ambulatory surgical center to a hospital on or after the + date of enactment of this subsection. + ``(2) <<NOTE: Deadline. Web posting.>> Publication of + information reported.--The Secretary shall publish, and update + on an annual basis, the information submitted by hospitals under + paragraph (1)(C)(i) on the public Internet website of the + Centers for Medicare & Medicaid Services. + ``(3) Exception to prohibition on expansion of facility + capacity.-- + ``(A) Process.-- + ``(i) Establishment.--The Secretary shall + establish and implement a process under which an + applicable hospital (as defined in subparagraph + (E)) may apply for an exception from the + requirement under paragraph (1)(B). + ``(ii) Opportunity for community input.--The + process under clause (i) shall provide individuals + and entities in the community in which the + applicable hospital applying for an exception is + located with the opportunity to provide input with + respect to the application. + ``(iii) Timing for implementation.--The + Secretary shall implement the process under clause + (i) on August 1, 2011. + ``(iv) <<NOTE: Deadline.>> Regulations.--Not + later than July 1, 2011, the Secretary shall + promulgate regulations to carry out the process + under clause (i). + ``(B) Frequency.--The process described in + subparagraph (A) shall permit an applicable hospital to + apply for an exception up to once every 2 years. + ``(C) Permitted increase.-- + ``(i) In general.--Subject to clause (ii) and + subparagraph (D), an applicable hospital granted + an exception under the process described in + subparagraph (A) may increase the number of + operating rooms, procedure rooms, and beds for + which the applicable hospital is licensed above + the baseline number of operating rooms, procedure + rooms, and beds of the applicable hospital (or, if + the applicable hospital has been granted a + previous exception under this paragraph, above the + number of operating rooms, procedure rooms, and + beds for which the hospital is licensed after the + application of the most recent increase under such + an exception). + ``(ii) 100 percent increase limitation.--The + Secretary shall not permit an increase in the + number of operating rooms, procedure rooms, and + beds for which an applicable hospital is licensed + under clause (i) to the extent such increase would + result in the number of operating rooms, procedure + rooms, and beds for which the applicable hospital + is licensed exceeding 200 percent of the baseline + number of operating rooms, procedure rooms, and + beds of the applicable hospital. + ``(iii) Baseline number of operating rooms, + procedure rooms, and beds.--In this paragraph, the + term `baseline number of operating rooms, + procedure + +[[Page 124 STAT. 688]] + + rooms, and beds' means the number of operating + rooms, procedure rooms, and beds for which the + applicable hospital is licensed as of the date of + enactment of this subsection. + ``(D) Increase limited to facilities on the main + campus of the hospital.--Any increase in the number of + operating rooms, procedure rooms, and beds for which an + applicable hospital is licensed pursuant to this + paragraph may only occur in facilities on the main + campus of the applicable hospital. + ``(E) Applicable hospital.--In this paragraph, the + term `applicable hospital' means a hospital-- + ``(i) that is located in a county in which the + percentage increase in the population during the + most recent 5-year period (as of the date of the + application under subparagraph (A)) is at least + 150 percent of the percentage increase in the + population growth of the State in which the + hospital is located during that period, as + estimated by Bureau of the Census; + ``(ii) whose annual percent of total inpatient + admissions that represent inpatient admissions + under the program under title XIX is equal to or + greater than the average percent with respect to + such admissions for all hospitals located in the + county in which the hospital is located; + ``(iii) that does not discriminate against + beneficiaries of Federal health care programs and + does not permit physicians practicing at the + hospital to discriminate against such + beneficiaries; + ``(iv) that is located in a State in which the + average bed capacity in the State is less than the + national average bed capacity; and + ``(v) that has an average bed occupancy rate + that is greater than the average bed occupancy + rate in the State in which the hospital is + located. + ``(F) Procedure rooms.--In this subsection, the term + `procedure rooms' includes rooms in which + catheterizations, angiographies, angiograms, and + endoscopies are performed, except such term shall not + include emergency rooms or departments (exclusive of + rooms in which catheterizations, angiographies, + angiograms, and endoscopies are performed). + ``(G) <<NOTE: Deadline. Federal Register, + publication.>> Publication of final decisions.--Not + later than 60 days after receiving a complete + application under this paragraph, the Secretary shall + publish in the Federal Register the final decision with + respect to such application. + ``(H) Limitation on review.--There shall be no + administrative or judicial review under section 1869, + section 1878, or otherwise of the process under this + paragraph (including the establishment of such process). + ``(4) Collection of ownership and investment information.-- + For purposes of subparagraphs (A)(i) and (D)(i) of paragraph + (1), the Secretary shall collect physician ownership and + investment information for each hospital. + ``(5) Physician owner or investor defined.--For purposes of + this subsection, the term `physician owner or investor' means a + physician (or an immediate family member of such + +[[Page 124 STAT. 689]] + + physician) with a direct or an indirect ownership or investment + interest in the hospital. + ``(6) Clarification.--Nothing in this subsection shall be + construed as preventing the Secretary from revoking a hospital's + provider agreement if not in compliance with regulations + implementing section 1866.''. + + (b) Enforcement.-- + (1) <<NOTE: Procedures. 42 USC 1395nn note.>> Ensuring + compliance.--The Secretary of Health and Human Services shall + establish policies and procedures to ensure compliance with the + requirements described in subsection (i)(1) of section 1877 of + the Social Security Act, as added by subsection (a)(3), + beginning on the date such requirements first apply. Such + policies and procedures may include unannounced site reviews of + hospitals. + (2) <<NOTE: Deadline.>> Audits.--Beginning not later than + November 1, 2011, the Secretary of Health and Human Services + shall conduct audits to determine if hospitals violate the + requirements referred to in paragraph (1). + +SEC. 6002. TRANSPARENCY REPORTS AND REPORTING OF PHYSICIAN OWNERSHIP OR + INVESTMENT INTERESTS. + + Part A of title XI of the Social Security Act (42 U.S.C. 1301 et +seq.) is amended by inserting after section 1128F the following new +section: + +``SEC. 1128G. <<NOTE: Electronic format. 42 USC 1320a-7h.>> TRANSPARENCY + REPORTS AND REPORTING OF PHYSICIAN OWNERSHIP OR INVESTMENT + INTERESTS. + + ``(a) Transparency Reports.-- + ``(1) Payments or other transfers of value.-- + ``(A) In general.--On March 31, 2013, and on the + 90th day of each calendar year beginning thereafter, any + applicable manufacturer that provides a payment or other + transfer of value to a covered recipient (or to an + entity or individual at the request of or designated on + behalf of a covered recipient), shall submit to the + Secretary, in such electronic form as the Secretary + shall require, the following information with respect to + the preceding calendar year: + ``(i) The name of the covered recipient. + ``(ii) The business address of the covered + recipient and, in the case of a covered recipient + who is a physician, the specialty and National + Provider Identifier of the covered recipient. + ``(iii) The amount of the payment or other + transfer of value. + ``(iv) The dates on which the payment or other + transfer of value was provided to the covered + recipient. + ``(v) A description of the form of the payment + or other transfer of value, indicated (as + appropriate for all that apply) as-- + ``(I) cash or a cash equivalent; + ``(II) in-kind items or services; + ``(III) stock, a stock option, or + any other ownership interest, dividend, + profit, or other return on investment; + or + ``(IV) any other form of payment or + other transfer of value (as defined by + the Secretary). + +[[Page 124 STAT. 690]] + + ``(vi) A description of the nature of the + payment or other transfer of value, indicated (as + appropriate for all that apply) as-- + ``(I) consulting fees; + ``(II) compensation for services + other than consulting; + ``(III) honoraria; + ``(IV) gift; + ``(V) entertainment; + ``(VI) food; + ``(VII) travel (including the + specified destinations); + ``(VIII) education; + ``(IX) research; + ``(X) charitable contribution; + ``(XI) royalty or license; + ``(XII) current or prospective + ownership or investment interest; + ``(XIII) direct compensation for + serving as faculty or as a speaker for a + medical education program; + ``(XIV) grant; or + ``(XV) any other nature of the + payment or other transfer of value (as + defined by the Secretary). + ``(vii) If the payment or other transfer of + value is related to marketing, education, or + research specific to a covered drug, device, + biological, or medical supply, the name of that + covered drug, device, biological, or medical + supply. + ``(viii) Any other categories of information + regarding the payment or other transfer of value + the Secretary determines appropriate. + ``(B) Special rule for certain payments or other + transfers of value.--In the case where an applicable + manufacturer provides a payment or other transfer of + value to an entity or individual at the request of or + designated on behalf of a covered recipient, the + applicable manufacturer shall disclose that payment or + other transfer of value under the name of the covered + recipient. + ``(2) Physician ownership.--In addition to the requirement + under paragraph (1)(A), on March 31, 2013, and on the 90th day + of each calendar year beginning thereafter, any applicable + manufacturer or applicable group purchasing organization shall + submit to the Secretary, in such electronic form as the + Secretary shall require, the following information regarding any + ownership or investment interest (other than an ownership or + investment interest in a publicly traded security and mutual + fund, as described in section 1877(c)) held by a physician (or + an immediate family member of such physician (as defined for + purposes of section 1877(a))) in the applicable manufacturer or + applicable group purchasing organization during the preceding + year: + ``(A) The dollar amount invested by each physician + holding such an ownership or investment interest. + ``(B) The value and terms of each such ownership or + investment interest. + +[[Page 124 STAT. 691]] + + ``(C) Any payment or other transfer of value + provided to a physician holding such an ownership or + investment interest (or to an entity or individual at + the request of or designated on behalf of a physician + holding such an ownership or investment interest), + including the information described in clauses (i) + through (viii) of paragraph (1)(A), except that in + applying such clauses, `physician' shall be substituted + for `covered recipient' each place it appears. + ``(D) Any other information regarding the ownership + or investment interest the Secretary determines + appropriate. + + ``(b) Penalties for Noncompliance.-- + ``(1) Failure to report.-- + ``(A) In general.--Subject to subparagraph (B) + except as provided in paragraph (2), any applicable + manufacturer or applicable group purchasing organization + that fails to submit information required under + subsection (a) in a timely manner in accordance with + rules or regulations promulgated to carry out such + subsection, shall be subject to a civil money penalty of + not less than $1,000, but not more than $10,000, for + each payment or other transfer of value or ownership or + investment interest not reported as required under such + subsection. Such penalty shall be imposed and collected + in the same manner as civil money penalties under + subsection (a) of section 1128A are imposed and + collected under that section. + ``(B) Limitation.--The total amount of civil money + penalties imposed under subparagraph (A) with respect to + each annual submission of information under subsection + (a) by an applicable manufacturer or applicable group + purchasing organization shall not exceed $150,000. + ``(2) Knowing failure to report.-- + ``(A) In general.--Subject to subparagraph (B), any + applicable manufacturer or applicable group purchasing + organization that knowingly fails to submit information + required under subsection (a) in a timely manner in + accordance with rules or regulations promulgated to + carry out such subsection, shall be subject to a civil + money penalty of not less than $10,000, but not more + than $100,000, for each payment or other transfer of + value or ownership or investment interest not reported + as required under such subsection. Such penalty shall be + imposed and collected in the same manner as civil money + penalties under subsection (a) of section 1128A are + imposed and collected under that section. + ``(B) Limitation.--The total amount of civil money + penalties imposed under subparagraph (A) with respect to + each annual submission of information under subsection + (a) by an applicable manufacturer or applicable group + purchasing organization shall not exceed $1,000,000. + ``(3) Use of funds.--Funds collected by the Secretary as a + result of the imposition of a civil money penalty under this + subsection shall be used to carry out this section. + + ``(c) Procedures for Submission of Information and Public +Availability.-- + ``(1) In general.-- + +[[Page 124 STAT. 692]] + + ``(A) <<NOTE: Deadline.>> Establishment.--Not later + than October 1, 2011, the Secretary shall establish + procedures-- + ``(i) for applicable manufacturers and + applicable group purchasing organizations to + submit information to the Secretary under + subsection (a); and + ``(ii) for the Secretary to make such + information submitted available to the public. + ``(B) Definition of terms.--The procedures + established under subparagraph (A) shall provide for the + definition of terms (other than those terms defined in + subsection (e)), as appropriate, for purposes of this + section. + ``(C) <<NOTE: Deadlines. Web posting.>> Public + availability.--Except as provided in subparagraph (E), + the procedures established under subparagraph (A)(ii) + shall ensure that, not later than September 30, 2013, + and on June 30 of each calendar year beginning + thereafter, the information submitted under subsection + (a) with respect to the preceding calendar year is made + available through an Internet website that-- + ``(i) is searchable and is in a format that is + clear and understandable; + ``(ii) contains information that is presented + by the name of the applicable manufacturer or + applicable group purchasing organization, the name + of the covered recipient, the business address of + the covered recipient, the specialty of the + covered recipient, the value of the payment or + other transfer of value, the date on which the + payment or other transfer of value was provided to + the covered recipient, the form of the payment or + other transfer of value, indicated (as + appropriate) under subsection (a)(1)(A)(v), the + nature of the payment or other transfer of value, + indicated (as appropriate) under subsection + (a)(1)(A)(vi), and the name of the covered drug, + device, biological, or medical supply, as + applicable; + ``(iii) contains information that is able to + be easily aggregated and downloaded; + ``(iv) contains a description of any + enforcement actions taken to carry out this + section, including any penalties imposed under + subsection (b), during the preceding year; + ``(v) contains background information on + industry-physician relationships; + ``(vi) in the case of information submitted + with respect to a payment or other transfer of + value described in subparagraph (E)(i), lists such + information separately from the other information + submitted under subsection (a) and designates such + separately listed information as funding for + clinical research; + ``(vii) contains any other information the + Secretary determines would be helpful to the + average consumer; + ``(viii) does not contain the National + Provider Identifier of the covered recipient, and + ``(ix) subject to subparagraph (D), provides + the applicable manufacturer, applicable group + purchasing organization, or covered recipient an + opportunity to review and submit corrections to + the information submitted with respect to the + applicable manufacturer, + +[[Page 124 STAT. 693]] + + applicable group purchasing organization, or + covered recipient, respectively, for a period of + not less than 45 days prior to such information + being made available to the public. + ``(D) Clarification of time period for review and + corrections.--In no case may the 45-day period for + review and submission of corrections to information + under subparagraph (C)(ix) prevent such information from + being made available to the public in accordance with + the dates described in the matter preceding clause (i) + in subparagraph (C). + ``(E) Delayed publication for payments made pursuant + to product research or development agreements and + clinical investigations.-- + ``(i) In general.--In the case of information + submitted under subsection (a) with respect to a + payment or other transfer of value made to a + covered recipient by an applicable manufacturer + pursuant to a product research or development + agreement for services furnished in connection + with research on a potential new medical + technology or a new application of an existing + medical technology or the development of a new + drug, device, biological, or medical supply, or by + an applicable manufacturer in connection with a + clinical investigation regarding a new drug, + device, biological, or medical supply, the + procedures established under subparagraph (A)(ii) + shall provide that such information is made + available to the public on the first date + described in the matter preceding clause (i) in + subparagraph (C) after the earlier of the + following: + ``(I) The date of the approval or + clearance of the covered drug, device, + biological, or medical supply by the + Food and Drug Administration. + ``(II) Four calendar years after the + date such payment or other transfer of + value was made. + ``(ii) Confidentiality of information prior to + publication.--Information described in clause (i) + shall be considered confidential and shall not be + subject to disclosure under section 552 of title + 5, United States Code, or any other similar + Federal, State, or local law, until on or after + the date on which the information is made + available to the public under such clause. + ``(2) Consultation.--In establishing the procedures under + paragraph (1), the Secretary shall consult with the Inspector + General of the Department of Health and Human Services, affected + industry, consumers, consumer advocates, and other interested + parties in order to ensure that the information made available + to the public under such paragraph is presented in the + appropriate overall context. + + ``(d) Annual Reports and Relation to State Laws.-- + ``(1) Annual report to congress.--Not later than April 1 of + each year beginning with 2013, the Secretary shall submit to + Congress a report that includes the following: + ``(A) The information submitted under subsection (a) + during the preceding year, aggregated for each + applicable manufacturer and applicable group purchasing + organization that submitted such information during such + year + +[[Page 124 STAT. 694]] + + (except, in the case of information submitted with + respect to a payment or other transfer of value + described in subsection (c)(1)(E)(i), such information + shall be included in the first report submitted to + Congress after the date on which such information is + made available to the public under such subsection). + ``(B) A description of any enforcement actions taken + to carry out this section, including any penalties + imposed under subsection (b), during the preceding year. + ``(2) Annual reports to states.--Not later than September + 30, 2013 and on June 30 of each calendar year thereafter, the + Secretary shall submit to States a report that includes a + summary of the information submitted under subsection (a) during + the preceding year with respect to covered recipients in the + State (except, in the case of information submitted with respect + to a payment or other transfer of value described in subsection + (c)(1)(E)(i), such information shall be included in the first + report submitted to States after the date on which such + information is made available to the public under such + subsection). + ``(3) Relation to state laws.-- + ``(A) In general.--In the case of a payment or other + transfer of value provided by an applicable manufacturer + that is received by a covered recipient (as defined in + subsection (e)) on or after January 1, 2012, subject to + subparagraph (B), the provisions of this section shall + preempt any statute or regulation of a State or of a + political subdivision of a State that requires an + applicable manufacturer (as so defined) to disclose or + report, in any format, the type of information (as + described in subsection (a)) regarding such payment or + other transfer of value. + ``(B) No preemption of additional requirements.-- + Subparagraph (A) shall not preempt any statute or + regulation of a State or of a political subdivision of a + State that requires the disclosure or reporting of + information-- + ``(i) not of the type required to be disclosed + or reported under this section; + ``(ii) described in subsection (e)(10)(B), + except in the case of information described in + clause (i) of such subsection; + ``(iii) by any person or entity other than an + applicable manufacturer (as so defined) or a + covered recipient (as defined in subsection (e)); + or + ``(iv) to a Federal, State, or local + governmental agency for public health + surveillance, investigation, or other public + health purposes or health oversight purposes. + ``(C) Nothing in subparagraph (A) shall be construed + to limit the discovery or admissibility of information + described in such subparagraph in a criminal, civil, or + administrative proceeding. + ``(4) Consultation.--The Secretary shall consult with the + Inspector General of the Department of Health and Human Services + on the implementation of this section. + + ``(e) Definitions.--In this section: + ``(1) Applicable group purchasing organization.--The term + `applicable group purchasing organization' means a group + +[[Page 124 STAT. 695]] + + purchasing organization (as defined by the Secretary) that + purchases, arranges for, or negotiates the purchase of a covered + drug, device, biological, or medical supply which is operating + in the United States, or in a territory, possession, or + commonwealth of the United States. + ``(2) Applicable manufacturer.--The term `applicable + manufacturer' means a manufacturer of a covered drug, device, + biological, or medical supply which is operating in the United + States, or in a territory, possession, or commonwealth of the + United States. + ``(3) Clinical investigation.--The term `clinical + investigation' means any experiment involving 1 or more human + subjects, or materials derived from human subjects, in which a + drug or device is administered, dispensed, or used. + ``(4) Covered device.--The term `covered device' means any + device for which payment is available under title XVIII or a + State plan under title XIX or XXI (or a waiver of such a plan). + ``(5) Covered drug, device, biological, or medical supply.-- + The term `covered drug, device, biological, or medical supply' + means any drug, biological product, device, or medical supply + for which payment is available under title XVIII or a State plan + under title XIX or XXI (or a waiver of such a plan). + ``(6) Covered recipient.-- + ``(A) In general.--Except as provided in + subparagraph (B), the term `covered recipient' means the + following: + ``(i) A physician. + ``(ii) A teaching hospital. + ``(B) Exclusion.--Such term does not include a + physician who is an employee of the applicable + manufacturer that is required to submit information + under subsection (a). + ``(7) Employee.--The term `employee' has the meaning given + such term in section 1877(h)(2). + ``(8) Knowingly.--The term `knowingly' has the meaning given + such term in section 3729(b) of title 31, United States Code. + ``(9) Manufacturer of a covered drug, device, biological, or + medical supply.--The term `manufacturer of a covered drug, + device, biological, or medical supply' means any entity which is + engaged in the production, preparation, propagation, + compounding, or conversion of a covered drug, device, + biological, or medical supply (or any entity under common + ownership with such entity which provides assistance or support + to such entity with respect to the production, preparation, + propagation, compounding, conversion, marketing, promotion, + sale, or distribution of a covered drug, device, biological, or + medical supply). + ``(10) Payment or other transfer of value.-- + ``(A) In general.--The term `payment or other + transfer of value' means a transfer of anything of + value. Such term does not include a transfer of anything + of value that is made indirectly to a covered recipient + through a third party in connection with an activity or + service in the case where the applicable manufacturer is + unaware of the identity of the covered recipient. + +[[Page 124 STAT. 696]] + + ``(B) Exclusions.--An applicable manufacturer shall + not be required to submit information under subsection + (a) with respect to the following: + ``(i) A transfer of anything the value of + which is less than $10, unless the aggregate + amount transferred to, requested by, or designated + on behalf of the covered recipient by the + applicable manufacturer during the calendar year + exceeds $100. For calendar years after 2012, the + dollar amounts specified in the preceding sentence + shall be increased by the same percentage as the + percentage increase in the consumer price index + for all urban consumers (all items; U.S. city + average) for the 12-month period ending with June + of the previous year. + ``(ii) Product samples that are not intended + to be sold and are intended for patient use. + ``(iii) Educational materials that directly + benefit patients or are intended for patient use. + ``(iv) The loan of a covered device for a + short-term trial period, not to exceed 90 days, to + permit evaluation of the covered device by the + covered recipient. + ``(v) Items or services provided under a + contractual warranty, including the replacement of + a covered device, where the terms of the warranty + are set forth in the purchase or lease agreement + for the covered device. + ``(vi) A transfer of anything of value to a + covered recipient when the covered recipient is a + patient and not acting in the professional + capacity of a covered recipient. + ``(vii) Discounts (including rebates). + ``(viii) In-kind items used for the provision + of charity care. + ``(ix) A dividend or other profit distribution + from, or ownership or investment interest in, a + publicly traded security and mutual fund (as + described in section 1877(c)). + ``(x) In the case of an applicable + manufacturer who offers a self-insured plan, + payments for the provision of health care to + employees under the plan. + ``(xi) In the case of a covered recipient who + is a licensed non-medical professional, a transfer + of anything of value to the covered recipient if + the transfer is payment solely for the non-medical + professional services of such licensed non-medical + professional. + ``(xii) In the case of a covered recipient who + is a physician, a transfer of anything of value to + the covered recipient if the transfer is payment + solely for the services of the covered recipient + with respect to a civil or criminal action or an + administrative proceeding. + ``(11) Physician.--The term `physician' has the meaning + given that term in section 1861(r).''. + +[[Page 124 STAT. 697]] + +SEC. 6003. DISCLOSURE REQUIREMENTS FOR IN-OFFICE ANCILLARY SERVICES + EXCEPTION TO THE PROHIBITION ON PHYSICIAN SELF-REFERRAL FOR + CERTAIN IMAGING SERVICES. + + (a) In General.--Section 1877(b)(2) of the Social Security Act (42 +U.S.C. 1395nn(b)(2)) is amended by adding at the end the following new +sentence: ``Such requirements shall, with respect to magnetic resonance +imaging, computed tomography, positron emission tomography, and any +other designated health services specified under subsection (h)(6)(D) +that the Secretary determines appropriate, include a requirement that +the referring physician inform the individual in writing at the time of +the referral that the individual may obtain the services for which the +individual is being referred from a person other than a person described +in subparagraph (A)(i) and provide such individual with a written list +of suppliers (as defined in section 1861(d)) who furnish such services +in the area in which such individual resides.''. + (b) Effective Date. <<NOTE: 42 USC 1395nn note.>> --The amendment +made by this section shall apply to services furnished on or after +January 1, 2010. + +SEC. 6004. PRESCRIPTION DRUG SAMPLE TRANSPARENCY. + + Part A of title XI of the Social Security Act (42 U.S.C. 1301 et +seq.), as amended by section 6002, is amended by inserting after section +1128G the following new section: + +``SEC. 1128H. <<NOTE: 42 USC 1320a-7i.>> REPORTING OF INFORMATION + RELATING TO DRUG SAMPLES. + + ``(a) In General.--Not later than April 1 of each year (beginning +with 2012), each manufacturer and authorized distributor of record of an +applicable drug shall submit to the Secretary (in a form and manner +specified by the Secretary) the following information with respect to +the preceding year: + ``(1) In the case of a manufacturer or authorized + distributor of record which makes distributions by mail or + common carrier under subsection (d)(2) of section 503 of the + Federal Food, Drug, and Cosmetic Act (21 U.S.C. 353), the + identity and quantity of drug samples requested and the identity + and quantity of drug samples distributed under such subsection + during that year, aggregated by-- + ``(A) the name, address, professional designation, + and signature of the practitioner making the request + under subparagraph (A)(i) of such subsection, or of any + individual who makes or signs for the request on behalf + of the practitioner; and + ``(B) any other category of information determined + appropriate by the Secretary. + ``(2) In the case of a manufacturer or authorized + distributor of record which makes distributions by means other + than mail or common carrier under subsection (d)(3) of such + section 503, the identity and quantity of drug samples requested + and the identity and quantity of drug samples distributed under + such subsection during that year, aggregated by-- + ``(A) the name, address, professional designation, + and signature of the practitioner making the request + under subparagraph (A)(i) of such subsection, or of any + individual who makes or signs for the request on behalf + of the practitioner; and + +[[Page 124 STAT. 698]] + + ``(B) any other category of information determined + appropriate by the Secretary. + + ``(b) Definitions.--In this section: + ``(1) Applicable drug.--The term `applicable drug' means a + drug-- + ``(A) which is subject to subsection (b) of such + section 503; and + ``(B) for which payment is available under title + XVIII or a State plan under title XIX or XXI (or a + waiver of such a plan). + ``(2) Authorized distributor of record.--The term + `authorized distributor of record' has the meaning given that + term in subsection (e)(3)(A) of such section. + ``(3) Manufacturer.--The term `manufacturer' has the meaning + given that term for purposes of subsection (d) of such + section.''. + +SEC. 6005. <<NOTE: 42 USC 1320b-23.>> PHARMACY BENEFIT MANAGERS + TRANSPARENCY REQUIREMENTS. + + Part A of title XI of the Social Security Act (42 U.S.C. 1301 et +seq.) is amended by inserting after section 1150 the following new +section: + +``SEC. 1150A. PHARMACY BENEFIT MANAGERS TRANSPARENCY REQUIREMENTS. + + ``(a) Provision of Information.--A health benefits plan or any +entity that provides pharmacy benefits management services on behalf of +a health benefits plan (in this section referred to as a `PBM') that +manages prescription drug coverage under a contract with-- + ``(1) a PDP sponsor of a prescription drug plan or an MA + organization offering an MA-PD plan under part D of title XVIII; + or + ``(2) a qualified health benefits plan offered through an + exchange established by a State under section 1311 of the + Patient Protection and Affordable Care Act, + +shall provide the information described in subsection (b) to the +Secretary and, in the case of a PBM, to the plan with which the PBM is +under contract with, at such times, and in such form and manner, as the +Secretary shall specify. + ``(b) Information Described.--The information described in this +subsection is the following with respect to services provided by a +health benefits plan or PBM for a contract year: + ``(1) The percentage of all prescriptions that were provided + through retail pharmacies compared to mail order pharmacies, and + the percentage of prescriptions for which a generic drug was + available and dispensed (generic dispensing rate), by pharmacy + type (which includes an independent pharmacy, chain pharmacy, + supermarket pharmacy, or mass merchandiser pharmacy that is + licensed as a pharmacy by the State and that dispenses + medication to the general public), that is paid by the health + benefits plan or PBM under the contract. + ``(2) The aggregate amount, and the type of rebates, + discounts, or price concessions (excluding bona fide service + fees, which include but are not limited to distribution service + fees, inventory management fees, product stocking allowances, + and fees associated with administrative services agreements and + patient care programs (such as medication compliance programs + +[[Page 124 STAT. 699]] + + and patient education programs)) that the PBM negotiates that + are attributable to patient utilization under the plan, and the + aggregate amount of the rebates, discounts, or price concessions + that are passed through to the plan sponsor, and the total + number of prescriptions that were dispensed. + ``(3) The aggregate amount of the difference between the + amount the health benefits plan pays the PBM and the amount that + the PBM pays retail pharmacies, and mail order pharmacies, and + the total number of prescriptions that were dispensed. + + ``(c) Confidentiality.--Information disclosed by a health benefits +plan or PBM under this section is confidential and shall not be +disclosed by the Secretary or by a plan receiving the information, +except that the Secretary may disclose the information in a form which +does not disclose the identity of a specific PBM, plan, or prices +charged for drugs, for the following purposes: + ``(1) As the Secretary determines to be necessary to carry + out this section or part D of title XVIII. + ``(2) To permit the Comptroller General to review the + information provided. + ``(3) To permit the Director of the Congressional Budget + Office to review the information provided. + ``(4) To States to carry out section 1311 of the Patient + Protection and Affordable Care Act. + + ``(d) Penalties. <<NOTE: Applicability.>> --The provisions of +subsection (b)(3)(C) of section 1927 shall apply to a health benefits +plan or PBM that fails to provide information required under subsection +(a) on a timely basis or that knowingly provides false information in +the same manner as such provisions apply to a manufacturer with an +agreement under that section.''. + + Subtitle B--Nursing Home Transparency and Improvement + + PART I--IMPROVING TRANSPARENCY OF INFORMATION + +SEC. 6101. REQUIRED DISCLOSURE OF OWNERSHIP AND ADDITIONAL DISCLOSABLE + PARTIES INFORMATION. + + (a) In General.--Section 1124 of the Social Security Act (42 U.S.C. +1320a-3) is amended by adding at the end the following new subsection: + ``(c) Required Disclosure of Ownership and Additional Disclosable +Parties Information.-- + ``(1) Disclosure.--A facility shall have the information + described in paragraph (2) available-- + ``(A) <<NOTE: Time period.>> during the period + beginning on the date of the enactment of this + subsection and ending on the date such information is + made available to the public under section 6101(b) of + the Patient Protection and Affordable Care Act for + submission to the Secretary, the Inspector General of + the Department of Health and Human Services, the State + in which the facility is located, and the State long- + term care ombudsman in the case where the Secretary, the + +[[Page 124 STAT. 700]] + + Inspector General, the State, or the State long-term + care ombudsman requests such information; and + ``(B) beginning on the effective date of the final + regulations promulgated under paragraph (3)(A), for + reporting such information in accordance with such final + regulations. + Nothing in subparagraph (A) shall be construed as authorizing a + facility to dispose of or delete information described in such + subparagraph after the effective date of the final regulations + promulgated under paragraph (3)(A). + ``(2) Information described.-- + ``(A) In general.--The following information is + described in this paragraph: + ``(i) The information described in subsections + (a) and (b), subject to subparagraph (C). + ``(ii) The identity of and information on-- + ``(I) each member of the governing + body of the facility, including the + name, title, and period of service of + each such member; + ``(II) each person or entity who is + an officer, director, member, partner, + trustee, or managing employee of the + facility, including the name, title, and + period of service of each such person or + entity; and + ``(III) each person or entity who is + an additional disclosable party of the + facility. + ``(iii) The organizational structure of each + additional disclosable party of the facility and a + description of the relationship of each such + additional disclosable party to the facility and + to one another. + ``(B) Special rule where information is already + reported or submitted.--To the extent that information + reported by a facility to the Internal Revenue Service + on Form 990, information submitted by a facility to the + Securities and Exchange Commission, or information + otherwise submitted to the Secretary or any other + Federal agency contains the information described in + clauses (i), (ii), or (iii) of subparagraph (A), the + facility may provide such Form or such information + submitted to meet the requirements of paragraph (1). + ``(C) Special rule.--In applying subparagraph + (A)(i)-- + ``(i) with respect to subsections (a) and (b), + `ownership or control interest' shall include + direct or indirect interests, including such + interests in intermediate entities; and + ``(ii) subsection (a)(3)(A)(ii) shall include + the owner of a whole or part interest in any + mortgage, deed of trust, note, or other obligation + secured, in whole or in part, by the entity or any + of the property or assets thereof, if the interest + is equal to or exceeds 5 percent of the total + property or assets of the entirety. + ``(3) Reporting.-- + ``(A) In general. <<NOTE: Regulations. Effective + date. Federal Register, publication.>> --Not later than + the date that is 2 years after the date of the enactment + of this subsection, the Secretary shall promulgate final + regulations requiring, effective on the date that is 90 + days after the date on which such final regulations are + published in the Federal Register, a facility to report + the information described in + +[[Page 124 STAT. 701]] + + paragraph (2) to the Secretary in a standardized format, + and such other regulations as are necessary to carry out + this subsection. <<NOTE: Certification.>> Such final + regulations shall ensure that the facility certifies, as + a condition of participation and payment under the + program under title XVIII or XIX, that the information + reported by the facility in accordance with such final + regulations is, to the best of the facility's knowledge, + accurate and current. + ``(B) Guidance.--The Secretary shall provide + guidance and technical assistance to States on how to + adopt the standardized format under subparagraph (A). + ``(4) No effect on existing reporting requirements.--Nothing + in this subsection shall reduce, diminish, or alter any + reporting requirement for a facility that is in effect as of the + date of the enactment of this subsection. + ``(5) Definitions.--In this subsection: + ``(A) Additional disclosable party.--The term + `additional disclosable party' means, with respect to a + facility, any person or entity who-- + ``(i) exercises operational, financial, or + managerial control over the facility or a part + thereof, or provides policies or procedures for + any of the operations of the facility, or provides + financial or cash management services to the + facility; + ``(ii) leases or subleases real property to + the facility, or owns a whole or part interest + equal to or exceeding 5 percent of the total value + of such real property; or + ``(iii) provides management or administrative + services, management or clinical consulting + services, or accounting or financial services to + the facility. + ``(B) Facility.--The term `facility' means a + disclosing entity which is-- + ``(i) a skilled nursing facility (as defined + in section 1819(a)); or + ``(ii) a nursing facility (as defined in + section 1919(a)). + ``(C) Managing employee.--The term `managing + employee' means, with respect to a facility, an + individual (including a general manager, business + manager, administrator, director, or consultant) who + directly or indirectly manages, advises, or supervises + any element of the practices, finances, or operations of + the facility. + ``(D) Organizational structure.--The term + `organizational structure' means, in the case of-- + ``(i) a corporation, the officers, directors, + and shareholders of the corporation who have an + ownership interest in the corporation which is + equal to or exceeds 5 percent; + ``(ii) a limited liability company, the + members and managers of the limited liability + company (including, as applicable, what percentage + each member and manager has of the ownership + interest in the limited liability company); + ``(iii) a general partnership, the partners of + the general partnership; + +[[Page 124 STAT. 702]] + + ``(iv) a limited partnership, the general + partners and any limited partners of the limited + partnership who have an ownership interest in the + limited partnership which is equal to or exceeds + 10 percent; + ``(v) a trust, the trustees of the trust; + ``(vi) an individual, contact information for + the individual; and + ``(vii) any other person or entity, such + information as the Secretary determines + appropriate.''. + + (b) Public Availability of +Information. <<NOTE: Deadline. Procedures. 42 USC 1320a-3 note.>> --Not +later than the date that is 1 year after the date on which the final +regulations promulgated under section 1124(c)(3)(A) of the Social +Security Act, as added by subsection (a), are published in the Federal +Register, the Secretary of Health and Human Services shall make the +information reported in accordance with such final regulations available +to the public in accordance with procedures established by the +Secretary. + + (c) Conforming Amendments.-- + (1) In general.-- + (A) Skilled nursing facilities.--Section 1819(d)(1) + of the Social Security Act (42 U.S.C. 1395i-3(d)(1)) is + amended by striking subparagraph (B) and redesignating + subparagraph (C) as subparagraph (B). + (B) Nursing facilities.--Section 1919(d)(1) of the + Social Security Act (42 U.S.C. 1396r(d)(1)) is amended + by striking subparagraph (B) and redesignating + subparagraph (C) as subparagraph (B). + (2) <<NOTE: 42 USC 1395i-3 note.>> Effective date.--The + amendments made by paragraph (1) shall take effect on the date + on which the Secretary makes the information described in + subsection (b)(1) available to the public under such subsection. + +SEC. 6102. ACCOUNTABILITY REQUIREMENTS FOR SKILLED NURSING FACILITIES + AND NURSING FACILITIES. + + Part A of title XI of the Social Security Act (42 U.S.C. 1301 et +seq.), as amended by sections 6002 and 6004, is amended by inserting +after section 1128H the following new section: + +``SEC. 1128I. <<NOTE: 42 USC 1320a-7j.>> ACCOUNTABILITY REQUIREMENTS FOR + FACILITIES. + + ``(a) Definition of Facility.--In this section, the term `facility' +means-- + ``(1) a skilled nursing facility (as defined in section + 1819(a)); or + ``(2) a nursing facility (as defined in section 1919(a)). + + ``(b) Effective Compliance and Ethics Programs.-- + ``(1) Requirement. <<NOTE: Effective date.>> --On or after + the date that is 36 months after the date of the enactment of + this section, a facility shall, with respect to the entity that + operates the facility (in this subparagraph referred to as the + `operating organization' or `organization'), have in operation a + compliance and ethics program that is effective in preventing + and detecting criminal, civil, and administrative violations + under this Act and in promoting quality of care consistent with + regulations developed under paragraph (2). + ``(2) <<NOTE: Deadlines.>> Development of regulations.-- + ``(A) In general.--Not later than the date that is 2 + years after such date of the enactment, the Secretary, + +[[Page 124 STAT. 703]] + + working jointly with the Inspector General of the + Department of Health and Human Services, shall + promulgate regulations for an effective compliance and + ethics program for operating organizations, which may + include a model compliance program. + ``(B) Design of regulations.--Such regulations with + respect to specific elements or formality of a program + shall, in the case of an organization that operates 5 or + more facilities, vary with the size of the organization, + such that larger organizations should have a more formal + program and include established written policies + defining the standards and procedures to be followed by + its employees. Such requirements may specifically apply + to the corporate level management of multi unit nursing + home chains. + ``(C) Evaluation.--Not later than 3 years after the + date of the promulgation of regulations under this + paragraph, the Secretary shall complete an evaluation of + the compliance and ethics programs required to be + established under this subsection. Such evaluation shall + determine if such programs led to changes in deficiency + citations, changes in quality performance, or changes in + other metrics of patient quality of + care. <<NOTE: Reports.>> The Secretary shall submit to + Congress a report on such evaluation and shall include + in such report such recommendations regarding changes in + the requirements for such programs as the Secretary + determines appropriate. + ``(3) Requirements for compliance and ethics + programs. <<NOTE: Definition.>> --In this subsection, the term + `compliance and ethics program' means, with respect to a + facility, a program of the operating organization that-- + ``(A) has been reasonably designed, implemented, and + enforced so that it generally will be effective in + preventing and detecting criminal, civil, and + administrative violations under this Act and in + promoting quality of care; and + ``(B) includes at least the required components + specified in paragraph (4). + ``(4) Required components of program.--The required + components of a compliance and ethics program of an operating + organization are the following: + ``(A) The organization must have established + compliance standards and procedures to be followed by + its employees and other agents that are reasonably + capable of reducing the prospect of criminal, civil, and + administrative violations under this Act. + ``(B) Specific individuals within high-level + personnel of the organization must have been assigned + overall responsibility to oversee compliance with such + standards and procedures and have sufficient resources + and authority to assure such compliance. + ``(C) The organization must have used due care not + to delegate substantial discretionary authority to + individuals whom the organization knew, or should have + known through the exercise of due diligence, had a + propensity to engage in criminal, civil, and + administrative violations under this Act. + ``(D) The organization must have taken steps to + communicate effectively its standards and procedures to + all + +[[Page 124 STAT. 704]] + + employees and other agents, such as by requiring + participation in training programs or by disseminating + publications that explain in a practical manner what is + required. + ``(E) The organization must have taken reasonable + steps to achieve compliance with its standards, such as + by utilizing monitoring and auditing systems reasonably + designed to detect criminal, civil, and administrative + violations under this Act by its employees and other + agents and by having in place and publicizing a + reporting system whereby employees and other agents + could report violations by others within the + organization without fear of retribution. + ``(F) The standards must have been consistently + enforced through appropriate disciplinary mechanisms, + including, as appropriate, discipline of individuals + responsible for the failure to detect an offense. + ``(G) After an offense has been detected, the + organization must have taken all reasonable steps to + respond appropriately to the offense and to prevent + further similar offenses, including any necessary + modification to its program to prevent and detect + criminal, civil, and administrative violations under + this Act. + ``(H) The organization must periodically undertake + reassessment of its compliance program to identify + changes necessary to reflect changes within the + organization and its facilities. + + ``(c) Quality Assurance and Performance Improvement Program.-- + ``(1) In general. <<NOTE: Deadlines.>> --Not later than + December 31, 2011, the Secretary shall establish and implement a + quality assurance and performance improvement program (in this + subparagraph referred to as the `QAPI program') for facilities, + including multi unit chains of + facilities. <<NOTE: Standards.>> Under the QAPI program, the + Secretary shall establish standards relating to quality + assurance and performance improvement with respect to facilities + and provide technical assistance to facilities on the + development of best practices in order to meet such + standards. <<NOTE: Plan.>> Not later than 1 year after the date + on which the regulations are promulgated under paragraph (2), a + facility must submit to the Secretary a plan for the facility to + meet such standards and implement such best practices, including + how to coordinate the implementation of such plan with quality + assessment and assurance activities conducted under sections + 1819(b)(1)(B) and 1919(b)(1)(B), as applicable. + ``(2) Regulations.--The Secretary shall promulgate + regulations to carry out this subsection.''. + +SEC. 6103. NURSING HOME COMPARE MEDICARE WEBSITE. + + (a) Skilled Nursing Facilities.-- + (1) In general.--Section 1819 of the Social Security Act (42 + U.S.C. 1395i-3) is amended-- + (A) by redesignating subsection (i) as subsection + (j); and + (B) by inserting after subsection (h) the following + new subsection: + + ``(i) Nursing Home Compare Website.-- + ``(1) Inclusion of additional information.-- + +[[Page 124 STAT. 705]] + + ``(A) In general.--The Secretary shall ensure that + the Department of Health and Human Services includes, as + part of the information provided for comparison of + nursing homes on the official Internet website of the + Federal Government for Medicare beneficiaries (commonly + referred to as the `Nursing Home Compare' Medicare + website) (or a successor website), the following + information in a manner that is prominent, updated on a + timely basis, easily accessible, readily understandable + to consumers of long-term care services, and searchable: + ``(i) Staffing data for each facility + (including resident census data and data on the + hours of care provided per resident per day) based + on data submitted under section 1128I(g), + including information on staffing turnover and + tenure, in a format that is clearly understandable + to consumers of long-term care services and allows + such consumers to compare differences in staffing + between facilities and State and national averages + for the facilities. Such format shall include-- + ``(I) concise explanations of how to + interpret the data (such as a plain + English explanation of data reflecting + `nursing home staff hours per resident + day'); + ``(II) differences in types of staff + (such as training associated with + different categories of staff); + ``(III) the relationship between + nurse staffing levels and quality of + care; and + ``(IV) an explanation that + appropriate staffing levels vary based + on patient case mix. + ``(ii) Links to State Internet websites with + information regarding State survey and + certification programs, links to Form 2567 State + inspection reports (or a successor form) on such + websites, information to guide consumers in how to + interpret and understand such reports, and the + facility plan of correction or other response to + such report. Any such links shall be posted on a + timely basis. + ``(iii) The standardized complaint form + developed under section 1128I(f), including + explanatory material on what complaint forms are, + how they are used, and how to file a complaint + with the State survey and certification program + and the State long-term care ombudsman program. + ``(iv) Summary information on the number, + type, severity, and outcome of substantiated + complaints. + ``(v) The number of adjudicated instances of + criminal violations by a facility or the employees + of a facility-- + ``(I) that were committed inside the + facility; + ``(II) with respect to such + instances of violations or crimes + committed inside of the facility that + were the violations or crimes of abuse, + neglect, and exploitation, criminal + sexual abuse, or other violations or + crimes that resulted in serious bodily + injury; and + +[[Page 124 STAT. 706]] + + ``(III) the number of civil monetary + penalties levied against the facility, + employees, contractors, and other + agents. + ``(B) Deadline for provision of information.-- + ``(i) In general.--Except as provided in + clause (ii), the Secretary shall ensure that the + information described in subparagraph (A) is + included on such website (or a successor website) + not later than 1 year after the date of the + enactment of this subsection. + ``(ii) Exception.--The Secretary shall ensure + that the information described in subparagraph + (A)(i) is included on such website (or a successor + website) not later than the date on which the + requirements under section 1128I(g) are + implemented. + ``(2) Review and modification of website.-- + ``(A) In general. <<NOTE: Procedures.>> --The + Secretary shall establish a process-- + ``(i) to review the accuracy, clarity of + presentation, timeliness, and comprehensiveness of + information reported on such website as of the day + before the date of the enactment of this + subsection; and + ``(ii) <<NOTE: Deadline.>> not later than 1 + year after the date of the enactment of this + subsection, to modify or revamp such website in + accordance with the review conducted under clause + (i). + ``(B) Consultation.--In conducting the review under + subparagraph (A)(i), the Secretary shall consult with-- + ``(i) State long-term care ombudsman programs; + ``(ii) consumer advocacy groups; + ``(iii) provider stakeholder groups; and + ``(iv) any other representatives of programs + or groups the Secretary determines appropriate.''. + (2) Timeliness of submission of survey and certification + information.-- + (A) In general.--Section 1819(g)(5) of the Social + Security Act (42 U.S.C. 1395i-3(g)(5)) is amended by + adding at the end the following new subparagraph: + ``(E) Submission of survey and certification + information to the secretary.--In order to improve the + timeliness of information made available to the public + under subparagraph (A) and provided on the Nursing Home + Compare Medicare website under subsection (i), each + State shall submit information respecting any survey or + certification made respecting a skilled nursing facility + (including any enforcement actions taken by the State) + to the Secretary not later than the date on which the + State sends such information to the facility. The + Secretary shall use the information submitted under the + preceding sentence to update the information provided on + the Nursing Home Compare Medicare website as + expeditiously as practicable but not less frequently + than quarterly.''. + (B) <<NOTE: 42 USC 1395i-3 note.>> Effective date.-- + The amendment made by this paragraph shall take effect 1 + year after the date of the enactment of this Act. + (3) Special focus facility program.--Section 1819(f) of the + Social Security Act (42 U.S.C. 1395i-3(f)) is amended by adding + at the end the following new paragraph: + +[[Page 124 STAT. 707]] + + ``(8) Special focus facility program.-- + ``(A) In general.--The Secretary shall conduct a + special focus facility program for enforcement of + requirements for skilled nursing facilities that the + Secretary has identified as having substantially failed + to meet applicable requirement of this Act. + ``(B) Periodic surveys.--Under such program the + Secretary shall conduct surveys of each facility in the + program not less than once every 6 months.''. + + (b) Nursing Facilities.-- + (1) In general.--Section 1919 of the Social Security Act (42 + U.S.C. 1396r) is amended-- + (A) by redesignating subsection (i) as subsection + (j); and + (B) by inserting after subsection (h) the following + new subsection: + + ``(i) Nursing Home Compare Website.-- + ``(1) Inclusion of additional information.-- + ``(A) In general.--The Secretary shall ensure that + the Department of Health and Human Services includes, as + part of the information provided for comparison of + nursing homes on the official Internet website of the + Federal Government for Medicare beneficiaries (commonly + referred to as the `Nursing Home Compare' Medicare + website) (or a successor website), the following + information in a manner that is prominent, updated on a + timely basis, easily accessible, readily understandable + to consumers of long-term care services, and searchable: + ``(i) Staffing data for each facility + (including resident census data and data on the + hours of care provided per resident per day) based + on data submitted under section 1128I(g), + including information on staffing turnover and + tenure, in a format that is clearly understandable + to consumers of long-term care services and allows + such consumers to compare differences in staffing + between facilities and State and national averages + for the facilities. Such format shall include-- + ``(I) concise explanations of how to + interpret the data (such as plain + English explanation of data reflecting + `nursing home staff hours per resident + day'); + ``(II) differences in types of staff + (such as training associated with + different categories of staff); + ``(III) the relationship between + nurse staffing levels and quality of + care; and + ``(IV) an explanation that + appropriate staffing levels vary based + on patient case mix. + ``(ii) Links to State Internet websites with + information regarding State survey and + certification programs, links to Form 2567 State + inspection reports (or a successor form) on such + websites, information to guide consumers in how to + interpret and understand such reports, and the + facility plan of correction or other response to + such report. Any such links shall be posted on a + timely basis. + +[[Page 124 STAT. 708]] + + ``(iii) The standardized complaint form + developed under section 1128I(f), including + explanatory material on what complaint forms are, + how they are used, and how to file a complaint + with the State survey and certification program + and the State long-term care ombudsman program. + ``(iv) Summary information on the number, + type, severity, and outcome of substantiated + complaints. + ``(v) The number of adjudicated instances of + criminal violations by a facility or the employees + of a facility-- + ``(I) that were committed inside of + the facility; and + ``(II) with respect to such + instances of violations or crimes + committed outside of the facility, that + were violations or crimes that resulted + in the serious bodily injury of an + elder. + ``(B) Deadline for provision of information.-- + ``(i) In general.--Except as provided in + clause (ii), the Secretary shall ensure that the + information described in subparagraph (A) is + included on such website (or a successor website) + not later than 1 year after the date of the + enactment of this subsection. + ``(ii) Exception.--The Secretary shall ensure + that the information described in subparagraph + (A)(i) is included on such website (or a successor + website) not later than the date on which the + requirements under section 1128I(g) are + implemented. + ``(2) Review and modification of website.-- + ``(A) In general. <<NOTE: Procedures.>> --The + Secretary shall establish a process-- + ``(i) to review the accuracy, clarity of + presentation, timeliness, and comprehensiveness of + information reported on such website as of the day + before the date of the enactment of this + subsection; and + ``(ii) <<NOTE: Deadline.>> not later than 1 + year after the date of the enactment of this + subsection, to modify or revamp such website in + accordance with the review conducted under clause + (i). + ``(B) Consultation.--In conducting the review under + subparagraph (A)(i), the Secretary shall consult with-- + ``(i) State long-term care ombudsman programs; + ``(ii) consumer advocacy groups; + ``(iii) provider stakeholder groups; + ``(iv) skilled nursing facility employees and + their representatives; and + ``(v) any other representatives of programs or + groups the Secretary determines appropriate.''. + (2) Timeliness of submission of survey and certification + information.-- + (A) In general.--Section 1919(g)(5) of the Social + Security Act (42 U.S.C. 1396r(g)(5)) is amended by + adding at the end the following new subparagraph: + ``(E) <<NOTE: Deadline.>> Submission of survey and + certification information to the secretary.--In order to + improve the timeliness of information made available to + the public under subparagraph (A) and provided on the + Nursing Home + +[[Page 124 STAT. 709]] + + Compare Medicare website under subsection (i), each + State shall submit information respecting any survey or + certification made respecting a nursing facility + (including any enforcement actions taken by the State) + to the Secretary not later than the date on which the + State sends such information to the facility. The + Secretary shall use the information submitted under the + preceding sentence to update the information provided on + the Nursing Home Compare Medicare website as + expeditiously as practicable but not less frequently + than quarterly.''. + (B) Effective date. <<NOTE: 42 USC 1396r note.>> -- + The amendment made by this paragraph shall take effect 1 + year after the date of the enactment of this Act. + (3) Special focus facility program.--Section 1919(f) of the + Social Security Act (42 U.S.C. 1396r(f)) is amended by adding at + the end of the following new paragraph: + ``(10) Special focus facility program.-- + ``(A) In general.--The Secretary shall conduct a + special focus facility program for enforcement of + requirements for nursing facilities that the Secretary + has identified as having substantially failed to meet + applicable requirements of this Act. + ``(B) Periodic surveys.--Under such program the + Secretary shall conduct surveys of each facility in the + program not less often than once every 6 months.''. + + (c) Availability of Reports on Surveys, Certifications, and +Complaint Investigations.-- + (1) Skilled nursing facilities.--Section 1819(d)(1) of the + Social Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by + section 6101, is amended by adding at the end the following new + subparagraph: + ``(C) Availability of survey, certification, and + complaint investigation reports.--A skilled nursing + facility must-- + ``(i) have reports with respect to any + surveys, certifications, and complaint + investigations made respecting the facility during + the 3 preceding years available for any individual + to review upon request; and + ``(ii) <<NOTE: Public information.>> post + notice of the availability of such reports in + areas of the facility that are prominent and + accessible to the public. + The facility shall not make available under clause (i) + identifying information about complainants or + residents.''. + (2) Nursing facilities.--Section 1919(d)(1) of the Social + Security Act (42 U.S.C. 1396r(d)(1)), as amended by section + 6101, is amended by adding at the end the following new + subparagraph: + ``(V) Availability of survey, certification, and + complaint investigation reports.--A nursing facility + must-- + ``(i) have reports with respect to any + surveys, certifications, and complaint + investigations made respecting the facility during + the 3 preceding years available for any individual + to review upon request; and + +[[Page 124 STAT. 710]] + + ``(ii) <<NOTE: Public information.>> post + notice of the availability of such reports in + areas of the facility that are prominent and + accessible to the public. + The facility shall not make available under clause (i) + identifying information about complainants or + residents.''. + (3) Effective date. <<NOTE: 42 USC 1395i-3 note.>> --The + amendments made by this subsection shall take effect 1 year + after the date of the enactment of this Act. + + (d) Guidance to States on Form 2567 State Inspection Reports and +Complaint Investigation Reports.-- + (1) Guidance. <<NOTE: 42 USC 1395i-3 note. Web posting.>> -- + The Secretary of Health and Human Services (in this subtitle + referred to as the ``Secretary'') shall provide guidance to + States on how States can establish electronic links to Form 2567 + State inspection reports (or a successor form), complaint + investigation reports, and a facility's plan of correction or + other response to such Form 2567 State inspection reports (or a + successor form) on the Internet website of the State that + provides information on skilled nursing facilities and nursing + facilities and the Secretary shall, if possible, include such + information on Nursing Home Compare. + (2) Requirement.--Section 1902(a)(9) of the Social Security + Act (42 U.S.C. 1396a(a)(9)) is amended-- + (A) by striking ``and'' at the end of subparagraph + (B); + (B) by striking the semicolon at the end of + subparagraph (C) and inserting ``, and''; and + (C) by adding at the end the following new + subparagraph: + ``(D) that the State maintain a consumer-oriented + website providing useful information to consumers + regarding all skilled nursing facilities and all nursing + facilities in the State, including for each facility, + Form 2567 State inspection reports (or a successor + form), complaint investigation reports, the facility's + plan of correction, and such other information that the + State or the Secretary considers useful in assisting the + public to assess the quality of long term care options + and the quality of care provided by individual + facilities;''. + (3) <<NOTE: 42 USC 1395i-3 note.>> Definitions.--In this + subsection: + (A) Nursing facility.--The term ``nursing facility'' + has the meaning given such term in section 1919(a) of + the Social Security Act (42 U.S.C. 1396r(a)). + (B) Secretary.--The term ``Secretary'' means the + Secretary of Health and Human Services. + (C) Skilled nursing facility.--The term ``skilled + nursing facility'' has the meaning given such term in + section 1819(a) of the Social Security Act (42 U.S.C. + 1395i-3(a)). + + (e) <<NOTE: 42 USC 1395i-3 note. Deadline.>> Development of Consumer +Rights Information Page on Nursing Home Compare Website.--Not later than +1 year after the date of enactment of this Act, the Secretary shall +ensure that the Department of Health and Human Services, as part of the +information provided for comparison of nursing facilities on the Nursing +Home Compare Medicare website develops and includes a consumer rights +information page that contains links to descriptions of, and information +with respect to, the following: + (1) The documentation on nursing facilities that is + available to the public. + +[[Page 124 STAT. 711]] + + (2) General information and tips on choosing a nursing + facility that meets the needs of the individual. + (3) General information on consumer rights with respect to + nursing facilities. + (4) The nursing facility survey process (on a national and + State-specific basis). + (5) On a State-specific basis, the services available + through the State long-term care ombudsman for such State. + +SEC. 6104. REPORTING OF EXPENDITURES. + + Section 1888 of the Social Security Act (42 U.S.C. 1395yy) is +amended by adding at the end the following new subsection: + ``(f) Reporting of Direct Care Expenditures.-- + ``(1) In general.--For cost reports submitted under this + title for cost reporting periods beginning on or after the date + that is 2 years after the date of the enactment of this + subsection, skilled nursing facilities shall separately report + expenditures for wages and benefits for direct care staff + (breaking out (at a minimum) registered nurses, licensed + professional nurses, certified nurse assistants, and other + medical and therapy staff). + ``(2) Modification of form.--The Secretary, in consultation + with private sector accountants experienced with Medicare and + Medicaid nursing facility home cost reports, shall redesign such + reports to meet the requirement of paragraph (1) not later than + 1 year after the date of the enactment of this subsection. + ``(3) Categorization by functional accounts.--Not later than + 30 months after the date of the enactment of this subsection, + the Secretary, working in consultation with the Medicare Payment + Advisory Commission, the Medicaid and CHIP Payment and Access + Commission, the Inspector General of the Department of Health + and Human Services, and other expert parties the Secretary + determines appropriate, shall take the expenditures listed on + cost reports, as modified under paragraph (1), submitted by + skilled nursing facilities and categorize such expenditures, + regardless of any source of payment for such expenditures, for + each skilled nursing facility into the following functional + accounts on an annual basis: + ``(A) Spending on direct care services (including + nursing, therapy, and medical services). + ``(B) Spending on indirect care (including + housekeeping and dietary services). + ``(C) Capital assets (including building and land + costs). + ``(D) Administrative services costs. + ``(4) Availability of information + submitted. <<NOTE: Procedures.>> --The Secretary shall establish + procedures to make information on expenditures submitted under + this subsection readily available to interested parties upon + request, subject to such requirements as the Secretary may + specify under the procedures established under this + paragraph.''. + +SEC. 6105. STANDARDIZED COMPLAINT FORM. + + (a) In General.--Section 1128I of the Social Security Act, as added +and amended by this Act, is amended by adding at the end the following +new subsection: + ``(f) <<NOTE: 42 USC 1320a-7j.>> Standardized Complaint Form.-- + ``(1) Development by the secretary.--The Secretary shall + develop a standardized complaint form for use by a resident + +[[Page 124 STAT. 712]] + + (or a person acting on the resident's behalf) in filing a + complaint with a State survey and certification agency and a + State long-term care ombudsman program with respect to a + facility. + ``(2) Complaint forms and resolution processes.-- + ``(A) Complaint forms.--The State must make the + standardized complaint form developed under paragraph + (1) available upon request to-- + ``(i) a resident of a facility; and + ``(ii) any person acting on the resident's + behalf. + ``(B) Complaint resolution process.--The State must + establish a complaint resolution process in order to + ensure that the legal representative of a resident of a + facility or other responsible party is not denied access + to such resident or otherwise retaliated against if they + have complained about the quality of care provided by + the facility or other issues relating to the facility. + Such complaint resolution process shall include-- + ``(i) procedures to assure accurate tracking + of complaints received, including notification to + the complainant that a complaint has been + received; + ``(ii) procedures to determine the likely + severity of a complaint and for the investigation + of the complaint; and + ``(iii) deadlines for responding to a + complaint and for notifying the complainant of the + outcome of the investigation. + ``(3) Rule of construction.--Nothing in this subsection + shall be construed as preventing a resident of a facility (or a + person acting on the resident's behalf) from submitting a + complaint in a manner or format other than by using the + standardized complaint form developed under paragraph (1) + (including submitting a complaint orally).''. + + (b) <<NOTE: 42 USC 1320a-7j note.>> Effective Date.--The amendment +made by this section shall take effect 1 year after the date of the +enactment of this Act. + +SEC. 6106. ENSURING STAFFING ACCOUNTABILITY. + + Section 1128I of the Social Security Act, as added and amended by +this Act, <<NOTE: 42 USC 1320a-7j.>> is amended by adding at the end the +following new subsection: + + ``(g) Submission of Staffing Information Based on Payroll Data in a +Uniform Format. <<NOTE: Deadline.>> --Beginning not later than 2 years +after the date of the enactment of this subsection, and after consulting +with State long-term care ombudsman programs, consumer advocacy groups, +provider stakeholder groups, employees and their representatives, and +other parties the Secretary deems appropriate, the Secretary shall +require a facility to electronically submit to the Secretary direct care +staffing information (including information with respect to agency and +contract staff) based on payroll and other verifiable and auditable data +in a uniform format (according to specifications established by the +Secretary in consultation with such programs, groups, and parties). Such +specifications shall require that the information submitted under the +preceding sentence-- + ``(1) specify the category of work a certified employee + performs (such as whether the employee is a registered nurse, + +[[Page 124 STAT. 713]] + + licensed practical nurse, licensed vocational nurse, certified + nursing assistant, therapist, or other medical personnel); + ``(2) include resident census data and information on + resident case mix; + ``(3) include a regular reporting schedule; and + ``(4) include information on employee turnover and tenure + and on the hours of care provided by each category of certified + employees referenced in paragraph (1) per resident per day. + +Nothing in this subsection shall be construed as preventing the +Secretary from requiring submission of such information with respect to +specific categories, such as nursing staff, before other categories of +certified employees. Information under this subsection with respect to +agency and contract staff shall be kept separate from information on +employee staffing.''. + +SEC. 6107. GAO STUDY AND REPORT ON FIVE-STAR QUALITY RATING SYSTEM. + + (a) Study.--The Comptroller General of the United States (in this +section referred to as the ``Comptroller General'') shall conduct a +study on the Five-Star Quality Rating System for nursing homes of the +Centers for Medicare & Medicaid Services. Such study shall include an +analysis of-- + (1) how such system is being implemented; + (2) any problems associated with such system or its + implementation; and + (3) how such system could be improved. + + (b) Report.--Not later than 2 years after the date of enactment of +this Act, the Comptroller General shall submit to Congress a report +containing the results of the study conducted under subsection (a), +together with recommendations for such legislation and administrative +action as the Comptroller General determines appropriate. + + PART II--TARGETING ENFORCEMENT + +SEC. 6111. CIVIL MONEY PENALTIES. + + (a) Skilled Nursing Facilities.-- + (1) In general.--Section 1819(h)(2)(B)(ii) of the Social + Security Act (42 U.S.C. 1395i-3(h)(2)(B)(ii)) is amended-- + (A) by striking ``Penalties.--The Secretary'' and + inserting ``penalties.-- + ``(I) In general.--Subject to + subclause (II), the Secretary''; and + (B) by adding at the end the following new + subclauses: + ``(II) Reduction of civil money + penalties in certain + circumstances. <<NOTE: Deadline.>> -- + Subject to subclause (III), in the case + where a facility self-reports and + promptly corrects a deficiency for which + a penalty was imposed under this clause + not later than 10 calendar days after + the date of such imposition, the + Secretary may reduce the amount of the + penalty imposed by not more than 50 + percent. + ``(III) Prohibitions on reduction + for certain deficiencies.-- + ``(aa) Repeat + deficiencies.--The Secretary may + not reduce the amount of a + penalty under subclause (II) if + the Secretary had + +[[Page 124 STAT. 714]] + + reduced a penalty imposed on the + facility in the preceding year + under such subclause with + respect to a repeat deficiency. + ``(bb) Certain other + deficiencies.--The Secretary may + not reduce the amount of a + penalty under subclause (II) if + the penalty is imposed on the + facility for a deficiency that + is found to result in a pattern + of harm or widespread harm, + immediately jeopardizes the + health or safety of a resident + or residents of the facility, or + results in the death of a + resident of the facility. + ``(IV) Collection of civil money + penalties. <<NOTE: Regulations.>> --In + the case of a civil money penalty + imposed under this clause, the Secretary + shall issue regulations that-- + + ``(aa) <<NOTE: Deadline.>> subjec + t to item (cc), not later than + 30 days after the imposition of + the penalty, provide for the + facility to have the opportunity + to participate in an independent + informal dispute resolution + process which generates a + written record prior to the + collection of such penalty; + ``(bb) <<NOTE: Time + period.>> in the case where the + penalty is imposed for each day + of noncompliance, provide that a + penalty may not be imposed for + any day during the period + beginning on the initial day of + the imposition of the penalty + and ending on the day on which + the informal dispute resolution + process under item (aa) is + completed; + ``(cc) may provide for the + collection of such civil money + penalty and the placement of + such amounts collected in an + escrow account under the + direction of the Secretary on + the earlier of the date on which + the informal dispute resolution + process under item (aa) is + completed or the date that is 90 + days after the date of the + imposition of the penalty; + ``(dd) may provide that such + amounts collected are kept in + such account pending the + resolution of any subsequent + appeals; + ``(ee) in the case where the + facility successfully appeals + the penalty, may provide for the + return of such amounts collected + (plus interest) to the facility; + and + ``(ff) in the case where all + such appeals are unsuccessful, + may provide that some portion of + such amounts collected may be + used to support activities that + benefit residents, including + assistance to support and + protect residents of a facility + that closes (voluntarily or + involuntarily) or is decertified + (including offsetting costs of + relocating residents to home and + community-based settings or + another facility), projects that + support resident and + +[[Page 124 STAT. 715]] + + family councils and other + consumer involvement in assuring + quality care in facilities, and + facility improvement initiatives + approved by the Secretary + (including joint training of + facility staff and surveyors, + technical assistance for + facilities implementing quality + assurance programs, the + appointment of temporary + management firms, and other + activities approved by the + Secretary).''. + (2) Conforming amendment.--The second sentence of section + 1819(h)(5) of the Social Security Act (42 U.S.C. 1395i-3(h)(5)) + is amended by inserting ``(ii)(IV),'' after ``(i),''. + + (b) Nursing Facilities.-- + (1) In general.--Section 1919(h)(3)(C)(ii) of the Social + Security Act (42 U.S.C. 1396r(h)(3)(C)) is amended-- + (A) by striking ``Penalties.--The Secretary'' and + inserting ``penalties.-- + ``(I) In general.--Subject to + subclause (II), the Secretary''; and + (B) by adding at the end the following new + subclauses: + ``(II) Reduction of civil money + penalties in certain + circumstances. <<NOTE: Deadline.>> -- + Subject to subclause (III), in the case + where a facility self-reports and + promptly corrects a deficiency for which + a penalty was imposed under this clause + not later than 10 calendar days after + the date of such imposition, the + Secretary may reduce the amount of the + penalty imposed by not more than 50 + percent. + ``(III) Prohibitions on reduction + for certain deficiencies.-- + ``(aa) Repeat + deficiencies.--The Secretary may + not reduce the amount of a + penalty under subclause (II) if + the Secretary had reduced a + penalty imposed on the facility + in the preceding year under such + subclause with respect to a + repeat deficiency. + ``(bb) Certain other + deficiencies.--The Secretary may + not reduce the amount of a + penalty under subclause (II) if + the penalty is imposed on the + facility for a deficiency that + is found to result in a pattern + of harm or widespread harm, + immediately jeopardizes the + health or safety of a resident + or residents of the facility, or + results in the death of a + resident of the facility. + ``(IV) Collection of civil money + penalties. <<NOTE: Regulations.>> --In + the case of a civil money penalty + imposed under this clause, the Secretary + shall issue regulations that-- + + ``(aa) <<NOTE: Deadline.>> subjec + t to item (cc), not later than + 30 days after the imposition of + the penalty, provide for the + facility to have the opportunity + to participate in an independent + informal dispute resolution + process which generates a + written record prior to the + collection of such penalty; + +[[Page 124 STAT. 716]] + + ``(bb) <<NOTE: Time + period.>> in the case where the + penalty is imposed for each day + of noncompliance, provide that a + penalty may not be imposed for + any day during the period + beginning on the initial day of + the imposition of the penalty + and ending on the day on which + the informal dispute resolution + process under item (aa) is + completed; + ``(cc) may provide for the + collection of such civil money + penalty and the placement of + such amounts collected in an + escrow account under the + direction of the Secretary on + the earlier of the date on which + the informal dispute resolution + process under item (aa) is + completed or the date that is 90 + days after the date of the + imposition of the penalty; + ``(dd) may provide that such + amounts collected are kept in + such account pending the + resolution of any subsequent + appeals; + ``(ee) in the case where the + facility successfully appeals + the penalty, may provide for the + return of such amounts collected + (plus interest) to the facility; + and + ``(ff) in the case where all + such appeals are unsuccessful, + may provide that some portion of + such amounts collected may be + used to support activities that + benefit residents, including + assistance to support and + protect residents of a facility + that closes (voluntarily or + involuntarily) or is decertified + (including offsetting costs of + relocating residents to home and + community-based settings or + another facility), projects that + support resident and family + councils and other consumer + involvement in assuring quality + care in facilities, and facility + improvement initiatives approved + by the Secretary (including + joint training of facility staff + and surveyors, technical + assistance for facilities + implementing quality assurance + programs, the appointment of + temporary management firms, and + other activities approved by the + Secretary).''. + (2) Conforming amendment.--Section 1919(h)(5)(8) of the + Social Security Act (42 U.S.C. 1396r(h)(5)(8)) is amended by + inserting ``(ii)(IV),'' after ``(i),''. + + (c) <<NOTE: 42 USC 1395i-3 note.>> Effective Date.--The amendments +made by this section shall take effect 1 year after the date of the +enactment of this Act. + +SEC. 6112. <<NOTE: 42 USC 1320a-7j note.>> NATIONAL INDEPENDENT MONITOR + DEMONSTRATION PROJECT. + + (a) Establishment.-- + (1) In general.--The Secretary, in consultation with the + Inspector General of the Department of Health and Human + Services, shall conduct a demonstration project to develop, + test, and implement an independent monitor program to oversee + +[[Page 124 STAT. 717]] + + interstate and large intrastate chains of skilled nursing + facilities and nursing facilities. + (2) Selection.--The Secretary shall select chains of skilled + nursing facilities and nursing facilities described in paragraph + (1) to participate in the demonstration project under this + section from among those chains that submit an application to + the Secretary at such time, in such manner, and containing such + information as the Secretary may require. + (3) Duration.--The Secretary shall conduct the demonstration + project under this section for a 2-year period. + (4) Implementation. <<NOTE: Deadline.>> --The Secretary + shall implement the demonstration project under this section not + later than 1 year after the date of the enactment of this Act. + + (b) Requirements. <<NOTE: Evaluation.>> --The Secretary shall +evaluate chains selected to participate in the demonstration project +under this section based on criteria selected by the Secretary, +including where evidence suggests that a number of the facilities of the +chain are experiencing serious safety and quality of care problems. Such +criteria may include the evaluation of a chain that includes a number of +facilities participating in the ``Special Focus Facility'' program (or a +successor program) or multiple facilities with a record of repeated +serious safety and quality of care deficiencies. + + (c) Responsibilities. <<NOTE: Contracts.>> --An independent monitor +that enters into a contract with the Secretary to participate in the +conduct of the demonstration project under this section shall-- + (1) <<NOTE: Review.>> conduct periodic reviews and prepare + root-cause quality and deficiency analyses of a chain to assess + if facilities of the chain are in compliance with State and + Federal laws and regulations applicable to the facilities; + (2) conduct sustained oversight of the efforts of the chain, + whether publicly or privately held, to achieve compliance by + facilities of the chain with State and Federal laws and + regulations applicable to the facilities; + (3) analyze the management structure, distribution of + expenditures, and nurse staffing levels of facilities of the + chain in relation to resident census, staff turnover rates, and + tenure; + (4) <<NOTE: Reports.>> report findings and recommendations + with respect to such reviews, analyses, and oversight to the + chain and facilities of the chain, to the Secretary, and to + relevant States; and + (5) <<NOTE: Publication.>> publish the results of such + reviews, analyses, and oversight. + + (d) Implementation of Recommendations.-- + (1) Receipt of finding by chain. <<NOTE: Deadline.>> --Not + later than 10 days after receipt of a finding of an independent + monitor under subsection (c)(4), <<NOTE: Reports.>> a chain + participating in the demonstration project shall submit to the + independent monitor a report-- + (A) outlining corrective actions the chain will take + to implement the recommendations in such report; or + (B) indicating that the chain will not implement + such recommendations, and why it will not do so. + (2) Receipt of report by independent monitor.--Not later + than 10 days after receipt of a report submitted by a chain + under paragraph (1), an independent monitor shall finalize its + recommendations and submit a report to the chain and facilities + of the chain, the Secretary, and the State or States, as + appropriate, containing such final recommendations. + +[[Page 124 STAT. 718]] + + (e) Cost of Appointment.--A chain shall be responsible for a portion +of the costs associated with the appointment of independent monitors +under the demonstration project under this +section. <<NOTE: Payment. Procedures.>> The chain shall pay such portion +to the Secretary (in an amount and in accordance with procedures +established by the Secretary). + + (f) Waiver Authority.--The Secretary may waive such requirements of +titles XVIII and XIX of the Social Security Act (42 U.S.C. 1395 et seq.; +1396 et seq.) as may be necessary for the purpose of carrying out the +demonstration project under this section. + (g) Authorization of Appropriations.--There are authorized to be +appropriated such sums as may be necessary to carry out this section. + (h) Definitions.--In this section: + (1) Additional disclosable party.--The term ``additional + disclosable party'' has the meaning given such term in section + 1124(c)(5)(A) of the Social Security Act, as added by section + 4201(a). + (2) Facility.--The term ``facility'' means a skilled nursing + facility or a nursing facility. + (3) Nursing facility.--The term ``nursing facility'' has the + meaning given such term in section 1919(a) of the Social + Security Act (42 U.S.C. 1396r(a)). + (4) Secretary.--The term ``Secretary'' means the Secretary + of Health and Human Services, acting through the Assistant + Secretary for Planning and Evaluation. + (5) Skilled nursing facility.--The term ``skilled nursing + facility'' has the meaning given such term in section 1819(a) of + the Social Security Act (42 U.S.C. 1395(a)). + + (i) Evaluation and Report.-- + (1) Evaluation.--The Secretary, in consultation with the + Inspector General of the Department of Health and Human + Services, shall evaluate the demonstration project conducted + under this section. + (2) Report.--Not later than 180 days after the completion of + the demonstration project under this section, the Secretary + shall submit to Congress a report containing the results of the + evaluation conducted under paragraph (1), together with + recommendations-- + (A) as to whether the independent monitor program + should be established on a permanent basis; + (B) if the Secretary recommends that such program be + so established, on appropriate procedures and mechanisms + for such establishment; and + (C) for such legislation and administrative action + as the Secretary determines appropriate. + +SEC. 6113. NOTIFICATION OF FACILITY CLOSURE. + + (a) In General.--Section 1128I of the Social Security Act, as added +and amended by this Act, <<NOTE: 42 USC 1320a-7j.>> is amended by adding +at the end the following new subsection: + + ``(h) Notification of Facility Closure.-- + ``(1) In general.--Any individual who is the administrator + of a facility must-- + +[[Page 124 STAT. 719]] + + ``(A) <<NOTE: Notification. Deadlines.>> submit to + the Secretary, the State long-term care ombudsman, + residents of the facility, and the legal representatives + of such residents or other responsible parties, written + notification of an impending closure-- + ``(i) subject to clause (ii), not later than + the date that is 60 days prior to the date of such + closure; and + ``(ii) in the case of a facility where the + Secretary terminates the facility's participation + under this title, not later than the date that the + Secretary determines appropriate; + ``(B) ensure that the facility does not admit any + new residents on or after the date on which such written + notification is submitted; and + ``(C) <<NOTE: Plans.>> include in the notice a plan + for the transfer and adequate relocation of the + residents of the facility by a specified date prior to + closure that has been approved by the State, including + assurances that the residents will be transferred to the + most appropriate facility or other setting in terms of + quality, services, and location, taking into + consideration the needs, choice, and best interests of + each resident. + ``(2) Relocation.-- + ``(A) In general.--The State shall ensure that, + before a facility closes, all residents of the facility + have been successfully relocated to another facility or + an alternative home and community-based setting. + ``(B) Continuation of payments until residents + relocated.-- <<NOTE: Time period.>> The Secretary may, + as the Secretary determines appropriate, continue to + make payments under this title with respect to residents + of a facility that has submitted a notification under + paragraph (1) during the period beginning on the date + such notification is submitted and ending on the date on + which the resident is successfully relocated. + ``(3) Sanctions.--Any individual who is the administrator of + a facility that fails to comply with the requirements of + paragraph (1)-- + ``(A) shall be subject to a civil monetary penalty + of up to $100,000; + ``(B) may be subject to exclusion from participation + in any Federal health care program (as defined in + section 1128B(f)); and + ``(C) shall be subject to any other penalties that + may be prescribed by law. + ``(4) Procedure.-- <<NOTE: Applicability.>> The provisions + of section 1128A (other than subsections (a) and (b) and the + second sentence of subsection (f)) shall apply to a civil money + penalty or exclusion under paragraph (3) in the same manner as + such provisions apply to a penalty or proceeding under section + 1128A(a).''. + + (b) Conforming Amendments.--Section 1819(h)(4) of the Social +Security Act (42 U.S.C. 1395i-3(h)(4)) is amended-- + (1) in the first sentence, by striking ``the Secretary shall + terminate'' and inserting ``the Secretary, subject to section + 1128I(h), shall terminate''; and + (2) in the second sentence, by striking ``subsection + (c)(2)'' and inserting ``subsection (c)(2) and section + 1128I(h)''. + +[[Page 124 STAT. 720]] + + (c) <<NOTE: 42 USC 1320a-7j note.>> Effective Date.--The amendments +made by this section shall take effect 1 year after the date of the +enactment of this Act. + +SEC. 6114. <<NOTE: 42 USC 1395i-3 note.>> NATIONAL DEMONSTRATION + PROJECTS ON CULTURE CHANGE AND USE OF INFORMATION TECHNOLOGY + IN NURSING HOMES. + + (a) In General.--The Secretary shall conduct 2 demonstration +projects, 1 for the development of best practices in skilled nursing +facilities and nursing facilities that are involved in the culture +change movement (including the development of resources for facilities +to find and access funding in order to undertake culture change) and 1 +for the development of best practices in skilled nursing facilities and +nursing facilities for the use of information technology to improve +resident care. + (b) Conduct of Demonstration Projects.-- + (1) Grant award.--Under each demonstration project conducted + under this section, the Secretary shall award 1 or more grants + to facility-based settings for the development of best practices + described in subsection (a) with respect to the demonstration + project involved. Such award shall be made on a competitive + basis and may be allocated in 1 lump-sum payment. + (2) Consideration of special needs of residents.--Each + demonstration project conducted under this section shall take + into consideration the special needs of residents of skilled + nursing facilities and nursing facilities who have cognitive + impairment, including dementia. + + (c) Duration and Implementation.-- + (1) Duration.--The demonstration projects shall each be + conducted for a period not to exceed 3 years. + (2) Implementation.-- <<NOTE: Deadline.>> The demonstration + projects shall each be implemented not later than 1 year after + the date of the enactment of this Act. + + (d) Definitions.--In this section: + (1) Nursing facility.--The term ``nursing facility'' has the + meaning given such term in section 1919(a) of the Social + Security Act (42 U.S.C. 1396r(a)). + (2) Secretary.--The term ``Secretary'' means the Secretary + of Health and Human Services. + (3) Skilled nursing facility.--The term ``skilled nursing + facility'' has the meaning given such term in section 1819(a) of + the Social Security Act (42 U.S.C. 1395(a)). + + (e) Authorization of Appropriations.--There are authorized to be +appropriated such sums as may be necessary to carry out this section. + (f) Report.-- <<NOTE: Recommenda- tions.>> Not later than 9 months +after the completion of the demonstration project, the Secretary shall +submit to Congress a report on such project, together with +recommendations for such legislation and administrative action as the +Secretary determines appropriate. + + PART III--IMPROVING STAFF TRAINING + +SEC. 6121. DEMENTIA AND ABUSE PREVENTION TRAINING. + + (a) Skilled Nursing Facilities.-- + (1) In general.--Section 1819(f)(2)(A)(i)(I) of the Social + Security Act (42 U.S.C. 1395i-3(f)(2)(A)(i)(I)) is amended by + +[[Page 124 STAT. 721]] + + inserting ``(including, in the case of initial training and, if + the Secretary determines appropriate, in the case of ongoing + training, dementia management training, and patient abuse + prevention training'' before ``, (II)''. + (2) Clarification of definition of nurse aide.--Section + 1819(b)(5)(F) of the Social Security Act (42 U.S.C. 1395i- + 3(b)(5)(F)) is amended by adding at the end the following flush + sentence: + ``Such term includes an individual who provides such + services through an agency or under a contract with the + facility.''. + + (b) Nursing Facilities.-- + (1) In general.--Section 1919(f)(2)(A)(i)(I) of the Social + Security Act (42 U.S.C. 1396r(f)(2)(A)(i)(I)) is amended by + inserting ``(including, in the case of initial training and, if + the Secretary determines appropriate, in the case of ongoing + training, dementia management training, and patient abuse + prevention training'' before ``, (II)''. + (2) Clarification of definition of nurse aide.--Section + 1919(b)(5)(F) of the Social Security Act (42 U.S.C. + 1396r(b)(5)(F)) is amended by adding at the end the following + flush sentence: + ``Such term includes an individual who provides such + services through an agency or under a contract with the + facility.''. + + (c) <<NOTE: 42 USC 1395i-3 note.>> Effective Date.--The amendments +made by this section shall take effect 1 year after the date of the +enactment of this Act. + +Subtitle C--Nationwide Program for National and State Background Checks + on Direct Patient Access Employees of Long-term Care Facilities and + Providers + +SEC. 6201. <<NOTE: 42 USC 1320a-7l.>> NATIONWIDE PROGRAM FOR NATIONAL + AND STATE BACKGROUND CHECKS ON DIRECT PATIENT ACCESS + EMPLOYEES OF LONG-TERM CARE FACILITIES AND PROVIDERS. + + (a) In General.--The Secretary of Health and Human Services (in this +section referred to as the ``Secretary''), shall establish a program to +identify efficient, effective, and economical procedures for long term +care facilities or providers to conduct background checks on prospective +direct patient access employees on a nationwide basis (in this +subsection, such program shall be referred to as the ``nationwide +program''). Except for the following modifications, the Secretary shall +carry out the nationwide program under similar terms and conditions as +the pilot program under section 307 of the Medicare Prescription Drug, +Improvement, and Modernization Act of 2003 (Public Law 108-173; 117 +Stat. 2257), including the prohibition on hiring abusive workers and the +authorization of the imposition of penalties by a participating State +under subsection (b)(3)(A) and (b)(6), respectively, of such section +307: + (1) Agreements.-- + +[[Page 124 STAT. 722]] + + (A) Newly participating states.--The Secretary shall + enter into agreements with each State-- + (i) that the Secretary has not entered into an + agreement with under subsection (c)(1) of such + section 307; + (ii) that agrees to conduct background checks + under the nationwide program on a Statewide basis; + and + (iii) that submits an application to the + Secretary containing such information and at such + time as the Secretary may specify. + (B) Certain previously participating states.--The + Secretary shall enter into agreements with each State-- + (i) that the Secretary has entered into an + agreement with under such subsection (c)(1), but + only in the case where such agreement did not + require the State to conduct background checks + under the program established under subsection (a) + of such section 307 on a Statewide basis; + (ii) that agrees to conduct background checks + under the nationwide program on a Statewide basis; + and + (iii) that submits an application to the + Secretary containing such information and at such + time as the Secretary may specify. + (2) Nonapplication of selection criteria.--The selection + criteria required under subsection (c)(3)(B) of such section 307 + shall not apply. + (3) Required fingerprint check as part of criminal history + background check.--The procedures established under subsection + (b)(1) of such section 307 shall-- + (A) require that the long-term care facility or + provider (or the designated agent of the long-term care + facility or provider) obtain State and national criminal + history background checks on the prospective employee + through such means as the Secretary determines + appropriate, efficient, and effective that utilize a + search of State-based abuse and neglect registries and + databases, including the abuse and neglect registries of + another State in the case where a prospective employee + previously resided in that State, State criminal history + records, the records of any proceedings in the State + that may contain disqualifying information about + prospective employees (such as proceedings conducted by + State professional licensing and disciplinary boards and + State Medicaid Fraud Control Units), and Federal + criminal history records, including a fingerprint check + using the Integrated Automated Fingerprint + Identification System of the Federal Bureau of + Investigation; + (B) require States to describe and test methods that + reduce duplicative fingerprinting, including providing + for the development of ``rap back'' capability by the + State such that, if a direct patient access employee of + a long-term care facility or provider is convicted of a + crime following the initial criminal history background + check conducted + +[[Page 124 STAT. 723]] + + with respect to such employee, and the employee's + fingerprints match the prints on file with the State law + enforcement department, the department will immediately + inform the State and the State will immediately inform + the long-term care facility or provider which employs + the direct patient access employee of such conviction; + and + (C) require that criminal history background checks + conducted under the nationwide program remain valid for + a period of time specified by the Secretary. + (4) State requirements.--An agreement entered into under + paragraph (1) shall require that a participating State-- + (A) be responsible for monitoring compliance with + the requirements of the nationwide program; + (B) <<NOTE: Procedures.>> have procedures in place + to-- + (i) conduct screening and criminal history + background checks under the nationwide program in + accordance with the requirements of this section; + (ii) monitor compliance by long-term care + facilities and providers with the procedures and + requirements of the nationwide program; + (iii) as appropriate, provide for a + provisional period of employment by a long-term + care facility or provider of a direct patient + access employee, not to exceed 60 days, pending + completion of the required criminal history + background check and, in the case where the + employee has appealed the results of such + background check, pending completion of the + appeals process, during which the employee shall + be subject to direct on-site supervision (in + accordance with procedures established by the + State to ensure that a long-term care facility or + provider furnishes such direct on-site + supervision); + (iv) provide an independent process by which a + provisional employee or an employee may appeal or + dispute the accuracy of the information obtained + in a background check performed under the + nationwide program, including the specification of + criteria for appeals for direct patient access + employees found to have disqualifying information + which shall include consideration of the passage + of time, extenuating circumstances, demonstration + of rehabilitation, and relevancy of the particular + disqualifying information with respect to the + current employment of the individual; + (v) provide for the designation of a single + State agency as responsible for-- + (I) overseeing the coordination of + any State and national criminal history + background checks requested by a long- + term care facility or provider (or the + designated agent of the long-term care + facility or provider) utilizing a search + of State and Federal criminal history + records, including a fingerprint check + of such records; + (II) overseeing the design of + appropriate privacy and security + safeguards for use in the review of the + results of any State or national + criminal history background checks + conducted regarding a + +[[Page 124 STAT. 724]] + + prospective direct patient access + employee to determine whether the + employee has any conviction for a + relevant crime; + (III) immediately reporting to the + long-term care facility or provider that + requested the criminal history + background check the results of such + review; and + (IV) in the case of an employee with + a conviction for a relevant crime that + is subject to reporting under section + 1128E of the Social Security Act (42 + U.S.C. 1320a-7e), reporting the + existence of such conviction to the + database established under that section; + (vi) determine which individuals are direct + patient access employees (as defined in paragraph + (6)(B)) for purposes of the nationwide program; + (vii) as appropriate, specify offenses, + including convictions for violent crimes, for + purposes of the nationwide program; and + (viii) describe and test methods that reduce + duplicative fingerprinting, including providing + for the development of ``rap back'' capability + such that, if a direct patient access employee of + a long-term care facility or provider is convicted + of a crime following the initial criminal history + background check conducted with respect to such + employee, and the employee's fingerprints match + the prints on file with the State law enforcement + department-- + (I) the department will immediately + inform the State agency designated under + clause (v) and such agency will + immediately inform the facility or + provider which employs the direct + patient access employee of such + conviction; and + (II) the State will provide, or will + require the facility to provide, to the + employee a copy of the results of the + criminal history background check + conducted with respect to the employee + at no charge in the case where the + individual requests such a copy. + (5) Payments.-- + (A) Newly participating states.-- + (i) In general.--As part of the application + submitted by a State under paragraph (1)(A)(iii), + the State shall guarantee, with respect to the + costs to be incurred by the State in carrying out + the nationwide program, that the State will make + available (directly or through donations from + public or private entities) a particular amount of + non-Federal contributions, as a condition of + receiving the Federal match under clause (ii). + (ii) Federal match.--The payment amount to + each State that the Secretary enters into an + agreement with under paragraph (1)(A) shall be 3 + times the amount that the State guarantees to make + available under clause (i), except that in no case + may the payment amount exceed $3,000,000. + (B) Previously participating states.-- + +[[Page 124 STAT. 725]] + + (i) In general.--As part of the application + submitted by a State under paragraph (1)(B)(iii), + the State shall guarantee, with respect to the + costs to be incurred by the State in carrying out + the nationwide program, that the State will make + available (directly or through donations from + public or private entities) a particular amount of + non-Federal contributions, as a condition of + receiving the Federal match under clause (ii). + (ii) Federal match.--The payment amount to + each State that the Secretary enters into an + agreement with under paragraph (1)(B) shall be 3 + times the amount that the State guarantees to make + available under clause (i), except that in no case + may the payment amount exceed $1,500,000. + (6) Definitions.--Under the nationwide program: + (A) Conviction for a relevant crime.--The term + ``conviction for a relevant crime'' means any Federal or + State criminal conviction for-- + (i) any offense described in section 1128(a) + of the Social Security Act (42 U.S.C. 1320a-7); or + (ii) such other types of offenses as a + participating State may specify for purposes of + conducting the program in such State. + (B) Disqualifying information.--The term + ``disqualifying information'' means a conviction for a + relevant crime or a finding of patient or resident + abuse. + (C) Finding of patient or resident abuse.--The term + ``finding of patient or resident abuse'' means any + substantiated finding by a State agency under section + 1819(g)(1)(C) or 1919(g)(1)(C) of the Social Security + Act (42 U.S.C. 1395i-3(g)(1)(C), 1396r(g)(1)(C)) or a + Federal agency that a direct patient access employee has + committed-- + (i) an act of patient or resident abuse or + neglect or a misappropriation of patient or + resident property; or + (ii) such other types of acts as a + participating State may specify for purposes of + conducting the program in such State. + (D) Direct patient access employee.--The term + ``direct patient access employee'' means any individual + who has access to a patient or resident of a long-term + care facility or provider through employment or through + a contract with such facility or provider and has duties + that involve (or may involve) one-on-one contact with a + patient or resident of the facility or provider, as + determined by the State for purposes of the nationwide + program. Such term does not include a volunteer unless + the volunteer has duties that are equivalent to the + duties of a direct patient access employee and those + duties involve (or may involve) one-on-one contact with + a patient or resident of the long-term care facility or + provider. + (E) Long-term care facility or provider.--The term + ``long-term care facility or provider'' means the + following facilities or providers which receive payment + for services under title XVIII or XIX of the Social + Security Act: + +[[Page 124 STAT. 726]] + + (i) A skilled nursing facility (as defined in + section 1819(a) of the Social Security Act (42 + U.S.C. 1395i-3(a))). + (ii) A nursing facility (as defined in section + 1919(a) of such Act (42 U.S.C. 1396r(a))). + (iii) A home health agency. + (iv) A provider of hospice care (as defined in + section 1861(dd)(1) of such Act (42 U.S.C. + 1395x(dd)(1))). + (v) A long-term care hospital (as described in + section 1886(d)(1)(B)(iv) of such Act (42 U.S.C. + 1395ww(d)(1)(B)(iv))). + (vi) A provider of personal care services. + (vii) A provider of adult day care. + (viii) A residential care provider that + arranges for, or directly provides, long-term care + services, including an assisted living facility + that provides a level of care established by the + Secretary. + (ix) An intermediate care facility for the + mentally retarded (as defined in section 1905(d) + of such Act (42 U.S.C. 1396d(d))). + (x) Any other facility or provider of long- + term care services under such titles as the + participating State determines appropriate. + (7) Evaluation and report.-- + (A) Evaluation.-- + (i) In general.--The Inspector General of the + Department of Health and Human Services shall + conduct an evaluation of the nationwide program. + (ii) Inclusion of specific topics.--The + evaluation conducted under clause (i) shall + include the following: + (I) A review of the various + procedures implemented by participating + States for long-term care facilities or + providers, including staffing agencies, + to conduct background checks of direct + patient access employees under the + nationwide program and identification of + the most appropriate, efficient, and + effective procedures for conducting such + background checks. + (II) An assessment of the costs of + conducting such background checks + (including start up and administrative + costs). + (III) A determination of the extent + to which conducting such background + checks leads to any unintended + consequences, including a reduction in + the available workforce for long-term + care facilities or providers. + (IV) An assessment of the impact of + the nationwide program on reducing the + number of incidents of neglect, abuse, + and misappropriation of resident + property to the extent practicable. + (V) An evaluation of other aspects + of the nationwide program, as determined + appropriate by the Secretary. + (B) Report.--Not later than 180 days after the + completion of the nationwide program, the Inspector + General of the Department of Health and Human Services + shall + +[[Page 124 STAT. 727]] + + submit a report to Congress containing the results of + the evaluation conducted under subparagraph (A). + + (b) Funding.-- + (1) Notification.--The Secretary of Health and Human + Services shall notify the Secretary of the Treasury of the + amount necessary to carry out the nationwide program under this + section for the period of fiscal years 2010 through 2012, except + that in no case shall such amount exceed $160,000,000. + (2) Transfer of funds.-- + (A) In general.--Out of any funds in the Treasury + not otherwise appropriated, the Secretary of the + Treasury shall provide for the transfer to the Secretary + of Health and Human Services of the amount specified as + necessary to carry out the nationwide program under + paragraph (1). Such amount shall remain available until + expended. + (B) Reservation of funds for conduct of + evaluation.--The Secretary may reserve not more than + $3,000,000 of the amount transferred under subparagraph + (A) to provide for the conduct of the evaluation under + subsection (a)(7)(A). + + Subtitle D--Patient-Centered Outcomes Research + +SEC. 6301. PATIENT-CENTERED OUTCOMES RESEARCH. + + (a) In General.--Title XI of the Social Security Act (42 U.S.C. 1301 +et seq.) is amended by adding at the end the following new part: + + ``Part D--Comparative Clinical Effectiveness Research + + + ``comparative clinical effectiveness research + + + ``Sec. 1181. <<NOTE: 42 USC 1320e.>> (a) Definitions.--In this +section: + ``(1) Board.--The term `Board' means the Board of Governors + established under subsection (f). + ``(2) Comparative clinical effectiveness research; + research.-- + ``(A) In general.--The terms `comparative clinical + effectiveness research' and `research' mean research + evaluating and comparing health outcomes and the + clinical effectiveness, risks, and benefits of 2 or more + medical treatments, services, and items described in + subparagraph (B). + ``(B) Medical treatments, services, and items + described.--The medical treatments, services, and items + described in this subparagraph are health care + interventions, protocols for treatment, care management, + and delivery, procedures, medical devices, diagnostic + tools, pharmaceuticals (including drugs and + biologicals), integrative health practices, and any + other strategies or items being used in the treatment, + management, and diagnosis of, or prevention of illness + or injury in, individuals. + ``(3) Conflict of interest.--The term `conflict of interest' + means an association, including a financial or personal + association, that have the potential to bias or have the + appearance + +[[Page 124 STAT. 728]] + + of biasing an individual's decisions in matters related to the + Institute or the conduct of activities under this section. + ``(4) Real conflict of interest.--The term `real conflict of + interest' means any instance where a member of the Board, the + methodology committee established under subsection (d)(6), or an + advisory panel appointed under subsection (d)(4), or a close + relative of such member, has received or could receive either of + the following: + ``(A) A direct financial benefit of any amount + deriving from the result or findings of a study + conducted under this section. + ``(B) A financial benefit from individuals or + companies that own or manufacture medical treatments, + services, or items to be studied under this section that + in the aggregate exceeds $10,000 per year. For purposes + of the preceding sentence, a financial benefit includes + honoraria, fees, stock, or other financial benefit and + the current value of the member or close relative's + already existing stock holdings, in addition to any + direct financial benefit deriving from the results or + findings of a study conducted under this section. + + ``(b) Patient-Centered Outcomes Research Institute.-- + ``(1) Establishment.--There is authorized to be established + a nonprofit corporation, to be known as the `Patient-Centered + Outcomes Research Institute' (referred to in this section as the + `Institute') which is neither an agency nor establishment of the + United States Government. + ``(2) <<NOTE: District of Columbia.>> Application of + provisions.--The Institute shall be subject to the provisions of + this section, and, to the extent consistent with this section, + to the District of Columbia Nonprofit Corporation Act. + ``(3) Funding of comparative clinical effectiveness + research.--For fiscal year 2010 and each subsequent fiscal year, + amounts in the Patient-Centered Outcomes Research Trust Fund + (referred to in this section as the `PCORTF') under section 9511 + of the Internal Revenue Code of 1986 shall be available, without + further appropriation, to the Institute to carry out this + section. + + ``(c) Purpose.--The purpose of the Institute is to assist patients, +clinicians, purchasers, and policy-makers in making informed health +decisions by advancing the quality and relevance of evidence concerning +the manner in which diseases, disorders, and other health conditions can +effectively and appropriately be prevented, diagnosed, treated, +monitored, and managed through research and evidence synthesis that +considers variations in patient subpopulations, and the dissemination of +research findings with respect to the relative health outcomes, clinical +effectiveness, and appropriateness of the medical treatments, services, +and items described in subsection (a)(2)(B). + ``(d) Duties.-- + ``(1) Identifying research priorities and establishing + research project agenda.-- + ``(A) Identifying research priorities.--The + Institute shall identify national priorities for + research, taking into account factors of disease + incidence, prevalence, and burden in the United States + (with emphasis on chronic conditions), gaps in evidence + in terms of clinical outcomes, practice + +[[Page 124 STAT. 729]] + + variations and health disparities in terms of delivery + and outcomes of care, the potential for new evidence to + improve patient health, well-being, and the quality of + care, the effect on national expenditures associated + with a health care treatment, strategy, or health + conditions, as well as patient needs, outcomes, and + preferences, the relevance to patients and clinicians in + making informed health decisions, and priorities in the + National Strategy for quality care established under + section 399H of the Public Health Service Act that are + consistent with this section. + ``(B) Establishing research project agenda.--The + Institute shall establish and update a research project + agenda for research to address the priorities identified + under subparagraph (A), taking into consideration the + types of research that might address each priority and + the relative value (determined based on the cost of + conducting research compared to the potential usefulness + of the information produced by research) associated with + the different types of research, and such other factors + as the Institute determines appropriate. + ``(2) Carrying out research project agenda.-- + ``(A) Research.--The Institute shall carry out the + research project agenda established under paragraph + (1)(B) in accordance with the methodological standards + adopted under paragraph (9) using methods, including the + following: + ``(i) Systematic reviews and assessments of + existing and future research and evidence + including original research conducted subsequent + to the date of the enactment of this section. + ``(ii) Primary research, such as randomized + clinical trials, molecularly informed trials, and + observational studies. + ``(iii) Any other methodologies recommended by + the methodology committee established under + paragraph (6) that are adopted by the Board under + paragraph (9). + ``(B) Contracts for the management of funding and + conduct of research.-- + ``(i) Contracts.-- + ``(I) In general.--In accordance + with the research project agenda + established under paragraph (1)(B), the + Institute shall enter into contracts for + the management of funding and conduct of + research in accordance with the + following: + ``(aa) Appropriate agencies + and instrumentalities of the + Federal Government. + ``(bb) Appropriate academic + research, private sector + research, or study-conducting + entities. + ``(II) Preference.--In entering into + contracts under subclause (I), the + Institute shall give preference to the + Agency for Healthcare Research and + Quality and the National Institutes of + Health, but only if the research to be + conducted or managed under such contract + is authorized by the governing statutes + of such Agency or Institutes. + +[[Page 124 STAT. 730]] + + ``(ii) Conditions for contracts.--A contract + entered into under this subparagraph shall require + that the agency, instrumentality, or other + entity-- + ``(I) abide by the transparency and + conflicts of interest requirements under + subsection (h) that apply to the + Institute with respect to the research + managed or conducted under such + contract; + ``(II) comply with the + methodological standards adopted under + paragraph (9) with respect to such + research; + ``(III) consult with the expert + advisory panels for clinical trials and + rare disease appointed under clauses + (ii) and (iii), respectively, of + paragraph (4)(A); + ``(IV) subject to clause (iv), + permit a researcher who conducts + original research under the contract for + the agency, instrumentality, or other + entity to have such research published + in a peer-reviewed journal or other + publication; + ``(V) have appropriate processes in + place to manage data privacy and meet + ethical standards for the research; + ``(VI) comply with the requirements + of the Institute for making the + information available to the public + under paragraph (8); and + ``(VII) comply with other terms and + conditions determined necessary by the + Institute to carry out the research + agenda adopted under paragraph (2). + ``(iii) Coverage of copayments or + coinsurance.--A contract entered into under this + subparagraph may allow for the coverage of + copayments or coinsurance, or allow for other + appropriate measures, to the extent that such + coverage or other measures are necessary to + preserve the validity of a research project, such + as in the case where the research project must be + blinded. + ``(iv) Requirements for publication of + research.--Any research published under clause + (ii)(IV) shall be within the bounds of and + entirely consistent with the evidence and findings + produced under the contract with the Institute + under this subparagraph. If the Institute + determines that those requirements are not met, + the Institute shall not enter into another + contract with the agency, instrumentality, or + entity which managed or conducted such research + for a period determined appropriate by the + Institute (but not less than 5 years). + ``(C) Review and update of evidence.--The Institute + shall review and update evidence on a periodic basis as + appropriate. + ``(D) Taking into account potential differences.-- + Research shall be designed, as appropriate, to take into + account the potential for differences in the + effectiveness of health care treatments, services, and + items as used with various subpopulations, such as + racial and ethnic minorities, women, age, and groups of + individuals with different comorbidities, genetic and + molecular sub-types, + +[[Page 124 STAT. 731]] + + or quality of life preferences and include members of + such subpopulations as subjects in the research as + feasible and appropriate. + ``(E) Differences in treatment modalities.--Research + shall be designed, as appropriate, to take into account + different characteristics of treatment modalities that + may affect research outcomes, such as the phase of the + treatment modality in the innovation cycle and the + impact of the skill of the operator of the treatment + modality. + ``(3) Data collection.-- + ``(A) In general.--The Secretary shall, with + appropriate safeguards for privacy, make available to + the Institute such data collected by the Centers for + Medicare & Medicaid Services under the programs under + titles XVIII, XIX, and XXI, as well as provide access to + the data networks developed under section 937(f) of the + Public Health Service Act, as the Institute and its + contractors may require to carry out this section. The + Institute may also request and obtain data from Federal, + State, or private entities, including data from clinical + databases and registries. + ``(B) Use of data.--The Institute shall only use + data provided to the Institute under subparagraph (A) in + accordance with laws and regulations governing the + release and use of such data, including applicable + confidentiality and privacy standards. + ``(4) Appointing expert advisory panels.-- + ``(A) Appointment.-- + ``(i) In general.--The Institute may appoint + permanent or ad hoc expert advisory panels as + determined appropriate to assist in identifying + research priorities and establishing the research + project agenda under paragraph (1) and for other + purposes. + ``(ii) Expert advisory panels for clinical + trials.--The Institute shall appoint expert + advisory panels in carrying out randomized + clinical trials under the research project agenda + under paragraph (2)(A)(ii). Such expert advisory + panels shall advise the Institute and the agency, + instrumentality, or entity conducting the research + on the research question involved and the research + design or protocol, including important patient + subgroups and other parameters of the research. + Such panels shall be available as a resource for + technical questions that may arise during the + conduct of such research. + ``(iii) Expert advisory panel for rare + disease.--In the case of a research study for rare + disease, the Institute shall appoint an expert + advisory panel for purposes of assisting in the + design of the research study and determining the + relative value and feasibility of conducting the + research study. + ``(B) Composition.--An expert advisory panel + appointed under subparagraph (A) shall include + representatives of practicing and research clinicians, + patients, and experts in scientific and health services + research, health services delivery, and evidence-based + medicine who have experience in the relevant topic, and + as appropriate, experts + +[[Page 124 STAT. 732]] + + in integrative health and primary prevention strategies. + The Institute may include a technical expert of each + manufacturer or each medical technology that is included + under the relevant topic, project, or category for which + the panel is established. + ``(5) Supporting patient and consumer representatives.--The + Institute shall provide support and resources to help patient + and consumer representatives effectively participate on the + Board and expert advisory panels appointed by the Institute + under paragraph (4). + ``(6) Establishing methodology committee.-- + ``(A) In general.--The Institute shall establish a + standing methodology committee to carry out the + functions described in subparagraph (C). + ``(B) Appointment and composition.--The methodology + committee established under subparagraph (A) shall be + composed of not more than 15 members appointed by the + Comptroller General of the United States. Members + appointed to the methodology committee shall be experts + in their scientific field, such as health services + research, clinical research, comparative clinical + effectiveness research, biostatistics, genomics, and + research methodologies. Stakeholders with such expertise + may be appointed to the methodology committee. In + addition to the members appointed under the first + sentence, the Directors of the National Institutes of + Health and the Agency for Healthcare Research and + Quality (or their designees) shall each be included as + members of the methodology committee. + ``(C) Functions.-- <<NOTE: Deadline.>> Subject to + subparagraph (D), the methodology committee shall work + to develop and improve the science and methods of + comparative clinical effectiveness research by, not + later than 18 months after the establishment of the + Institute, directly or through subcontract, developing + and periodically updating the following: + ``(i) Methodological standards for research. + Such methodological standards shall provide + specific criteria for internal validity, + generalizability, feasibility, and timeliness of + research and for health outcomes measures, risk + adjustment, and other relevant aspects of research + and assessment with respect to the design of + research. Any methodological standards developed + and updated under this subclause shall be + scientifically based and include methods by which + new information, data, or advances in technology + are considered and incorporated into ongoing + research projects by the Institute, as + appropriate. The process for developing and + updating such standards shall include input from + relevant experts, stakeholders, and + decisionmakers, and shall provide opportunities + for public comment. Such standards shall also + include methods by which patient subpopulations + can be accounted for and evaluated in different + types of research. As appropriate, such standards + shall build on existing work on methodological + standards for defined categories of health + interventions and for each of the major categories + of + +[[Page 124 STAT. 733]] + + comparative clinical effectiveness research + methods (determined as of the date of enactment of + the Patient Protection and Affordable Care Act). + ``(ii) A translation table that is designed to + provide guidance and act as a reference for the + Board to determine research methods that are most + likely to address each specific research question. + ``(D) Consultation and conduct of examinations.--The + methodology committee may consult and contract with the + Institute of Medicine of the National Academies and + academic, nonprofit, or other private and governmental + entities with relevant expertise to carry out activities + described in subparagraph (C) and may consult with + relevant stakeholders to carry out such activities. + ``(E) Reports.--The methodology committee shall + submit reports to the Board on the committee's + performance of the functions described in subparagraph + (C). <<NOTE: Recommenda- tions.>> Reports shall contain + recommendations for the Institute to adopt + methodological standards developed and updated by the + methodology committee as well as other actions deemed + necessary to comply with such methodological standards. + ``(7) Providing for a peer-review process for primary + research.-- + ``(A) In general.--The Institute shall ensure that + there is a process for peer review of primary research + described in subparagraph (A)(ii) of paragraph (2) that + is conducted under such paragraph. Under such process-- + ``(i) evidence from such primary research + shall be reviewed to assess scientific integrity + and adherence to methodological standards adopted + under paragraph (9); and + ``(ii) <<NOTE: Lists. Public information.>> a + list of the names of individuals contributing to + any peer-review process during the preceding year + or years shall be made public and included in + annual reports in accordance with paragraph + (10)(D). + ``(B) Composition.--Such peer-review process shall + be designed in a manner so as to avoid bias and + conflicts of interest on the part of the reviewers and + shall be composed of experts in the scientific field + relevant to the research under review. + ``(C) Use of existing processes.-- + ``(i) Processes of another entity.--In the + case where the Institute enters into a contract or + other agreement with another entity for the + conduct or management of research under this + section, the Institute may utilize the peer-review + process of such entity if such process meets the + requirements under subparagraphs (A) and (B). + ``(ii) Processes of appropriate medical + journals.--The Institute may utilize the peer- + review process of appropriate medical journals if + such process meets the requirements under + subparagraphs (A) and (B). + ``(8) Release of research findings.-- + ``(A) In general.-- <<NOTE: Deadline.>> The + Institute shall, not later than 90 days after the + conduct or receipt of research findings under this part, + make such research findings available + +[[Page 124 STAT. 734]] + + to clinicians, patients, and the general public. The + Institute shall ensure that the research findings-- + ``(i) convey the findings of research in a + manner that is comprehensible and useful to + patients and providers in making health care + decisions; + ``(ii) fully convey findings and discuss + considerations specific to certain subpopulations, + risk factors, and comorbidities, as appropriate; + ``(iii) include limitations of the research + and what further research may be needed as + appropriate; + ``(iv) not be construed as mandates for + practice guidelines, coverage recommendations, + payment, or policy recommendations; and + ``(v) not include any data which would violate + the privacy of research participants or any + confidentiality agreements made with respect to + the use of data under this section. + ``(B) Definition of research findings.--In this + paragraph, the term `research findings' means the + results of a study or assessment. + ``(9) Adoption.--Subject to subsection (h)(1), the Institute + shall adopt the national priorities identified under paragraph + (1)(A), the research project agenda established under paragraph + (1)(B), the methodological standards developed and updated by + the methodology committee under paragraph (6)(C)(i), and any + peer-review process provided under paragraph (7) by majority + vote. In the case where the Institute does not adopt such + processes in accordance with the preceding sentence, the + processes shall be referred to the appropriate staff or entity + within the Institute (or, in the case of the methodological + standards, the methodology committee) for further review. + ``(10) <<NOTE: Public information.>> Annual reports.--The + Institute shall submit an annual report to Congress and the + President, and shall make the annual report available to the + public. Such report shall contain-- + ``(A) a description of the activities conducted + under this section, research priorities identified under + paragraph (1)(A) and methodological standards developed + and updated by the methodology committee under paragraph + (6)(C)(i) that are adopted under paragraph (9) during + the preceding year; + ``(B) the research project agenda and budget of the + Institute for the following year; + ``(C) any administrative activities conducted by the + Institute during the preceding year; + ``(D) the names of individuals contributing to any + peer-review process under paragraph (7), without + identifying them with a particular research project; and + ``(E) any other relevant information (including + information on the membership of the Board, expert + advisory panels, methodology committee, and the + executive staff of the Institute, any conflicts of + interest with respect to these individuals, and any + bylaws adopted by the Board during the preceding year). + + ``(e) Administration.-- + ``(1) In general.--Subject to paragraph (2), the Board shall + carry out the duties of the Institute. + +[[Page 124 STAT. 735]] + + ``(2) Nondelegable duties.--The activities described in + subsections (d)(1) and (d)(9) are nondelegable. + + ``(f) Board of Governors.-- + ``(1) <<NOTE: Establishment.>> In general.--The Institute + shall have a Board of Governors, which shall consist of the + following members: + ``(A) The Director of Agency for Healthcare Research + and Quality (or the Director's designee). + ``(B) The Director of the National Institutes of + Health (or the Director's designee). + ``(C) <<NOTE: Deadline.>> Seventeen members + appointed, not later than 6 months after the date of + enactment of this section, by the Comptroller General of + the United States as follows: + ``(i) 3 members representing patients and + health care consumers. + ``(ii) 5 members representing physicians and + providers, including at least 1 surgeon, nurse, + State-licensed integrative health care + practitioner, and representative of a hospital. + ``(iii) 3 members representing private payers, + of whom at least 1 member shall represent health + insurance issuers and at least 1 member shall + represent employers who self-insure employee + benefits. + ``(iv) 3 members representing pharmaceutical, + device, and diagnostic manufacturers or + developers. + ``(v) 1 member representing quality + improvement or independent health service + researchers. + ``(vi) 2 members representing the Federal + Government or the States, including at least 1 + member representing a Federal health program or + agency. + ``(2) Qualifications.--The Board shall represent a broad + range of perspectives and collectively have scientific expertise + in clinical health sciences research, including epidemiology, + decisions sciences, health economics, and statistics. In + appointing the Board, the Comptroller General of the United + States shall consider and disclose any conflicts of interest in + accordance with subsection (h)(4)(B). Members of the Board shall + be recused from relevant Institute activities in the case where + the member (or an immediate family member of such member) has a + real conflict of interest directly related to the research + project or the matter that could affect or be affected by such + participation. + ``(3) Terms; vacancies.--A member of the Board shall be + appointed for a term of 6 years, except with respect to the + members first appointed, whose terms of appointment shall be + staggered evenly over 2-year increments. No individual shall be + appointed to the Board for more than 2 terms. Vacancies shall be + filled in the same manner as the original appointment was made. + ``(4) Chairperson and vice-chairperson.-- + <<NOTE: Designation.>> The Comptroller General of the United + States shall designate a Chairperson and Vice Chairperson of the + Board from among the members of the Board. Such members shall + serve as Chairperson or Vice Chairperson for a period of 3 + years. + ``(5) Compensation.--Each member of the Board who is not an + officer or employee of the Federal Government shall be entitled + to compensation (equivalent to the rate provided for level IV of + the Executive Schedule under section 5315 of + +[[Page 124 STAT. 736]] + + title 5, United States Code) and expenses incurred while + performing the duties of the Board. An officer or employee of + the Federal government who is a member of the Board shall be + exempt from compensation. + ``(6) Director and staff; experts and consultants.--The + Board may employ and fix the compensation of an Executive + Director and such other personnel as may be necessary to carry + out the duties of the Institute and may seek such assistance and + support of, or contract with, experts and consultants that may + be necessary for the performance of the duties of the Institute. + ``(7) Meetings and hearings.--The Board shall meet and hold + hearings at the call of the Chairperson or a majority of its + members. Meetings not solely concerning matters of personnel + shall be advertised at least 7 days in advance and open to the + public. A majority of the Board members shall constitute a + quorum, but a lesser number of members may meet and hold + hearings. + + ``(g) Financial and Governmental Oversight.-- + ``(1) Contract for audit.--The Institute shall provide for + the conduct of financial audits of the Institute on an annual + basis by a private entity with expertise in conducting financial + audits. + ``(2) Review and annual reports.-- + ``(A) Review.--The Comptroller General of the United + States shall review the following: + ``(i) Not less frequently than on an annual + basis, the financial audits conducted under + paragraph (1). + ``(ii) Not less frequently than every 5 years, + the processes established by the Institute, + including the research priorities and the conduct + of research projects, in order to determine + whether information produced by such research + projects is objective and credible, is produced in + a manner consistent with the requirements under + this section, and is developed through a + transparent process. + ``(iii) Not less frequently than every 5 + years, the dissemination and training activities + and data networks established under section 937 of + the Public Health Service Act, including the + methods and products used to disseminate research, + the types of training conducted and supported, and + the types and functions of the data networks + established, in order to determine whether the + activities and data are produced in a manner + consistent with the requirements under such + section. + ``(iv) Not less frequently than every 5 years, + the overall effectiveness of activities conducted + under this section and the dissemination, + training, and capacity building activities + conducted under section 937 of the Public Health + Service Act. Such review shall include an analysis + of the extent to which research findings are used + by health care decision-makers, the effect of the + dissemination of such findings on reducing + practice variation and disparities in health care, + and the effect of the research conducted and + disseminated on + +[[Page 124 STAT. 737]] + + innovation and the health care economy of the + United States. + ``(v) Not later than 8 years after the date of + enactment of this section, the adequacy and use of + the funding for the Institute and the activities + conducted under section 937 of the Public Health + Service Act, including a determination as to + whether, based on the utilization of research + findings by public and private payers, funding + sources for the Patient-Centered Outcomes Research + Trust Fund under section 9511 of the Internal + Revenue Code of 1986 are appropriate and whether + such sources of funding should be continued or + adjusted. + ``(B) Annual reports.-- <<NOTE: Recommenda- + tions.>> Not later than April 1 of each year, the + Comptroller General of the United States shall submit to + Congress a report containing the results of the review + conducted under subparagraph (A) with respect to the + preceding year (or years, if applicable), together with + recommendations for such legislation and administrative + action as the Comptroller General determines + appropriate. + + ``(h) Ensuring Transparency, Credibility, and Access.-- +<<NOTE: Procedures.>> The Institute shall establish procedures to ensure +that the following requirements for ensuring transparency, credibility, +and access are met: + ``(1) Public comment periods.--The Institute shall provide + for a public comment period of not less than 45 days and not + more than 60 days prior to the adoption under subsection (d)(9) + of the national priorities identified under subsection + (d)(1)(A), the research project agenda established under + subsection (d)(1)(B), the methodological standards developed and + updated by the methodology committee under subsection + (d)(6)(C)(i), and the peer-review process provided under + paragraph (7), and after the release of draft findings with + respect to systematic reviews of existing research and evidence. + ``(2) Additional forums.--The Institute shall support forums + to increase public awareness and obtain and incorporate public + input and feedback through media (such as an Internet website) + on research priorities, research findings, and other duties, + activities, or processes the Institute determines appropriate. + ``(3) Public availability.-- <<NOTE: Web posting.>> The + Institute shall make available to the public and disclose + through the official public Internet website of the Institute + the following: + ``(A) Information contained in research findings as + specified in subsection (d)(9). + ``(B) The process and methods for the conduct of + research, including the identity of the entity and the + investigators conducing such research and any conflicts + of interests of such parties, any direct or indirect + links the entity has to industry, and research + protocols, including measures taken, methods of research + and analysis, research results, and such other + information the Institute determines appropriate) + concurrent with the release of research findings. + ``(C) <<NOTE: Notice.>> Notice of public comment + periods under paragraph (1), including deadlines for + public comments. + +[[Page 124 STAT. 738]] + + ``(D) Subsequent comments received during each of + the public comment periods. + ``(E) In accordance with applicable laws and + processes and as the Institute determines appropriate, + proceedings of the Institute. + ``(4) Disclosure of conflicts of interest.-- + ``(A) In general.--A conflict of interest shall be + disclosed in the following manner: + ``(i) By the Institute in appointing members + to an expert advisory panel under subsection + (d)(4), in selecting individuals to contribute to + any peer-review process under subsection (d)(7), + and for employment as executive staff of the + Institute. + ``(ii) By the Comptroller General in + appointing members of the methodology committee + under subsection (d)(6); + ``(iii) By the Institute in the annual report + under subsection (d)(10), except that, in the case + of individuals contributing to any such peer + review process, such description shall be in a + manner such that those individuals cannot be + identified with a particular research project. + ``(B) Manner of disclosure.-- <<NOTE: Web + posting.>> Conflicts of interest shall be disclosed as + described in subparagraph (A) as soon as practicable on + the Internet web site of the Institute and of the + Government Accountability Office. The information + disclosed under the preceding sentence shall include the + type, nature, and magnitude of the interests of the + individual involved, except to the extent that the + individual recuses himself or herself from participating + in the consideration of or any other activity with + respect to the study as to which the potential conflict + exists. + + ``(i) Rules.--The Institute, its Board or staff, shall be prohibited +from accepting gifts, bequeaths, or donations of services or property. +In addition, the Institute shall be prohibited from establishing a +corporation or generating revenues from activities other than as +provided under this section. + ``(j) Rules of Construction.-- + ``(1) Coverage.--Nothing in this section shall be + construed-- + ``(A) to permit the Institute to mandate coverage, + reimbursement, or other policies for any public or + private payer; or + ``(B) as preventing the Secretary from covering the + routine costs of clinical care received by an individual + entitled to, or enrolled for, benefits under title + XVIII, XIX, or XXI in the case where such individual is + participating in a clinical trial and such costs would + otherwise be covered under such title with respect to + the beneficiary.''. + + (b) Dissemination and Building Capacity for Research.--Title IX of +the Public Health Service Act (42 U.S.C. 299 et seq.), as amended by +section 3606, is further amended by inserting after section 936 the +following: + +``SEC. 937. <<NOTE: 42 USC 299b-37.>> DISSEMINATION AND BUILDING + CAPACITY FOR RESEARCH. + + ``(a) In General.-- + +[[Page 124 STAT. 739]] + + ``(1) Dissemination.--The Office of Communication and + Knowledge Transfer (referred to in this section as the `Office') + at the Agency for Healthcare Research and Quality (or any other + relevant office designated by Agency for Healthcare Research and + Quality), in consultation with the National Institutes of + Health, shall broadly disseminate the research findings that are + published by the Patient Centered Outcomes Research Institute + established under section 1181(b) of the Social Security Act + (referred to in this section as the `Institute') and other + government-funded research relevant to comparative clinical + effectiveness research. The Office shall create informational + tools that organize and disseminate research findings for + physicians, health care providers, patients, payers, and policy + makers. <<NOTE: Public information.>> The Office shall also + develop a publicly available resource database that collects and + contains government-funded evidence and research from public, + private, not-for profit, and academic sources. + ``(2) Requirements.--The Office shall provide for the + dissemination of the Institute's research findings and + government-funded research relevant to comparative clinical + effectiveness research to physicians, health care providers, + patients, vendors of health information technology focused on + clinical decision support, appropriate professional + associations, and Federal and private health plans. Materials, + forums, and media used to disseminate the findings, + informational tools, and resource databases shall-- + ``(A) include a description of considerations for + specific subpopulations, the research methodology, and + the limitations of the research, and the names of the + entities, agencies, instrumentalities, and individuals + who conducted any research which was published by the + Institute; and + ``(B) not be construed as mandates, guidelines, or + recommendations for payment, coverage, or treatment. + + ``(b) Incorporation of Research Findings.--The Office, in +consultation with relevant medical and clinical associations, shall +assist users of health information technology focused on clinical +decision support to promote the timely incorporation of research +findings disseminated under subsection (a) into clinical practices and +to promote the ease of use of such incorporation. + ``(c) Feedback.--The Office shall establish a process to receive +feedback from physicians, health care providers, patients, and vendors +of health information technology focused on clinical decision support, +appropriate professional associations, and Federal and private health +plans about the value of the information disseminated and the assistance +provided under this section. + ``(d) Rule of Construction.--Nothing in this section shall preclude +the Institute from making its research findings publicly available as +required under section 1181(d)(8) of the Social Security Act. + ``(e) Training of Researchers.--The Agency for Health Care Research +and Quality, in consultation with the National Institutes of Health, +shall build capacity for comparative clinical effectiveness research by +establishing a grant program that provides for the training of +researchers in the methods used to conduct such research, including +systematic reviews of existing research and primary research such as +clinical trials. At a minimum, such + +[[Page 124 STAT. 740]] + +training shall be in methods that meet the methodological standards +adopted under section 1181(d)(9) of the Social Security Act. + ``(f) Building Data for Research.--The Secretary shall provide for +the coordination of relevant Federal health programs to build data +capacity for comparative clinical effectiveness research, including the +development and use of clinical registries and health outcomes research +data networks, in order to develop and maintain a comprehensive, +interoperable data network to collect, link, and analyze data on +outcomes and effectiveness from multiple sources, including electronic +health records. + ``(g) Authority To Contract With the Institute.--Agencies and +instrumentalities of the Federal Government may enter into agreements +with the Institute, and accept and retain funds, for the conduct and +support of research described in this part, provided that the research +to be conducted or supported under such agreements is authorized under +the governing statutes of such agencies and instrumentalities.''. + (c) In General.--Part D of title XI of the Social Security Act, as +added by subsection (a), is amended by adding at the end the following +new section: + + + ``limitations on certain uses of comparative clinical effectiveness + research + + + ``Sec. 1182. <<NOTE: 42 USC 1320e-1.>> (a) The Secretary may only +use evidence and findings from research conducted under section 1181 to +make a determination regarding coverage under title XVIII if such use is +through an iterative and transparent process which includes public +comment and considers the effect on subpopulations. + + ``(b) Nothing in section 1181 shall be construed as-- + ``(1) superceding or modifying the coverage of items or + services under title XVIII that the Secretary determines are + reasonable and necessary under section 1862(l)(1); or + ``(2) authorizing the Secretary to deny coverage of items or + services under such title solely on the basis of comparative + clinical effectiveness research. + + ``(c)(1) The Secretary shall not use evidence or findings from +comparative clinical effectiveness research conducted under section 1181 +in determining coverage, reimbursement, or incentive programs under +title XVIII in a manner that treats extending the life of an elderly, +disabled, or terminally ill individual as of lower value than extending +the life of an individual who is younger, nondisabled, or not terminally +ill. + ``(2) Paragraph (1) shall not be construed as preventing the +Secretary from using evidence or findings from such comparative clinical +effectiveness research in determining coverage, reimbursement, or +incentive programs under title XVIII based upon a comparison of the +difference in the effectiveness of alternative treatments in extending +an individual's life due to the individual's age, disability, or +terminal illness. + ``(d)(1) The Secretary shall not use evidence or findings from +comparative clinical effectiveness research conducted under section 1181 +in determining coverage, reimbursement, or incentive programs under +title XVIII in a manner that precludes, or with the intent to +discourage, an individual from choosing a health care treatment based on +how the individual values the tradeoff between extending the length of +their life and the risk of disability. + ``(2)(A) Paragraph (1) shall not be construed to-- + +[[Page 124 STAT. 741]] + + ``(i) limit the application of differential copayments under + title XVIII based on factors such as cost or type of service; or + ``(ii) prevent the Secretary from using evidence or findings + from such comparative clinical effectiveness research in + determining coverage, reimbursement, or incentive programs under + such title based upon a comparison of the difference in the + effectiveness of alternative health care treatments in extending + an individual's life due to that individual's age, disability, + or terminal illness. + + ``(3) Nothing in the provisions of, or amendments made by the +Patient Protection and Affordable Care Act, shall be construed to limit +comparative clinical effectiveness research or any other research, +evaluation, or dissemination of information concerning the likelihood +that a health care treatment will result in disability. + ``(e) The Patient-Centered Outcomes Research Institute established +under section 1181(b)(1) shall not develop or employ a dollars-per- +quality adjusted life year (or similar measure that discounts the value +of a life because of an individual's disability) as a threshold to +establish what type of health care is cost effective or recommended. The +Secretary shall not utilize such an adjusted life year (or such a +similar measure) as a threshold to determine coverage, reimbursement, or +incentive programs under title XVIII.''. + (d) In General.--Part D of title XI of the Social Security Act, as +added by subsection (a) and amended by subsection (c), is amended by +adding at the end the following new section: + + + ``trust fund transfers to patient-centered outcomes research trust fund + + + ``Sec. 1183. <<NOTE: 42 USC 1320e-2.>> (a) In General.--The +Secretary shall provide for the transfer, from the Federal Hospital +Insurance Trust Fund under section 1817 and the Federal Supplementary +Medical Insurance Trust Fund under section 1841, in proportion (as +estimated by the Secretary) to the total expenditures during such fiscal +year that are made under title XVIII from the respective trust fund, to +the Patient-Centered Outcomes Research Trust Fund (referred to in this +section as the `PCORTF') under section 9511 of the Internal Revenue Code +of 1986, of the following: + ``(1) For fiscal year 2013, an amount equal to $1 multiplied + by the average number of individuals entitled to benefits under + part A, or enrolled under part B, of title XVIII during such + fiscal year. + ``(2) For each of fiscal years 2014, 2015, 2016, 2017, 2018, + and 2019, an amount equal to $2 multiplied by the average number + of individuals entitled to benefits under part A, or enrolled + under part B, of title XVIII during such fiscal year. + + ``(b) Adjustments for Increases in Health Care Spending.--In the +case of any fiscal year beginning after September 30, 2014, the dollar +amount in effect under subsection (a)(2) for such fiscal year shall be +equal to the sum of such dollar amount for the previous fiscal year +(determined after the application of this subsection), plus an amount +equal to the product of-- + ``(1) such dollar amount for the previous fiscal year, + multiplied by + ``(2) the percentage increase in the projected per capita + amount of National Health Expenditures, as most recently + published by the Secretary before the beginning of the fiscal + year.''. + +[[Page 124 STAT. 742]] + + (e) Patient-Centered Outcomes Research Trust Fund; Financing for +Trust Fund.-- + (1) Establishment of trust fund.-- + (A) In general.--Subchapter A of chapter 98 of the + Internal Revenue Code of 1986 (relating to establishment + of trust funds) is amended by adding at the end the + following new section: + +``SEC. 9511. <<NOTE: 26 USC 9511.>> PATIENT-CENTERED OUTCOMES RESEARCH + TRUST FUND. + + ``(a) Creation of Trust Fund.--There is established in the Treasury +of the United States a trust fund to be known as the `Patient-Centered +Outcomes Research Trust Fund' (hereafter in this section referred to as +the `PCORTF'), consisting of such amounts as may be appropriated or +credited to such Trust Fund as provided in this section and section +9602(b). + ``(b) Transfers to Fund.-- + ``(1) Appropriation.--There are hereby appropriated to the + Trust Fund the following: + ``(A) For fiscal year 2010, $10,000,000. + ``(B) For fiscal year 2011, $50,000,000. + ``(C) For fiscal year 2012, $150,000,000. + ``(D) For fiscal year 2013-- + ``(i) an amount equivalent to the net revenues + received in the Treasury from the fees imposed + under subchapter B of chapter 34 (relating to fees + on health insurance and self-insured plans) for + such fiscal year; and + ``(ii) $150,000,000. + ``(E) For each of fiscal years 2014, 2015, 2016, + 2017, 2018, and 2019-- + ``(i) an amount equivalent to the net revenues + received in the Treasury from the fees imposed + under subchapter B of chapter 34 (relating to fees + on health insurance and self-insured plans) for + such fiscal year; and + ``(ii) $150,000,000. + The amounts appropriated under subparagraphs (A), (B), + (C), (D)(ii), and (E)(ii) shall be transferred from the + general fund of the Treasury, from funds not otherwise + appropriated. + ``(2) Trust fund transfers.--In addition to the amounts + appropriated under paragraph (1), there shall be credited to the + PCORTF the amounts transferred under section 1183 of the Social + Security Act. + ``(3) Limitation on transfers to pcortf.--No amount may be + appropriated or transferred to the PCORTF on and after the date + of any expenditure from the PCORTF which is not an expenditure + permitted under this section. The determination of whether an + expenditure is so permitted shall be made without regard to-- + ``(A) any provision of law which is not contained or + referenced in this chapter or in a revenue Act, and + ``(B) whether such provision of law is a + subsequently enacted provision or directly or indirectly + seeks to waive the application of this paragraph. + + ``(c) Trustee.--The Secretary of the Treasury shall be a trustee of +the PCORTF. + +[[Page 124 STAT. 743]] + + ``(d) Expenditures From Fund.-- + ``(1) Amounts available to the patient-centered outcomes + research institute.--Subject to paragraph (2), amounts in the + PCORTF are available, without further appropriation, to the + Patient-Centered Outcomes Research Institute established under + section 1181(b) of the Social Security Act for carrying out part + D of title XI of the Social Security Act (as in effect on the + date of enactment of such Act). + ``(2) Transfer of funds.-- + ``(A) In general.--The trustee of the PCORTF shall + provide for the transfer from the PCORTF of 20 percent + of the amounts appropriated or credited to the PCORTF + for each of fiscal years 2011 through 2019 to the + Secretary of Health and Human Services to carry out + section 937 of the Public Health Service Act. + ``(B) Availability.--Amounts transferred under + subparagraph (A) shall remain available until expended. + ``(C) Requirements.--Of the amounts transferred + under subparagraph (A) with respect to a fiscal year, + the Secretary of Health and Human Services shall + distribute-- + ``(i) 80 percent to the Office of + Communication and Knowledge Transfer of the Agency + for Healthcare Research and Quality (or any other + relevant office designated by Agency for + Healthcare Research and Quality) to carry out the + activities described in section 937 of the Public + Health Service Act; and + ``(ii) 20 percent to the Secretary to carry + out the activities described in such section 937. + + ``(e) Net Revenues.-- <<NOTE: Definition.>> For purposes of this +section, the term `net revenues' means the amount estimated by the +Secretary of the Treasury based on the excess of-- + ``(1) the fees received in the Treasury under subchapter B + of chapter 34, over + ``(2) the decrease in the tax imposed by chapter 1 resulting + from the fees imposed by such subchapter. + + ``(f) Termination.--No amounts shall be available for expenditure +from the PCORTF after September 30, 2019, and any amounts in such Trust +Fund after such date shall be transferred to the general fund of the +Treasury.''. + (B) Clerical amendment.--The table of sections for + subchapter A of chapter 98 of such Code is amended by + adding at the end the following new item: + +``Sec. 9511. Patient-centered outcomes research trust fund.''. + + (2) Financing for fund from fees on insured and self-insured + health plans.-- + (A) General rule.--Chapter 34 of the Internal + Revenue Code of 1986 is amended by adding at the end the + following new subchapter: + + ``Subchapter B--Insured and Self-Insured Health Plans + +``Sec. 4375. Health insurance. +``Sec. 4376. Self-insured health plans. +``Sec. 4377. Definitions and special rules. + +``SEC. 4375. <<NOTE: 26 USC 4375.>> HEALTH INSURANCE. + + ``(a) Imposition of Fee.--There is hereby imposed on each specified +health insurance policy for each policy year ending after + +[[Page 124 STAT. 744]] + +September 30, 2012, a fee equal to the product of $2 ($1 in the case of +policy years ending during fiscal year 2013) multiplied by the average +number of lives covered under the policy. + ``(b) Liability for Fee.--The fee imposed by subsection (a) shall be +paid by the issuer of the policy. + ``(c) Specified Health Insurance Policy.--For purposes of this +section: + ``(1) In general.-- <<NOTE: Definition.>> Except as + otherwise provided in this section, the term `specified health + insurance policy' means any accident or health insurance policy + (including a policy under a group health plan) issued with + respect to individuals residing in the United States. + ``(2) Exemption for certain policies.--The term `specified + health insurance policy' does not include any insurance if + substantially all of its coverage is of excepted benefits + described in section 9832(c). + ``(3) Treatment of prepaid health coverage arrangements.-- + ``(A) In general.--In the case of any arrangement + described in subparagraph (B), such arrangement shall be + treated as a specified health insurance policy, and the + person referred to in such subparagraph shall be treated + as the issuer. + ``(B) Description of arrangements.--An arrangement + is described in this subparagraph if under such + arrangement fixed payments or premiums are received as + consideration for any person's agreement to provide or + arrange for the provision of accident or health coverage + to residents of the United States, regardless of how + such coverage is provided or arranged to be provided. + + ``(d) Adjustments for Increases in Health Care Spending.--In the +case of any policy year ending in any fiscal year beginning after +September 30, 2014, the dollar amount in effect under subsection (a) for +such policy year shall be equal to the sum of such dollar amount for +policy years ending in the previous fiscal year (determined after the +application of this subsection), plus an amount equal to the product +of-- + ``(1) such dollar amount for policy years ending in the + previous fiscal year, multiplied by + ``(2) the percentage increase in the projected per capita + amount of National Health Expenditures, as most recently + published by the Secretary before the beginning of the fiscal + year. + + ``(e) Termination.--This section shall not apply to policy years +ending after September 30, 2019. + +``SEC. 4376. <<NOTE: 26 USC 4376.>> SELF-INSURED HEALTH PLANS. + + ``(a) Imposition of Fee.--In the case of any applicable self-insured +health plan for each plan year ending after September 30, 2012, there is +hereby imposed a fee equal to $2 ($1 in the case of plan years ending +during fiscal year 2013) multiplied by the average number of lives +covered under the plan. + ``(b) Liability for Fee.-- + ``(1) In general.--The fee imposed by subsection (a) shall + be paid by the plan sponsor. + ``(2) Plan sponsor.-- <<NOTE: Definition.>> For purposes of + paragraph (1) the term `plan sponsor' means-- + +[[Page 124 STAT. 745]] + + ``(A) the employer in the case of a plan established + or maintained by a single employer, + ``(B) the employee organization in the case of a + plan established or maintained by an employee + organization, + ``(C) in the case of-- + ``(i) a plan established or maintained by 2 or + more employers or jointly by 1 or more employers + and 1 or more employee organizations, + ``(ii) a multiple employer welfare + arrangement, or + ``(iii) a voluntary employees' beneficiary + association described in section 501(c)(9), the + association, committee, joint board of trustees, + or other similar group of representatives of the + parties who establish or maintain the plan, or + ``(D) the cooperative or association described in + subsection (c)(2)(F) in the case of a plan established + or maintained by such a cooperative or association. + + ``(c) Applicable Self-insured Health Plan.-- +<<NOTE: Definition.>> For purposes of this section, the term `applicable +self-insured health plan' means any plan for providing accident or +health coverage if-- + ``(1) any portion of such coverage is provided other than + through an insurance policy, and + ``(2) such plan is established or maintained-- + ``(A) by 1 or more employers for the benefit of + their employees or former employees, + ``(B) by 1 or more employee organizations for the + benefit of their members or former members, + ``(C) jointly by 1 or more employers and 1 or more + employee organizations for the benefit of employees or + former employees, + ``(D) by a voluntary employees' beneficiary + association described in section 501(c)(9), + ``(E) by any organization described in section + 501(c)(6), or + ``(F) in the case of a plan not described in the + preceding subparagraphs, by a multiple employer welfare + arrangement (as defined in section 3(40) of Employee + Retirement Income Security Act of 1974), a rural + electric cooperative (as defined in section 3(40)(B)(iv) + of such Act), or a rural telephone cooperative + association (as defined in section 3(40)(B)(v) of such + Act). + + ``(d) Adjustments for Increases in Health Care Spending.--In the +case of any plan year ending in any fiscal year beginning after +September 30, 2014, the dollar amount in effect under subsection (a) for +such plan year shall be equal to the sum of such dollar amount for plan +years ending in the previous fiscal year (determined after the +application of this subsection), plus an amount equal to the product +of-- + ``(1) such dollar amount for plan years ending in the + previous fiscal year, multiplied by + ``(2) the percentage increase in the projected per capita + amount of National Health Expenditures, as most recently + published by the Secretary before the beginning of the fiscal + year. + + ``(e) Termination.--This section shall not apply to plan years +ending after September 30, 2019. + +[[Page 124 STAT. 746]] + +``SEC. 4377. <<NOTE: 26 USC 4377.>> DEFINITIONS AND SPECIAL RULES. + + ``(a) Definitions.--For purposes of this subchapter-- + ``(1) Accident and health coverage.--The term `accident and + health coverage' means any coverage which, if provided by an + insurance policy, would cause such policy to be a specified + health insurance policy (as defined in section 4375(c)). + ``(2) Insurance policy.--The term `insurance policy' means + any policy or other instrument whereby a contract of insurance + is issued, renewed, or extended. + ``(3) United states.--The term `United States' includes any + possession of the United States. + + ``(b) Treatment of Governmental Entities.-- + ``(1) In general.--For purposes of this subchapter-- + ``(A) the term `person' includes any governmental + entity, and + ``(B) notwithstanding any other law or rule of law, + governmental entities shall not be exempt from the fees + imposed by this subchapter except as provided in + paragraph (2). + ``(2) Treatment of exempt governmental programs.--In the + case of an exempt governmental program, no fee shall be imposed + under section 4375 or section 4376 on any covered life under + such program. + ``(3) Exempt governmental program defined.--For purposes of + this subchapter, the term `exempt governmental program' means-- + ``(A) any insurance program established under title + XVIII of the Social Security Act, + ``(B) the medical assistance program established by + title XIX or XXI of the Social Security Act, + ``(C) any program established by Federal law for + providing medical care (other than through insurance + policies) to individuals (or the spouses and dependents + thereof) by reason of such individuals being members of + the Armed Forces of the United States or veterans, and + ``(D) any program established by Federal law for + providing medical care (other than through insurance + policies) to members of Indian tribes (as defined in + section 4(d) of the Indian Health Care Improvement Act). + + ``(c) Treatment as Tax.--For purposes of subtitle F, the fees +imposed by this subchapter shall be treated as if they were taxes. + ``(d) No Cover Over to Possessions.--Notwithstanding any other +provision of law, no amount collected under this subchapter shall be +covered over to any possession of the United States.''. + (B) Clerical amendments.-- + (i) Chapter 34 of such Code is amended by + striking the chapter heading and inserting the + following: + +[[Page 124 STAT. 747]] + + ``CHAPTER 34--TAXES ON CERTAIN INSURANCE POLICIES + + ``subchapter a. policies issued by foreign insurers + + ``subchapter b. insured and self-insured health plans + + ``Subchapter A--Policies Issued By Foreign Insurers''. + + (ii) The table of chapters for subtitle D of + such Code is amended by striking the item relating + to chapter 34 and inserting the following new + item: + + ``Chapter 34--Taxes on Certain Insurance Policies''. + + (f) Tax-exempt Status of the Patient-centered Outcomes Research +Institute.--Subsection 501(l) of the Internal Revenue Code of +1986 <<NOTE: 26 USC 501.>> is amended by adding at the end the following +new paragraph: + ``(4) The Patient-Centered Outcomes Research Institute + established under section 1181(b) of the Social Security Act.''. + +SEC. 6302. <<NOTE: 42 USC 2996-8 note.>> FEDERAL COORDINATING COUNCIL + FOR COMPARATIVE EFFECTIVENESS RESEARCH. + + <<NOTE: Termination date.>> Notwithstanding any other provision of +law, the Federal Coordinating Council for Comparative Effectiveness +Research established under section 804 of Division A of the American +Recovery and Reinvestment Act of 2009 (42 U.S.C. 299b-8), including the +requirement under subsection (e)(2) of such section, shall terminate on +the date of enactment of this Act. + + Subtitle E--Medicare, Medicaid, and CHIP Program Integrity Provisions + +SEC. 6401. PROVIDER SCREENING AND OTHER ENROLLMENT REQUIREMENTS UNDER + MEDICARE, MEDICAID, AND CHIP. + + (a) Medicare.--Section 1866(j) of the Social Security Act (42 U.S.C. +1395cc(j)) is amended-- + (1) in paragraph (1)(A), by adding at the end the following: + ``Such process shall include screening of providers and + suppliers in accordance with paragraph (2), a provisional period + of enhanced oversight in accordance with paragraph (3), + disclosure requirements in accordance with paragraph (4), the + imposition of temporary enrollment moratoria in accordance with + paragraph (5), and the establishment of compliance programs in + accordance with paragraph (6).''; + (2) by redesignating paragraph (2) as paragraph (7); and + (3) by inserting after paragraph (1) the following: + ``(2) Provider screening.-- + ``(A) Procedures.-- <<NOTE: Deadline.>> Not later + than 180 days after the date of enactment of this + paragraph, the Secretary, in consultation with the + Inspector General of the Department of Health and Human + Services, shall establish procedures under which + screening is conducted with respect to providers of + medical or other items or services and suppliers under + the program under this title, the Medicaid program under + title XIX, and the CHIP program under title XXI. + +[[Page 124 STAT. 748]] + + ``(B) Level of screening.-- + <<NOTE: Determination.>> The Secretary shall determine + the level of screening conducted under this paragraph + according to the risk of fraud, waste, and abuse, as + determined by the Secretary, with respect to the + category of provider of medical or other items or + services or supplier. Such screening-- + ``(i) shall include a licensure check, which + may include such checks across States; and + ``(ii) may, as the Secretary determines + appropriate based on the risk of fraud, waste, and + abuse described in the preceding sentence, + include-- + ``(I) a criminal background check; + ``(II) fingerprinting; + ``(III) unscheduled and unannounced + site visits, including preenrollment + site visits; + ``(IV) database checks (including + such checks across States); and + ``(V) such other screening as the + Secretary determines appropriate. + ``(C) Application fees.-- + ``(i) Individual providers.--Except as + provided in clause (iii), the Secretary shall + impose a fee on each individual provider of + medical or other items or services or supplier + (such as a physician, physician assistant, nurse + practitioner, or clinical nurse specialist) with + respect to which screening is conducted under this + paragraph in an amount equal to-- + ``(I) for 2010, $200; and + ``(II) for 2011 and each subsequent + year, the amount determined under this + clause for the preceding year, adjusted + by the percentage change in the consumer + price index for all urban consumers (all + items; United States city average) for + the 12-month period ending with June of + the previous year. + ``(ii) Institutional providers.--Except as + provided in clause (iii), the Secretary shall + impose a fee on each institutional provider of + medical or other items or services or supplier + (such as a hospital or skilled nursing facility) + with respect to which screening is conducted under + this paragraph in an amount equal to-- + ``(I) for 2010, $500; and + ``(II) for 2011 and each subsequent + year, the amount determined under this + clause for the preceding year, adjusted + by the percentage change in the consumer + price index for all urban consumers (all + items; United States city average) for + the 12-month period ending with June of + the previous year. + ``(iii) Hardship exception; waiver for certain + medicaid providers.-- <<NOTE: Determination.>> The + Secretary may, on a case-by-case basis, exempt a + provider of medical or other items or services or + supplier from the imposition of an application fee + under this subparagraph if the Secretary + determines that the imposition of the application + fee would result in a hardship. The Secretary may + +[[Page 124 STAT. 749]] + + waive the application fee under this subparagraph + for providers enrolled in a State Medicaid program + for whom the State demonstrates that imposition of + the fee would impede beneficiary access to care. + ``(iv) Use of funds.--Amounts collected as a + result of the imposition of a fee under this + subparagraph shall be used by the Secretary for + program integrity efforts, including to cover the + costs of conducting screening under this paragraph + and to carry out this subsection and section + 1128J. + ``(D) Application and enforcement.-- + ``(i) New providers of services and + suppliers.--The screening under this paragraph + shall apply, in the case of a provider of medical + or other items or services or supplier who is not + enrolled in the program under this title, title + XIX , or title XXI as of the date of enactment of + this paragraph, on or after the date that is 1 + year after such date of enactment. + ``(ii) Current providers of services and + suppliers.--The screening under this paragraph + shall apply, in the case of a provider of medical + or other items or services or supplier who is + enrolled in the program under this title, title + XIX, or title XXI as of such date of enactment, on + or after the date that is 2 years after such date + of enactment. + ``(iii) Revalidation of enrollment.-- + <<NOTE: Effective date.>> Effective beginning on + the date that is 180 days after such date of + enactment, the screening under this paragraph + shall apply with respect to the revalidation of + enrollment of a provider of medical or other items + or services or supplier in the program under this + title, title XIX, or title XXI. + ``(iv) Limitation on enrollment and + revalidation of enrollment.--In no case may a + provider of medical or other items or services or + supplier who has not been screened under this + paragraph be initially enrolled or reenrolled in + the program under this title, title XIX, or title + XXI on or after the date that is 3 years after + such date of enactment. + ``(E) Expedited rulemaking.--The Secretary may + promulgate an interim final rule to carry out this + paragraph. + ``(3) Provisional period of enhanced oversight for new + providers of services and suppliers.-- + ``(A) In general.-- <<NOTE: Procedures.>> The + Secretary shall establish procedures to provide for a + provisional period of not less than 30 days and not more + than 1 year during which new providers of medical or + other items or services and suppliers, as the Secretary + determines appropriate, including categories of + providers or suppliers, would be subject to enhanced + oversight, such as prepayment review and payment caps, + under the program under this title, the Medicaid program + under title XIX. and the CHIP program under title XXI. + ``(B) Implementation.--The Secretary may establish + by program instruction or otherwise the procedures under + this paragraph. + +[[Page 124 STAT. 750]] + + ``(4) Increased disclosure requirements.-- + ``(A) Disclosure.--A provider of medical or other + items or services or supplier who submits an application + for enrollment or revalidation of enrollment in the + program under this title, title XIX, or title XXI on or + after the date that is 1 year after the date of + enactment of this paragraph shall disclose (in a form + and manner and at such time as determined by the + Secretary) any current or previous affiliation (directly + or indirectly) with a provider of medical or other items + or services or supplier that has uncollected debt, has + been or is subject to a payment suspension under a + Federal health care program (as defined in section + 1128B(f)), has been excluded from participation under + the program under this title, the Medicaid program under + title XIX, or the CHIP program under title XXI, or has + had its billing privileges denied or revoked. + ``(B) Authority to deny enrollment.-- + <<NOTE: Determination.>> If the Secretary determines + that such previous affiliation poses an undue risk of + fraud, waste, or abuse, the Secretary may deny such + application. Such a denial shall be subject to appeal in + accordance with paragraph (7). + ``(5) Authority to adjust payments of providers of services + and suppliers with the same tax identification number for past- + due obligations.-- + ``(A) In general.--Notwithstanding any other + provision of this title, in the case of an applicable + provider of services or supplier, the Secretary may make + any necessary adjustments to payments to the applicable + provider of services or supplier under the program under + this title in order to satisfy any past-due obligations + described in subparagraph (B)(ii) of an obligated + provider of services or supplier. + ``(B) Definitions.--In this paragraph: + ``(i) In general.--The term `applicable + provider of services or supplier' means a provider + of services or supplier that has the same taxpayer + identification number assigned under section 6109 + of the Internal Revenue Code of 1986 as is + assigned to the obligated provider of services or + supplier under such section, regardless of whether + the applicable provider of services or supplier is + assigned a different billing number or national + provider identification number under the program + under this title than is assigned to the obligated + provider of services or supplier. + ``(ii) Obligated provider of services or + supplier.--The term `obligated provider of + services or supplier' means a provider of services + or supplier that owes a past-due obligation under + the program under this title (as determined by the + Secretary). + ``(6) Temporary moratorium on enrollment of new providers.-- + ``(A) In general.-- <<NOTE: Determination.>> The + Secretary may impose a temporary moratorium on the + enrollment of new providers of services and suppliers, + including categories of providers of services and + suppliers, in the program under this title, under the + Medicaid program under title XIX, or under + +[[Page 124 STAT. 751]] + + the CHIP program under title XXI if the Secretary + determines such moratorium is necessary to prevent or + combat fraud, waste, or abuse under either such program. + ``(B) Limitation on review.--There shall be no + judicial review under section 1869, section 1878, or + otherwise, of a temporary moratorium imposed under + subparagraph (A). + ``(7) Compliance programs.-- + ``(A) In general.--On or after the date of + implementation determined by the Secretary under + subparagraph (C), a provider of medical or other items + or services or supplier within a particular industry + sector or category shall, as a condition of enrollment + in the program under this title, title XIX, or title + XXI, establish a compliance program that contains the + core elements established under subparagraph (B) with + respect to that provider or supplier and industry or + category. + ``(B) Establishment of core elements.--The + Secretary, in consultation with the Inspector General of + the Department of Health and Human Services, shall + establish core elements for a compliance program under + subparagraph (A) for providers or suppliers within a + particular industry or category. + ``(C) Timeline for implementation.-- + <<NOTE: Determination.>> The Secretary shall determine + the timeline for the establishment of the core elements + under subparagraph (B) and the date of the + implementation of subparagraph (A) for providers or + suppliers within a particular industry or category. The + Secretary shall, in determining such date of + implementation, consider the extent to which the + adoption of compliance programs by a provider of medical + or other items or services or supplier is widespread in + a particular industry sector or with respect to a + particular provider or supplier category.''. + + (b) Medicaid.-- + (1) State plan amendment.--Section 1902(a) of the Social + Security Act (42 U.S.C. 1396a(a)), as amended by section + 4302(b), is amended-- + (A) in subsection (a)-- + (i) by striking ``and'' at the end of + paragraph (75); + (ii) by striking the period at the end of + paragraph (76) and inserting a semicolon; and + (iii) by inserting after paragraph (76) the + following: + ``(77) provide that the State shall comply with provider and + supplier screening, oversight, and reporting requirements in + accordance with subsection (ii);''; and + (B) by adding at the end the following: + + ``(ii) Provider and Supplier Screening, Oversight, and Reporting +Requirements.--For purposes of subsection (a)(77), the requirements of +this subsection are the following: + ``(1) Screening.--The State complies with the process for + screening providers and suppliers under this title, as + established by the Secretary under section 1886(j)(2). + ``(2) Provisional period of enhanced oversight for new + providers and suppliers.--The State complies with procedures to + provide for a provisional period of enhanced oversight for new + providers and suppliers under this title, as established by the + Secretary under section 1886(j)(3). + +[[Page 124 STAT. 752]] + + ``(3) Disclosure requirements.--The State requires providers + and suppliers under the State plan or under a waiver of the plan + to comply with the disclosure requirements established by the + Secretary under section 1886(j)(4). + ``(4) Temporary moratorium on enrollment of new providers or + suppliers.-- + ``(A) Temporary moratorium imposed by the + secretary.-- + ``(i) In general.--Subject to clause (ii), the + State complies with any temporary moratorium on + the enrollment of new providers or suppliers + imposed by the Secretary under section 1886(j)(6). + ``(ii) Exception.-- <<NOTE: Determination.>> A + State shall not be required to comply with a + temporary moratorium described in clause (i) if + the State determines that the imposition of such + temporary moratorium would adversely impact + beneficiaries' access to medical assistance. + ``(B) Moratorium on enrollment of providers and + suppliers.-- <<NOTE: Determination.>> At the option of + the State, the State imposes, for purposes of entering + into participation agreements with providers or + suppliers under the State plan or under a waiver of the + plan, periods of enrollment moratoria, or numerical caps + or other limits, for providers or suppliers identified + by the Secretary as being at high-risk for fraud, waste, + or abuse as necessary to combat fraud, waste, or abuse, + but only if the State determines that the imposition of + any such period, cap, or other limits would not + adversely impact beneficiaries' access to medical + assistance. + ``(5) Compliance programs.--The State requires providers and + suppliers under the State plan or under a waiver of the plan to + establish, in accordance with the requirements of section + 1866(j)(7), a compliance program that contains the core elements + established under subparagraph (B) of that section 1866(j)(7) + for providers or suppliers within a particular industry or + category. + ``(6) Reporting of adverse provider actions.--The State + complies with the national system for reporting criminal and + civil convictions, sanctions, negative licensure actions, and + other adverse provider actions to the Secretary, through the + Administrator of the Centers for Medicare & Medicaid Services, + in accordance with regulations of the Secretary. + ``(7) Enrollment and npi of ordering or referring + providers.--The State requires-- + ``(A) all ordering or referring physicians or other + professionals to be enrolled under the State plan or + under a waiver of the plan as a participating provider; + and + ``(B) the national provider identifier of any + ordering or referring physician or other professional to + be specified on any claim for payment that is based on + an order or referral of the physician or other + professional. + ``(8) Other state oversight.--Nothing in this subsection + shall be interpreted to preclude or limit the ability of a State + to engage in provider and supplier screening or enhanced + provider and supplier oversight activities beyond those required + by the Secretary.''. + (2) <<NOTE: 42 USC 1395cc note.>> Disclosure of medicare + terminated providers and suppliers to states.--The Administrator + of the Centers for + +[[Page 124 STAT. 753]] + + Medicare & Medicaid Services shall establish a process for + making available to the each State agency with responsibility + for administering a State Medicaid plan (or a waiver of such + plan) under title XIX of the Social Security Act or a child + health plan under title XXI the name, national provider + identifier, and other identifying information for any provider + of medical or other items or services or supplier under the + Medicare program under title XVIII or under the CHIP program + under title XXI that is terminated from participation under that + program within 30 days of the termination (and, with respect to + all such providers or suppliers who are terminated from the + Medicare program on the date of enactment of this Act, within 90 + days of such date). + (3) Conforming amendment.--Section 1902(a)(23) of the Social + Security Act (42 U.S.C. 1396a), is amended by inserting before + the semicolon at the end the following: ``or by a provider or + supplier to which a moratorium under subsection (ii)(4) is + applied during the period of such moratorium''. + + (c) CHIP.--Section 2107(e)(1) of the Social Security Act (42 U.S.C. +1397gg(e)(1)), as amended by section 2101(d), is amended-- + (1) by redesignating subparagraphs (D) through (M) as + subparagraphs (E) through (N), respectively; and + (2) by inserting after subparagraph (C), the following: + ``(D) Subsections (a)(77) and (ii) of section 1902 + (relating to provider and supplier screening, oversight, + and reporting requirements).''. + +SEC. 6402. ENHANCED MEDICARE AND MEDICAID PROGRAM INTEGRITY PROVISIONS. + + (a) In General.--Part A of title XI of the Social Security Act (42 +U.S.C. 1301 et seq.), as amended by sections 6002, 6004, and 6102, is +amended by inserting after section 1128I the following new section: + +``SEC. 1128J. <<NOTE: 42 USC 1320a-7k.>> MEDICARE AND MEDICAID PROGRAM + INTEGRITY PROVISIONS. + + ``(a) Data Matching.-- + ``(1) Integrated data repository.-- + ``(A) Inclusion of certain data.-- + ``(i) In general.--The Integrated Data + Repository of the Centers for Medicare & Medicaid + Services shall include, at a minimum, claims and + payment data from the following: + ``(I) The programs under titles + XVIII and XIX (including parts A, B, C, + and D of title XVIII). + ``(II) The program under title XXI. + ``(III) Health-related programs + administered by the Secretary of + Veterans Affairs. + ``(IV) Health-related programs + administered by the Secretary of + Defense. + ``(V) The program of old-age, + survivors, and disability insurance + benefits established under title II. + ``(VI) The Indian Health Service and + the Contract Health Service program. + ``(ii) Priority for inclusion of certain + data.--Inclusion of the data described in + subclause (I) of such clause in the Integrated + Data Repository shall be a + +[[Page 124 STAT. 754]] + + priority. Data described in subclauses (II) + through (VI) of such clause shall be included in + the Integrated Data Repository as appropriate. + ``(B) Data sharing and matching.-- + ``(i) In general.-- <<NOTE: Contracts.>> The + Secretary shall enter into agreements with the + individuals described in clause (ii) under which + such individuals share and match data in the + system of records of the respective agencies of + such individuals with data in the system of + records of the Department of Health and Human + Services for the purpose of identifying potential + fraud, waste, and abuse under the programs under + titles XVIII and XIX. + ``(ii) Individuals described.--The following + individuals are described in this clause: + ``(I) The Commissioner of Social + Security. + ``(II) The Secretary of Veterans + Affairs. + ``(III) The Secretary of Defense. + ``(IV) The Director of the Indian + Health Service. + ``(iii) Definition of system of records.--For + purposes of this paragraph, the term `system of + records' has the meaning given such term in + section 552a(a)(5) of title 5, United States Code. + ``(2) Access to claims and payment databases.--For purposes + of conducting law enforcement and oversight activities and to + the extent consistent with applicable information, privacy, + security, and disclosure laws, including the regulations + promulgated under the Health Insurance Portability and + Accountability Act of 1996 and section 552a of title 5, United + States Code, and subject to any information systems security + requirements under such laws or otherwise required by the + Secretary, the Inspector General of the Department of Health and + Human Services and the Attorney General shall have access to + claims and payment data of the Department of Health and Human + Services and its contractors related to titles XVIII, XIX, and + XXI. + + ``(b) OIG Authority To Obtain Information.-- + ``(1) In general.--Notwithstanding and in addition to any + other provision of law, the Inspector General of the Department + of Health and Human Services may, for purposes of protecting the + integrity of the programs under titles XVIII and XIX, obtain + information from any individual (including a beneficiary + provided all applicable privacy protections are followed) or + entity that-- + ``(A) is a provider of medical or other items or + services, supplier, grant recipient, contractor, or + subcontractor; or + ``(B) directly or indirectly provides, orders, + manufactures, distributes, arranges for, prescribes, + supplies, or receives medical or other items or services + payable by any Federal health care program (as defined + in section 1128B(f)) regardless of how the item or + service is paid for, or to whom such payment is made. + ``(2) Inclusion of certain information.--Information which + the Inspector General may obtain under paragraph (1) includes + any supporting documentation necessary to validate claims for + payment or payments under title XVIII or XIX, + +[[Page 124 STAT. 755]] + + including a prescribing physician's medical records for an + individual who is prescribed an item or service which is covered + under part B of title XVIII, a covered part D drug (as defined + in section 1860D-2(e)) for which payment is made under an MA-PD + plan under part C of such title, or a prescription drug plan + under part D of such title, and any records necessary for + evaluation of the economy, efficiency, and effectiveness of the + programs under titles XVIII and XIX. + + ``(c) Administrative Remedy for Knowing Participation by Beneficiary +in Health Care Fraud Scheme.-- + ``(1) In general.-- <<NOTE: Penalty.>> In addition to any + other applicable remedies, if an applicable individual has + knowingly participated in a Federal health care fraud offense or + a conspiracy to commit a Federal health care fraud offense, the + Secretary shall impose an appropriate administrative penalty + commensurate with the offense or conspiracy. + ``(2) Applicable individual.-- <<NOTE: Definition.>> For + purposes of paragraph (1), the term `applicable individual' + means an individual-- + ``(A) entitled to, or enrolled for, benefits under + part A of title XVIII or enrolled under part B of such + title; + ``(B) eligible for medical assistance under a State + plan under title XIX or under a waiver of such plan; or + ``(C) eligible for child health assistance under a + child health plan under title XXI. + + ``(d) Reporting and Returning of Overpayments.-- + ``(1) In general.--If a person has received an overpayment, + the person shall-- + ``(A) report and return the overpayment to the + Secretary, the State, an intermediary, a carrier, or a + contractor, as appropriate, at the correct address; and + ``(B) <<NOTE: Notification.>> notify the Secretary, + State, intermediary, carrier, or contractor to whom the + overpayment was returned in writing of the reason for + the overpayment. + ``(2) Deadline for reporting and returning overpayments.--An + overpayment must be reported and returned under paragraph (1) by + the later of-- + ``(A) the date which is 60 days after the date on + which the overpayment was identified; or + ``(B) the date any corresponding cost report is due, + if applicable. + ``(3) Enforcement.--Any overpayment retained by a person + after the deadline for reporting and returning the overpayment + under paragraph (2) is an obligation (as defined in section + 3729(b)(3) of title 31, United States Code) for purposes of + section 3729 of such title. + ``(4) Definitions.--In this subsection: + ``(A) Knowing and knowingly.--The terms `knowing' + and `knowingly' have the meaning given those terms in + section 3729(b) of title 31, United States Code. + ``(B) Overpayment.--The term ``overpayment'' means + any funds that a person receives or retains under title + XVIII or XIX to which the person, after applicable + reconciliation, is not entitled under such title. + ``(C) Person.-- + ``(i) In general.--The term `person' means a + provider of services, supplier, medicaid managed + care organization (as defined in section + 1903(m)(1)(A)), + +[[Page 124 STAT. 756]] + + Medicare Advantage organization (as defined in + section 1859(a)(1)), or PDP sponsor (as defined in + section 1860D-41(a)(13)). + ``(ii) Exclusion.--Such term does not include + a beneficiary. + + ``(e) Inclusion of National Provider Identifier on All Applications +and Claims.-- <<NOTE: Regulations. Deadline.>> The Secretary shall +promulgate a regulation that requires, not later than January 1, 2011, +all providers of medical or other items or services and suppliers under +the programs under titles XVIII and XIX that qualify for a national +provider identifier to include their national provider identifier on all +applications to enroll in such programs and on all claims for payment +submitted under such programs.''. + + (b) Access to Data.-- + (1) Medicare part d.--Section 1860D-15(f)(2) of the Social + Security Act (42 U.S.C. 1395w-116(f)(2)) <<NOTE: 42 USC 1395w- + 115.>> is amended by striking ``may be used by'' and all that + follows through the period at the end and inserting ``may be + used-- + ``(A) by officers, employees, and contractors of the + Department of Health and Human Services for the purposes + of, and to the extent necessary in-- + ``(i) carrying out this section; and + ``(ii) conducting oversight, evaluation, and + enforcement under this title; and + ``(B) by the Attorney General and the Comptroller + General of the United States for the purposes of, and to + the extent necessary in, carrying out health oversight + activities.''. + (2) Data matching.--Section 552a(a)(8)(B) of title 5, United + States Code, is amended-- + (A) in clause (vii), by striking ``or'' at the end; + (B) in clause (viii), by inserting ``or'' after the + semicolon; and + (C) by adding at the end the following new clause: + ``(ix) matches performed by the Secretary of + Health and Human Services or the Inspector General + of the Department of Health and Human Services + with respect to potential fraud, waste, and abuse, + including matches of a system of records with non- + Federal records;''. + (3) Matching agreements with the commissioner of social + security.--Section 205(r) of the Social Security Act (42 U.S.C. + 405(r)) is amended by adding at the end the following new + paragraph: + ``(9)(A) The Commissioner of Social Security shall, upon the + request of the Secretary or the Inspector General of the + Department of Health and Human Services-- + ``(i) <<NOTE: Contracts.>> enter into an agreement + with the Secretary or such Inspector General for the + purpose of matching data in the system of records of the + Social Security Administration and the system of records + of the Department of Health and Human Services; and + ``(ii) include in such agreement safeguards to + assure the maintenance of the confidentiality of any + information disclosed. + +[[Page 124 STAT. 757]] + + ``(B) For purposes of this paragraph, the term `system of + records' has the meaning given such term in section 552a(a)(5) + of title 5, United States Code.''. + + (c) Withholding of Federal Matching Payments for States That Fail To +Report Enrollee Encounter Data in the Medicaid Statistical Information +System.--Section 1903(i) of the Social Security Act (42 U.S.C. 1396b(i)) +is amended-- + (1) in paragraph (23), by striking ``or'' at the end; + (2) in paragraph (24), by striking the period at the end and + inserting ``; or''; and + (3) by adding at the end the following new paragraph:. + ``(25) with respect to any amounts expended for medical + assistance for individuals for whom the State does not report + enrollee encounter data (as defined by the Secretary) to the + Medicaid Statistical Information System (MSIS) in a timely + manner (as determined by the Secretary).''. + + (d) Permissive Exclusions and Civil Monetary Penalties.-- + (1) Permissive exclusions.--Section 1128(b) of the Social + Security Act (42 U.S.C. 1320a-7(b)) is amended by adding at the + end the following new paragraph: + ``(16) Making false statements or misrepresentation of + material facts.--Any individual or entity that knowingly makes + or causes to be made any false statement, omission, or + misrepresentation of a material fact in any application, + agreement, bid, or contract to participate or enroll as a + provider of services or supplier under a Federal health care + program (as defined in section 1128B(f)), including Medicare + Advantage organizations under part C of title XVIII, + prescription drug plan sponsors under part D of title XVIII, + medicaid managed care organizations under title XIX, and + entities that apply to participate as providers of services or + suppliers in such managed care organizations and such plans.''. + (2) Civil monetary penalties.-- + (A) In general.--Section 1128A(a) of the Social + Security Act (42 U.S.C. 1320a-7a(a)) is amended-- + (i) in paragraph (1)(D), by striking ``was + excluded'' and all that follows through the period + at the end and inserting ``was excluded from the + Federal health care program (as defined in section + 1128B(f)) under which the claim was made pursuant + to Federal law.''; + (ii) in paragraph (6), by striking ``or'' at + the end; + (iii) by inserting after paragraph (7), the + following new paragraphs: + ``(8) orders or prescribes a medical or other item or + service during a period in which the person was excluded from a + Federal health care program (as so defined), in the case where + the person knows or should know that a claim for such medical or + other item or service will be made under such a program; + ``(9) knowingly makes or causes to be made any false + statement, omission, or misrepresentation of a material fact in + any application, bid, or contract to participate or enroll as a + provider of services or a supplier under a Federal health care + program (as so defined), including Medicare Advantage + organizations under part C of title XVIII, prescription drug + plan sponsors under part D of title XVIII, medicaid managed care + organizations under title XIX, and entities that apply to + participate + +[[Page 124 STAT. 758]] + + as providers of services or suppliers in such managed care + organizations and such plans; + ``(10) knows of an overpayment (as defined in paragraph (4) + of section 1128J(d)) and does not report and return the + overpayment in accordance with such section;''; + (iv) in the first sentence-- + (I) by striking the ``or'' after + ``prohibited relationship occurs;''; and + (II) by striking ``act)'' and + inserting ``act; or in cases under + paragraph (9), $50,000 for each false + statement or misrepresentation of a + material fact)''; and + (v) in the second sentence, by striking + ``purpose)'' and inserting ``purpose; or in cases + under paragraph (9), an assessment of not more + than 3 times the total amount claimed for each + item or service for which payment was made based + upon the application containing the false + statement or misrepresentation of a material + fact)''. + (B) Clarification of treatment of certain charitable + and other innocuous programs.--Section 1128A(i)(6) of + the Social Security Act (42 U.S.C. 1320a-7a(i)(6)) is + amended-- + (i) in subparagraph (C), by striking ``or'' at + the end; + (ii) in subparagraph (D), as redesignated by + section 4331(e) of the Balanced Budget Act of 1997 + (Public Law 105-33), by striking the period at the + end and inserting a semicolon; + (iii) by redesignating subparagraph (D), as + added by section 4523(c) of such Act, as + subparagraph (E) and striking the period at the + end and inserting ``; or''; and + (iv) by adding at the end the following new + subparagraphs: + ``(F) <<NOTE: Regulations.>> any other remuneration + which promotes access to care and poses a low risk of + harm to patients and Federal health care programs (as + defined in section 1128B(f) and designated by the + Secretary under regulations); + ``(G) the offer or transfer of items or services for + free or less than fair market value by a person, if-- + ``(i) the items or services consist of + coupons, rebates, or other rewards from a + retailer; + ``(ii) the items or services are offered or + transferred on equal terms available to the + general public, regardless of health insurance + status; and + ``(iii) the offer or transfer of the items or + services is not tied to the provision of other + items or services reimbursed in whole or in part + by the program under title XVIII or a State health + care program (as defined in section 1128(h)); + ``(H) the offer or transfer of items or services for + free or less than fair market value by a person, if-- + ``(i) the items or services are not offered as + part of any advertisement or solicitation; + +[[Page 124 STAT. 759]] + + ``(ii) the items or services are not tied to + the provision of other services reimbursed in + whole or in part by the program under title XVIII + or a State health care program (as so defined); + ``(iii) there is a reasonable connection + between the items or services and the medical care + of the individual; and + ``(iv) the person provides the items or + services after determining in good faith that the + individual is in financial need; or + ``(I) effective on a date specified by the Secretary + (but not earlier than January 1, 2011), the waiver by a + PDP sponsor of a prescription drug plan under part D of + title XVIII or an MA organization offering an MA-PD plan + under part C of such title of any copayment for the + first fill of a covered part D drug (as defined in + section 1860D-2(e)) that is a generic drug for + individuals enrolled in the prescription drug plan or + MA-PD plan, respectively.''. + + (e) Testimonial Subpoena Authority in Exclusion-only Cases.--Section +1128(f) of the Social Security Act (42 U.S.C. 1320a-7(f)) is amended by +adding at the end the following new paragraph: + ``(4) <<NOTE: Applicability.>> The provisions of subsections + (d) and (e) of section 205 shall apply with respect to this + section to the same extent as they are applicable with respect + to title II. The Secretary may delegate the authority granted by + section 205(d) (as made applicable to this section) to the + Inspector General of the Department of Health and Human Services + for purposes of any investigation under this section.''. + + (f) Health Care Fraud.-- + (1) Kickbacks.--Section 1128B of the Social Security Act (42 + U.S.C. 1320a-7b) is amended by adding at the end the following + new subsection: + + ``(g) In addition to the penalties provided for in this section or +section 1128A, a claim that includes items or services resulting from a +violation of this section constitutes a false or fraudulent claim for +purposes of subchapter III of chapter 37 of title 31, United States +Code.''. + (2) Revising the intent requirement.--Section 1128B of the + Social Security Act (42 U.S.C. 1320a-7b), as amended by + paragraph (1), is amended by adding at the end the following new + subsection: + + ``(h) With respect to violations of this section, a person need not +have actual knowledge of this section or specific intent to commit a +violation of this section.''. + (g) Surety Bond Requirements.-- + (1) Durable medical equipment.--Section 1834(a)(16)(B) of + the Social Security Act (42 U.S.C. 1395m(a)(16)(B)) is amended + by inserting ``that the Secretary determines is commensurate + with the volume of the billing of the supplier'' before the + period at the end. + (2) Home health agencies.--Section 1861(o)(7)(C) of the + Social Security Act (42 U.S.C. 1395x(o)(7)(C)) is amended by + inserting ``that the Secretary determines is commensurate with + the volume of the billing of the home health agency'' before the + semicolon at the end. + (3) Requirements for certain other providers of services and + suppliers.--Section 1862 of the Social Security Act + +[[Page 124 STAT. 760]] + + (42 U.S.C. 1395y) is amended by adding at the end the following + new subsection: + + ``(n) Requirement of a Surety Bond for Certain Providers of Services +and Suppliers.-- + ``(1) In general.--The Secretary may require a provider of + services or supplier described in paragraph (2) to provide the + Secretary on a continuing basis with a surety bond in a form + specified by the Secretary in an amount (not less than $50,000) + that the Secretary determines is commensurate with the volume of + the billing of the provider of services or supplier. + The <<NOTE: Waiver authority.>> Secretary may waive the + requirement of a bond under the preceding sentence in the case + of a provider of services or supplier that provides a comparable + surety bond under State law. + ``(2) Provider of services or supplier described.--A + provider of services or supplier described in this paragraph is + a provider of services or supplier the Secretary determines + appropriate based on the level of risk involved with respect to + the provider of services or supplier, and consistent with the + surety bond requirements under sections 1834(a)(16)(B) and + 1861(o)(7)(C).''. + + (h) Suspension of Medicare and Medicaid Payments Pending +Investigation of Credible Allegations of Fraud.-- + (1) Medicare.--Section 1862 of the Social Security Act (42 + U.S.C. 1395y), as amended by subsection (g)(3), is amended by + adding at the end the following new subsection: + + ``(o) Suspension of Payments Pending Investigation of Credible +Allegations of Fraud.-- + ``(1) In general.-- <<NOTE: Determination.>> The Secretary + may suspend payments to a provider of services or supplier under + this title pending an investigation of a credible allegation of + fraud against the provider of services or supplier, unless the + Secretary determines there is good cause not to suspend such + payments. + ``(2) Consultation.--The Secretary shall consult with the + Inspector General of the Department of Health and Human Services + in determining whether there is a credible allegation of fraud + against a provider of services or supplier. + ``(3) Promulgation of regulations.--The Secretary shall + promulgate regulations to carry out this subsection and section + 1903(i)(2)(C).''. + (2) Medicaid.--Section 1903(i)(2) of such Act (42 U.S.C. + 1396b(i)(2)) is amended-- + (A) in subparagraph (A), by striking ``or'' at the + end; and + (B) by inserting after subparagraph (B), the + following: + ``(C) <<NOTE: Determination.>> by any individual or + entity to whom the State has failed to suspend payments + under the plan during any period when there is pending + an investigation of a credible allegation of fraud + against the individual or entity, as determined by the + State in accordance with regulations promulgated by the + Secretary for purposes of section 1862(o) and this + subparagraph, unless the State determines in accordance + with such regulations there is good cause not to suspend + such payments; or''. + + (i) Increased Funding To Fight Fraud and Abuse.-- + (1) In general.--Section 1817(k) of the Social Security Act + (42 U.S.C. 1395i(k)) is amended-- + +[[Page 124 STAT. 761]] + + (A) by adding at the end the following new + paragraph: + ``(7) Additional funding.--In addition to the funds + otherwise appropriated to the Account from the Trust Fund under + paragraphs (3) and (4) and for purposes described in paragraphs + (3)(C) and (4)(A), there are hereby appropriated an additional + $10,000,000 to such Account from such Trust Fund for each of + fiscal years 2011 through 2020. The funds appropriated under + this paragraph shall be allocated in the same proportion as the + total funding appropriated with respect to paragraphs (3)(A) and + (4)(A) was allocated with respect to fiscal year 2010, and shall + be available without further appropriation until expended.''; + and + (B) in paragraph (4)(A), by inserting ``until + expended'' after ``appropriation''. + (2) Indexing of amounts appropriated.-- + (A) Departments of health and human services and + justice.--Section 1817(k)(3)(A)(i) of the Social + Security Act (42 U.S.C. 1395i(k)(3)(A)(i)) is amended-- + (i) in subclause (III), by inserting ``and'' + at the end; + (ii) in subclause (IV)-- + (I) by striking ``for each of fiscal + years 2007, 2008, 2009, and 2010'' and + inserting ``for each fiscal year after + fiscal year 2006''; and + (II) by striking ``; and'' and + inserting a period; and + (iii) by striking subclause (V). + (B) Office of the inspector general of the + department of health and human services.--Section + 1817(k)(3)(A)(ii) of such Act (42 U.S.C. + 1395i(k)(3)(A)(ii)) is amended-- + (i) in subclause (VIII), by inserting ``and'' + at the end; + (ii) in subclause (IX)-- + (I) by striking ``for each of fiscal + years 2008, 2009, and 2010'' and + inserting ``for each fiscal year after + fiscal year 2007''; and + (II) by striking ``; and'' and + inserting a period; and + (iii) by striking subclause (X). + (C) Federal bureau of investigation.--Section + 1817(k)(3)(B) of the Social Security Act (42 U.S.C. + 1395i(k)(3)(B)) is amended-- + (i) in clause (vii), by inserting ``and'' at + the end; + (ii) in clause (viii)-- + (I) by striking ``for each of fiscal + years 2007, 2008, 2009, and 2010'' and + inserting ``for each fiscal year after + fiscal year 2006''; and + (II) by striking ``; and'' and + inserting a period; and + (iii) by striking clause (ix). + (D) Medicare integrity program.--Section + 1817(k)(4)(C) of the Social Security Act (42 U.S.C. + 1395i(k)(4)(C)) is amended by adding at the end the + following new clause: + ``(ii) For each fiscal year after 2010, by the + percentage increase in the consumer price index + for all urban + +[[Page 124 STAT. 762]] + + consumers (all items; United States city average) + over the previous year.''. + + (j) Medicare Integrity Program and Medicaid Integrity Program.-- + (1) Medicare integrity program.-- + (A) Requirement to provide performance statistics.-- + Section 1893(c) of the Social Security Act (42 U.S.C. + 1395ddd(c)) is amended-- + (i) in paragraph (3), by striking ``and'' at + the end; + (ii) by redesignating paragraph (4) as + paragraph (5); and + (iii) by inserting after paragraph (3) the + following new paragraph: + ``(4) the entity agrees to provide the Secretary and the + Inspector General of the Department of Health and Human Services + with such performance statistics (including the number and + amount of overpayments recovered, the number of fraud referrals, + and the return on investment of such activities by the entity) + as the Secretary or the Inspector General may request; and''. + (B) Evaluations and annual report.--Section 1893 of + the Social Security Act (42 U.S.C. 1395ddd) is amended + by adding at the end the following new subsection: + + ``(i) Evaluations and Annual Report.-- + ``(1) Evaluations.--The Secretary shall conduct evaluations + of eligible entities which the Secretary contracts with under + the Program not less frequently than every 3 years. + ``(2) Annual report.--Not later than 180 days after the end + of each fiscal year (beginning with fiscal year 2011), the + Secretary shall submit a report to Congress which identifies-- + ``(A) the use of funds, including funds transferred + from the Federal Hospital Insurance Trust Fund under + section 1817 and the Federal Supplementary Insurance + Trust Fund under section 1841, to carry out this + section; and + ``(B) the effectiveness of the use of such funds.''. + (C) Flexibility in pursuing fraud and abuse.-- + Section 1893(a) of the Social Security Act (42 U.S.C. + 1395ddd(a)) is amended by inserting ``, or otherwise,'' + after ``entities''. + (2) Medicaid integrity program.-- + (A) Requirement to provide performance statistics.-- + Section 1936(c)(2) of the Social Security Act (42 U.S.C. + 1396u-6(c)(2)) is amended-- + (i) by redesignating subparagraph (D) as + subparagraph (E); and + (ii) by inserting after subparagraph (C) the + following new subparagraph: + ``(D) The entity agrees to provide the Secretary and + the Inspector General of the Department of Health and + Human Services with such performance statistics + (including the number and amount of overpayments + recovered, the number of fraud referrals, and the return + on investment of such activities by the entity) as the + Secretary or the Inspector General may request.''. + (B) Evaluations and annual report.--Section 1936(e) + of the Social Security Act <<NOTE: 42 USC 1396u-6.>> (42 + U.S.C. 1396u-7(e)) is amended-- + +[[Page 124 STAT. 763]] + + (i) by redesignating paragraph (4) as + paragraph (5); and + (ii) by inserting after paragraph (3) the + following new paragraph: + ``(4) Evaluations.--The Secretary shall conduct evaluations + of eligible entities which the Secretary contracts with under + the Program not less frequently than every 3 years.''. + + (k) Expanded Application of Hardship Waivers for Exclusions.-- +Section 1128(c)(3)(B) of the Social Security Act (42 U.S.C. 1320a- +7(c)(3)(B)) is amended by striking ``individuals entitled to benefits +under part A of title XVIII or enrolled under part B of such title, or +both'' and inserting ``beneficiaries (as defined in section 1128A(i)(5)) +of that program''. + +SEC. 6403. ELIMINATION OF DUPLICATION BETWEEN THE HEALTHCARE INTEGRITY + AND PROTECTION DATA BANK AND THE NATIONAL PRACTITIONER DATA + BANK. + + (a) Information Reported by Federal Agencies and Health Plans.-- +Section 1128E of the Social Security Act (42 U.S.C. 1320a-7e) is +amended-- + (1) by striking subsection (a) and inserting the following: + + ``(a) In General.--The Secretary shall maintain a national health +care fraud and abuse data collection program under this section for the +reporting of certain final adverse actions (not including settlements in +which no findings of liability have been made) against health care +providers, suppliers, or practitioners as required by subsection (b), +with access as set forth in subsection (d), and shall furnish the +information collected under this section to the National Practitioner +Data Bank established pursuant to the Health Care Quality Improvement +Act of 1986 (42 U.S.C. 11101 et seq.).''; + (2) by striking subsection (d) and inserting the following: + + ``(d) Access to Reported Information.-- + ``(1) Availability.--The information collected under this + section shall be available from the National Practitioner Data + Bank to the agencies, authorities, and officials which are + provided under section 1921(b) information reported under + section 1921(a). + ``(2) Fees for disclosure.--The Secretary may establish or + approve reasonable fees for the disclosure of information under + this section. The amount of such a fee may not exceed the costs + of processing the requests for disclosure and of providing such + information. Such fees shall be available to the Secretary to + cover such costs.''; + (3) by striking subsection (f) and inserting the following: + + ``(f) Appropriate Coordination.--In implementing this section, the +Secretary shall provide for the maximum appropriate coordination with +part B of the Health Care Quality Improvement Act of 1986 (42 U.S.C. +11131 et seq.) and section 1921.''; and + (4) in subsection (g)-- + (A) in paragraph (1)(A)-- + (i) in clause (iii)-- + (I) by striking ``or State'' each + place it appears; + (II) by redesignating subclauses + (II) and (III) as subclauses (III) and + (IV), respectively; and + (III) by inserting after subclause + (I) the following new subclause: + +[[Page 124 STAT. 764]] + + ``(II) any dismissal or closure of + the proceedings by reason of the + provider, supplier, or practitioner + surrendering their license or leaving + the State or jurisdiction''; and + (ii) by striking clause (iv) and inserting the + following: + ``(iv) Exclusion from participation in a + Federal health care program (as defined in section + 1128B(f)).''; + (B) in paragraph (3)-- + (i) by striking subparagraphs (D) and (E); and + (ii) by redesignating subparagraph (F) as + subparagraph (D); and + (C) in subparagraph (D) (as so redesignated), by + striking ``or State''. + + (b) Information Reported by State Law or Fraud Enforcement +Agencies.--Section 1921 of the Social Security Act (42 U.S.C. 1396r-2) +is amended-- + (1) in subsection (a)-- + (A) in paragraph (1)-- + (i) by striking ``system.--The State'' and all + that follows through the semicolon and inserting + system.-- + ``(A) Licensing or certification actions.-- + <<NOTE: Reports. Regulations.>> The State must have in + effect a system of reporting the following information + with respect to formal proceedings (as defined by the + Secretary in regulations) concluded against a health + care practitioner or entity by a State licensing or + certification agency:''; + (ii) by redesignating subparagraphs (A) + through (D) as clauses (i) through (iv), + respectively, and indenting appropriately; + (iii) in subparagraph (A)(iii) (as so + redesignated)-- + (I) by striking ``the license of'' + and inserting ``license or the right to + apply for, or renew, a license by''; and + (II) by inserting + ``nonrenewability,'' after ``voluntary + surrender,''; and + (iv) by adding at the end the following new + subparagraph: + ``(B) Other final adverse actions.-- + <<NOTE: Reports.>> The State must have in effect a + system of reporting information with respect to any + final adverse action (not including settlements in which + no findings of liability have been made) taken against a + health care provider, supplier, or practitioner by a + State law or fraud enforcement agency.''; and + (B) in paragraph (2), by striking ``the authority + described in paragraph (1)'' and inserting ``a State + licensing or certification agency or State law or fraud + enforcement agency''; + (2) in subsection (b)-- + (A) by striking paragraph (2) and inserting the + following: + ``(2) to State licensing or certification agencies and + Federal agencies responsible for the licensing and certification + of health care providers, suppliers, and licensed health care + practitioners;''; + +[[Page 124 STAT. 765]] + + (B) in each of paragraphs (4) and (6), by inserting + ``, but only with respect to information provided + pursuant to subsection (a)(1)(A)'' before the comma at + the end; + (C) by striking paragraph (5) and inserting the + following: + ``(5) to State law or fraud enforcement agencies,''; + (D) by redesignating paragraphs (7) and (8) as + paragraphs (8) and (9), respectively; and + (E) by inserting after paragraph (6) the following + new paragraph: + ``(7) to health plans (as defined in section 1128C(c));''; + (3) by redesignating subsection (d) as subsection (h), and + by inserting after subsection (c) the following new subsections: + + ``(d) Disclosure and Correction of Information.-- + ``(1) Disclosure.--With respect to information reported + pursuant to subsection (a)(1), the Secretary shall-- + ``(A) provide for disclosure of the information, + upon request, to the health care practitioner who, or + the entity that, is the subject of the information + reported; and + ``(B) <<NOTE: Procedures.>> establish procedures for + the case where the health care practitioner or entity + disputes the accuracy of the information reported. + ``(2) Corrections.-- <<NOTE: Reports. Regulations.>> Each + State licensing or certification agency and State law or fraud + enforcement agency shall report corrections of information + already reported about any formal proceeding or final adverse + action described in subsection (a), in such form and manner as + the Secretary prescribes by regulation. + + ``(e) Fees for Disclosure.--The Secretary may establish or approve +reasonable fees for the disclosure of information under this section. +The amount of such a fee may not exceed the costs of processing the +requests for disclosure and of providing such information. Such fees +shall be available to the Secretary to cover such costs. + ``(f) Protection From Liability for Reporting.--No person or entity, +including any agency designated by the Secretary in subsection (b), +shall be held liable in any civil action with respect to any reporting +of information as required under this section, without knowledge of the +falsity of the information contained in the report. + ``(g) References.--For purposes of this section: + ``(1) State licensing or certification agency.--The term + `State licensing or certification agency' includes any authority + of a State (or of a political subdivision thereof) responsible + for the licensing of health care practitioners (or any peer + review organization or private accreditation entity reviewing + the services provided by health care practitioners) or entities. + ``(2) State law or fraud enforcement agency.--The term + `State law or fraud enforcement agency' includes-- + ``(A) a State law enforcement agency; and + ``(B) a State medicaid fraud control unit (as + defined in section 1903(q)). + ``(3) Final adverse action.-- + ``(A) In general.--Subject to subparagraph (B), the + term `final adverse action' includes-- + +[[Page 124 STAT. 766]] + + ``(i) civil judgments against a health care + provider, supplier, or practitioner in State court + related to the delivery of a health care item or + service; + ``(ii) State criminal convictions related to + the delivery of a health care item or service; + ``(iii) exclusion from participation in State + health care programs (as defined in section + 1128(h)); + ``(iv) any licensing or certification action + described in subsection (a)(1)(A) taken against a + supplier by a State licensing or certification + agency; and + ``(v) any other adjudicated actions or + decisions that the Secretary shall establish by + regulation. + ``(B) Exception.--Such term does not include any + action with respect to a malpractice claim.''; and + (4) in subsection (h), as so redesignated, by striking ``The + Secretary'' and all that follows through the period at the end + and inserting ``In implementing this section, the Secretary + shall provide for the maximum appropriate coordination with part + B of the Health Care Quality Improvement Act of 1986 (42 U.S.C. + 11131 et seq.) and section 1128E.''. + + (c) Conforming Amendment.--Section 1128C(a)(1) of the Social +Security Act (42 U.S.C. 1320a-7c(a)(1)) is amended-- + (1) in subparagraph (C), by adding ``and'' after the comma + at the end; + (2) in subparagraph (D), by striking ``, and'' and inserting + a period; and + (3) by striking subparagraph (E). + + (d) <<NOTE: 42 USC 1320a-7e note.>> Transition Process; Effective +Date.-- + (1) In general.--Effective on the date of enactment of this + Act, the Secretary of Health and Human Services (in this section + referred to as the ``Secretary'') shall implement a transition + process under which, by not later than the end of the transition + period described in paragraph (5), the Secretary shall cease + operating the Healthcare Integrity and Protection Data Bank + established under section 1128E of the Social Security Act (as + in effect before the effective date specified in paragraph (6)) + and shall transfer all data collected in the Healthcare + Integrity and Protection Data Bank to the National Practitioner + Data Bank established pursuant to the Health Care Quality + Improvement Act of 1986 (42 U.S.C. 11101 et + seq.). <<NOTE: Procedures.>> During such transition process, the + Secretary shall have in effect appropriate procedures to ensure + that data collection and access to the Healthcare Integrity and + Protection Data Bank and the National Practitioner Data Bank are + not disrupted. + (2) Regulations.--The Secretary shall promulgate regulations + to carry out the amendments made by subsections (a) and (b). + (3) Funding.-- + (A) Availability of fees.--Fees collected pursuant + to section 1128E(d)(2) of the Social Security Act prior + to the effective date specified in paragraph (6) for the + disclosure of information in the Healthcare Integrity + and Protection Data Bank shall be available to the + Secretary, without fiscal year limitation, for payment + of costs related to the transition process described in + paragraph (1). Any such fees remaining after the + transition period is complete shall + +[[Page 124 STAT. 767]] + + be available to the Secretary, without fiscal year + limitation, for payment of the costs of operating the + National Practitioner Data Bank. + (B) Availability of additional funds.--In addition + to the fees described in subparagraph (A), any funds + available to the Secretary or to the Inspector General + of the Department of Health and Human Services for a + purpose related to combating health care fraud, waste, + or abuse shall be available to the extent necessary for + operating the Healthcare Integrity and Protection Data + Bank during the transition period, including systems + testing and other activities necessary to ensure that + information formerly reported to the Healthcare + Integrity and Protection Data Bank will be accessible + through the National Practitioner Data Bank after the + end of such transition period. + (4) Special provision for access to the national + practitioner data bank by the department of veterans affairs.-- + (A) In general.-- <<NOTE: Time + period.>> Notwithstanding any other provision of law, + during the 1-year period that begins on the effective + date specified in paragraph (6), the information + described in subparagraph (B) shall be available from + the National Practitioner Data Bank to the Secretary of + Veterans Affairs without charge. + (B) Information described.--For purposes of + subparagraph (A), the information described in this + subparagraph is the information that would, but for the + amendments made by this section, have been available to + the Secretary of Veterans Affairs from the Healthcare + Integrity and Protection Data Bank. + (5) Transition period defined.--For purposes of this + subsection, the term ``transition period'' means the period that + begins on the date of enactment of this Act and ends on the + later of-- + (A) the date that is 1 year after such date of + enactment; or + (B) the effective date of the regulations + promulgated under paragraph (2). + (6) Effective date.--The amendments made by subsections (a), + (b), and (c) shall take effect on the first day after the final + day of the transition period. + +SEC. 6404. MAXIMUM PERIOD FOR SUBMISSION OF MEDICARE CLAIMS REDUCED TO + NOT MORE THAN 12 MONTHS. + + (a) Reducing Maximum Period for Submission.-- + (1) Part a.--Section 1814(a) of the Social Security Act (42 + U.S.C. 1395f(a)(1)) is amended-- + (A) in paragraph (1), by striking ``period of 3 + calendar years'' and all that follows through the + semicolon and inserting ``period ending 1 calendar year + after the date of service;''; and + (B) by adding at the end the following new sentence: + ``In applying paragraph (1), the Secretary may specify + exceptions to the 1 calendar year period specified in + such paragraph.'' + (2) Part b.-- + +[[Page 124 STAT. 768]] + + (A) Section 1842(b)(3) of such Act (42 U.S.C. + 1395u(b)(3)(B)) is amended-- + (i) in subparagraph (B), in the flush language + following clause (ii), by striking ``close of the + calendar year following the year in which such + service is furnished (deeming any service + furnished in the last 3 months of any calendar + year to have been furnished in the succeeding + calendar year)'' and inserting ``period ending 1 + calendar year after the date of service''; and + (ii) by adding at the end the following new + sentence: ``In applying subparagraph (B), the + Secretary may specify exceptions to the 1 calendar + year period specified in such subparagraph.'' + (B) Section 1835(a) of such Act (42 U.S.C. 1395n(a)) + is amended-- + (i) in paragraph (1), by striking ``period of + 3 calendar years'' and all that follows through + the semicolon and inserting ``period ending 1 + calendar year after the date of service;''; and + (ii) by adding at the end the following new + sentence: ``In applying paragraph (1), the + Secretary may specify exceptions to the 1 calendar + year period specified in such paragraph.'' + + (b) <<NOTE: 42 USC 1395f note.>> Effective Date.-- + (1) In general.--The amendments made by subsection (a) shall + apply to services furnished on or after January 1, 2010. + (2) Services furnished before 2010.-- <<NOTE: Deadline.>> In + the case of services furnished before January 1, 2010, a bill or + request for payment under section 1814(a)(1), 1842(b)(3)(B), or + 1835(a) shall be filed not later that December 31, 2010. + +SEC. 6405. PHYSICIANS WHO ORDER ITEMS OR SERVICES REQUIRED TO BE + MEDICARE ENROLLED PHYSICIANS OR ELIGIBLE PROFESSIONALS. + + (a) DME.--Section 1834(a)(11)(B) of the Social Security Act (42 +U.S.C. 1395m(a)(11)(B)) is amended by striking ``physician'' and +inserting ``physician enrolled under section 1866(j) or an eligible +professional under section 1848(k)(3)(B) that is enrolled under section +1866(j)''. + (b) Home Health Services.-- + (1) Part a.--Section 1814(a)(2) of such Act <<NOTE: 42 USC + 1395f.>> (42 U.S.C. 1395(a)(2)) is amended in the matter + preceding subparagraph (A) by inserting ``in the case of + services described in subparagraph (C), a physician enrolled + under section 1866(j) or an eligible professional under section + 1848(k)(3)(B),'' before ``or, in the case of services''. + (2) Part b.--Section 1835(a)(2) of such Act (42 U.S.C. + 1395n(a)(2)) is amended in the matter preceding subparagraph (A) + by inserting ``, or in the case of services described in + subparagraph (A), a physician enrolled under section 1866(j) or + an eligible professional under section 1848(k)(3)(B),'' after + ``a physician''. + + (c) <<NOTE: 42 USC 1395f note.>> Application to Other Items or +Services.--The Secretary may extend the requirement applied by the +amendments made by subsections (a) and (b) to durable medical equipment +and home health services (relating to requiring certifications and +written + +[[Page 124 STAT. 769]] + +orders to be made by enrolled physicians and health professions) to all +other categories of items or services under title XVIII of the Social +Security Act (42 U.S.C. 1395 et seq.), including covered part D drugs as +defined in section 1860D-2(e) of such Act (42 U.S.C. 1395w-102), that +are ordered, prescribed, or referred by a physician enrolled under +section 1866(j) of such Act (42 U.S.C. 1395cc(j)) or an eligible +professional under section 1848(k)(3)(B) of such Act (42 U.S.C. 1395w- +4(k)(3)(B)). + + (d) <<NOTE: 42 USC 1395f note.>> Effective Date.--The amendments +made by this section shall apply to written orders and certifications +made on or after July 1, 2010. + +SEC. 6406. REQUIREMENT FOR PHYSICIANS TO PROVIDE DOCUMENTATION ON + REFERRALS TO PROGRAMS AT HIGH RISK OF WASTE AND ABUSE. + + (a) Physicians and Other Suppliers.--Section 1842(h) of the Social +Security Act (42 U.S.C. 1395u(h)) is amended by adding at the end the +following new paragraph: + ``(9) The Secretary may revoke enrollment, for a period of not more +than one year for each act, for a physician or supplier under section +1866(j) if such physician or supplier fails to maintain and, upon +request of the Secretary, provide access to documentation relating to +written orders or requests for payment for durable medical equipment, +certifications for home health services, or referrals for other items or +services written or ordered by such physician or supplier under this +title, as specified by the Secretary.''. + (b) Providers of Services.--Section 1866(a)(1) of such Act (42 +U.S.C. 1395cc) is further amended-- + (1) in subparagraph (U), by striking at the end ``and''; + (2) in subparagraph (V), by striking the period at the end + and adding ``; and''; and + (3) by adding at the end the following new subparagraph: + ``(W) maintain and, upon request of the Secretary, + provide access to documentation relating to written + orders or requests for payment for durable medical + equipment, certifications for home health services, or + referrals for other items or services written or ordered + by the provider under this title, as specified by the + Secretary.''. + + (c) OIG Permissive Exclusion Authority.--Section 1128(b)(11) of the +Social Security Act (42 U.S.C. 1320a-7(b)(11)) is amended by inserting +``, ordering, referring for furnishing, or certifying the need for'' +after ``furnishing''. + (d) <<NOTE: 42 USC 1320a-7 note.>> Effective Date.--The amendments +made by this section shall apply to orders, certifications, and +referrals made on or after January 1, 2010. + +SEC. 6407. FACE TO FACE ENCOUNTER WITH PATIENT REQUIRED BEFORE + PHYSICIANS MAY CERTIFY ELIGIBILITY FOR HOME HEALTH SERVICES + OR DURABLE MEDICAL EQUIPMENT UNDER MEDICARE. + + (a) Condition of Payment for Home Health Services.-- + (1) Part a.--Section 1814(a)(2)(C) of such Act <<NOTE: 42 + USC 1395f.>> is amended-- + (A) by striking ``and such services'' and inserting + ``such services''; and + (B) by inserting after ``care of a physician'' the + following: ``, and, in the case of a certification made + by a physician after January 1, 2010, prior to making + such + +[[Page 124 STAT. 770]] + + certification the physician must document that the + physician himself or herself has had a face-to-face + encounter (including through use of telehealth, subject + to the requirements in section 1834(m), and other than + with respect to encounters that are incident to services + involved) with the individual within a reasonable + timeframe as determined by the Secretary''. + (2) Part b.--Section 1835(a)(2)(A) of the Social Security + Act <<NOTE: 42 USC 1395n.>> is amended-- + (A) by striking ``and'' before ``(iii)''; and + (B) by inserting after ``care of a physician'' the + following: ``, and (iv) in the case of a certification + after January 1, 2010, prior to making such + certification the physician must document that the + physician has had a face-to-face encounter (including + through use of telehealth and other than with respect to + encounters that are incident to services involved) with + the individual during the 6-month period preceding such + certification, or other reasonable timeframe as + determined by the Secretary''. + + (b) Condition of Payment for Durable Medical Equipment.--Section +1834(a)(11)(B) of the Social Security Act (42 U.S.C. 1395m(a)(11)(B)) is +amended-- + (1) by striking ``Order.--The Secretary'' and inserting + ``Order.-- + ``(i) In general.--The Secretary''; and + (2) by adding at the end the following new clause: + ``(ii) Requirement for face to face + encounter.--The Secretary shall require that such + an order be written pursuant to the physician + documenting that a physician, a physician + assistant, a nurse practitioner, or a clinical + nurse specialist (as those terms are defined in + section 1861(aa)(5)) has had a face-to-face + encounter (including through use of telehealth + under subsection (m) and other than with respect + to encounters that are incident to services + involved) with the individual involved during the + 6-month period preceding such written order, or + other reasonable timeframe as determined by the + Secretary.''. + + (c) <<NOTE: 42 USC 1395f note.>> Application to Other Areas Under +Medicare.--The Secretary may apply the face-to-face encounter +requirement described in the amendments made by subsections (a) and (b) +to other items and services for which payment is provided under title +XVIII of the Social Security Act based upon a finding that such an +decision would reduce the risk of waste, fraud, or abuse. + + (d) <<NOTE: 42 USC 1395f note.>> Application to Medicaid.--The +requirements pursuant to the amendments made by subsections (a) and (b) +shall apply in the case of physicians making certifications for home +health services under title XIX of the Social Security Act in the same +manner and to the same extent as such requirements apply in the case of +physicians making such certifications under title XVIII of such Act. + +SEC. 6408. ENHANCED PENALTIES. + + (a) Civil Monetary Penalties for False Statements or Delaying +Inspections.--Section 1128A(a) of the Social Security Act (42 U.S.C. +1320a-7a(a)), as amended by section 5002(d)(2)(A), is amended-- + +[[Page 124 STAT. 771]] + + (1) in paragraph (6), by striking ``or'' at the end; and + (2) by inserting after paragraph (7) the following new + paragraphs: + ``(8) knowingly makes, uses, or causes to be made or used, a + false record or statement material to a false or fraudulent + claim for payment for items and services furnished under a + Federal health care program; or + ``(9) fails to grant timely access, upon reasonable request + (as defined by the Secretary in regulations), to the Inspector + General of the Department of Health and Human Services, for the + purpose of audits, investigations, evaluations, or other + statutory functions of the Inspector General of the Department + of Health and Human Services;''; and + (3) in the first sentence-- + (A) by striking ``or in cases under paragraph (7)'' + and inserting ``in cases under paragraph (7)''; and + (B) by striking ``act)'' and inserting ``act, in + cases under paragraph (8), $50,000 for each false record + or statement, or in cases under paragraph (9), $15,000 + for each day of the failure described in such + paragraph)''. + + (b) Medicare Advantage and Part D Plans.-- + (1) Ensuring timely inspections relating to contracts with + ma organizations.--Section 1857(d)(2) of such Act (42 U.S.C. + 1395w-27(d)(2)) is amended-- + (A) in subparagraph (A), by inserting ``timely'' + before ``inspect''; and + (B) in subparagraph (B), by inserting ``timely'' + before ``audit and inspect''. + (2) Marketing violations.--Section 1857(g)(1) of the Social + Security Act (42 U.S.C. 1395w-27(g)(1)) is amended-- + (A) in subparagraph (F), by striking ``or'' at the + end; + (B) by inserting after subparagraph (G) the + following new subparagraphs: + ``(H) except as provided under subparagraph (C) or + (D) of section 1860D-1(b)(1), enrolls an individual in + any plan under this part without the prior consent of + the individual or the designee of the individual; + ``(I) transfers an individual enrolled under this + part from one plan to another without the prior consent + of the individual or the designee of the individual or + solely for the purpose of earning a commission; + ``(J) fails to comply with marketing restrictions + described in subsections (h) and (j) of section 1851 or + applicable implementing regulations or guidance; or + ``(K) employs or contracts with any individual or + entity who engages in the conduct described in + subparagraphs (A) through (J) of this paragraph;''; and + (C) by adding at the end the following new sentence: + ``The <<NOTE: Determination.>> Secretary may provide, in + addition to any other remedies authorized by law, for + any of the remedies described in paragraph (2), if the + Secretary determines that any employee or agent of such + organization, or any provider or supplier who contracts + with such organization, has engaged in any conduct + described in subparagraphs (A) through (K) of this + paragraph.''. + (3) Provision of false information.--Section 1857(g)(2)(A) + of the Social Security Act (42 U.S.C. 1395w- + +[[Page 124 STAT. 772]] + + 27(g)(2)(A)) is amended by inserting ``except with respect to a + determination under subparagraph (E), an assessment of not more + than the amount claimed by such plan or plan sponsor based upon + the misrepresentation or falsified information involved,'' after + ``for each such determination,''. + + (c) Obstruction of Program Audits.--Section 1128(b)(2) of the Social +Security Act (42 U.S.C. 1320a-7(b)(2)) is amended-- + (1) in the heading, by inserting ``or audit'' after + ``investigation''; and + (2) by striking ``investigation into'' and all that follows + through the period and inserting ``investigation or audit + related to--'' + ``(i) any offense described in paragraph (1) + or in subsection (a); or + ``(ii) the use of funds received, directly or + indirectly, from any Federal health care program + (as defined in section 1128B(f)).''. + + (d) <<NOTE: 42 USC 1320a-7 note.>> Effective Date.-- + (1) In general.--Except as provided in paragraph (2), the + amendments made by this section shall apply to acts committed on + or after January 1, 2010. + (2) Exception.--The amendments made by subsection (b)(1) + take effect on the date of enactment of this Act. + +SEC. 6409. <<NOTE: 42 USC 1395nn note.>> MEDICARE SELF-REFERRAL + DISCLOSURE PROTOCOL. + + (a) Development of Self-Referral Disclosure Protocol.-- + (1) <<NOTE: Deadline.>> In general.--The Secretary of Health + and Human Services, in cooperation with the Inspector General of + the Department of Health and Human Services, shall establish, + not later than 6 months after the date of the enactment of this + Act, a protocol to enable health care providers of services and + suppliers to disclose an actual or potential violation of + section 1877 of the Social Security Act (42 U.S.C. 1395nn) + pursuant to a self-referral disclosure protocol (in this section + referred to as an ``SRDP''). The SRDP shall include direction to + health care providers of services and suppliers on-- + (A) a specific person, official, or office to whom + such disclosures shall be made; and + (B) instruction on the implication of the SRDP on + corporate integrity agreements and corporate compliance + agreements. + (2) Publication on internet website of srdp information.-- + The Secretary of Health and Human Services shall post + information on the public Internet website of the Centers for + Medicare & Medicaid Services to inform relevant stakeholders of + how to disclose actual or potential violations pursuant to an + SRDP. + (3) Relation to advisory opinions.--The SRDP shall be + separate from the advisory opinion process set forth in + regulations implementing section 1877(g) of the Social Security + Act. + + (b) Reduction in Amounts Owed.--The Secretary of Health and Human +Services is authorized to reduce the amount due and owing for all +violations under section 1877 of the Social Security Act to an amount +less than that specified in subsection (g) of such section. In +establishing such amount for a violation, the Secretary may consider the +following factors: + +[[Page 124 STAT. 773]] + + (1) The nature and extent of the improper or illegal + practice. + (2) The timeliness of such self-disclosure. + (3) The cooperation in providing additional information + related to the disclosure. + (4) Such other factors as the Secretary considers + appropriate. + + (c) Report.--Not later than 18 months after the date on which the +SRDP protocol is established under subsection (a)(1), the Secretary +shall submit to Congress a report on the implementation of this section. +Such report shall include-- + (1) the number of health care providers of services and + suppliers making disclosures pursuant to the SRDP; + (2) the amounts collected pursuant to the SRDP; + (3) the types of violations reported under the SRDP; and + (4) such other information as may be necessary to evaluate + the impact of this section. + +SEC. 6410. ADJUSTMENTS TO THE MEDICARE DURABLE MEDICAL EQUIPMENT, + PROSTHETICS, ORTHOTICS, AND SUPPLIES COMPETITIVE ACQUISITION + PROGRAM. + + (a) Expansion of Round 2 of the DME Competitive Bidding Program.-- +Section 1847(a)(1) of the Social Security Act (42 U.S.C. 1395w-3(a)(1)) +is amended-- + (1) in subparagraph (B)(i)(II), by striking ``70'' and + inserting ``91''; and + (2) in subparagraph (D)(ii)-- + (A) in subclause (I), by striking ``and'' at the + end; + (B) by redesignating subclause (II) as subclause + (III); and + (C) by inserting after subclause (I) the following + new subclause: + ``(II) the Secretary shall include + the next 21 largest metropolitan + statistical areas by total population + (after those selected under subclause + (I)) for such round; and''. + + (b) Requirement to Either Competitively Bid Areas or Use Competitive +Bid Prices by 2016.--Section 1834(a)(1)(F) of the Social Security Act +(42 U.S.C. 1395m(a)(1)(F)) is amended-- + (1) in clause (i), by striking ``and'' at the end; + (2) in clause (ii)-- + (A) by inserting ``(and, in the case of covered + items furnished on or after January 1, 2016, subject to + clause (iii), shall)'' after ``may''; and + (B) by striking the period at the end and inserting + ``; and''; and + (3) by adding at the end the following new clause: + ``(iii) in the case of covered items furnished + on or after January 1, 2016, the Secretary shall + continue to make such adjustments described in + clause (ii) as, under such competitive acquisition + programs, additional covered items are phased in + or information is updated as contracts under + section 1847 are recompeted in accordance with + section 1847(b)(3)(B).''. + +SEC. 6411. EXPANSION OF THE RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM. + + (a) Expansion to Medicaid.-- + +[[Page 124 STAT. 774]] + + (1) State plan amendment.--Section 1902(a)(42) of the Social + Security Act (42 U.S.C. 1396a(a)(42)) is amended-- + (A) by striking ``that the records'' and inserting + ``that-- + ``(A) the records''; + (B) by inserting ``and'' after the semicolon; and + (C) by adding at the end the following: + ``(B) <<NOTE: Deadline.>> not later than December + 31, 2010, the State shall-- + ``(i) establish a program under which the + State contracts (consistent with State law and in + the same manner as the Secretary enters into + contracts with recovery audit contractors under + section 1893(h), subject to such exceptions or + requirements as the Secretary may require for + purposes of this title or a particular State) with + 1 or more recovery audit contractors for the + purpose of identifying underpayments and + overpayments and recouping overpayments under the + State plan and under any waiver of the State plan + with respect to all services for which payment is + made to any entity under such plan or waiver; and + ``(ii) provide assurances satisfactory to the + Secretary that-- + ``(I) under such contracts, payment + shall be made to such a contractor only + from amounts recovered; + ``(II) from such amounts recovered, + payment-- + ``(aa) shall be made on a + contingent basis for collecting + overpayments; and + ``(bb) may be made in such + amounts as the State may specify + for identifying underpayments; + ``(III) the State has an adequate + process for entities to appeal any + adverse determination made by such + contractors; and + ``(IV) such program is carried out + in accordance with such requirements as + the Secretary shall specify, including-- + ``(aa) for purposes of + section 1903(a)(7), that amounts + expended by the State to carry + out the program shall be + considered amounts expended as + necessary for the proper and + efficient administration of the + State plan or a waiver of the + plan; + ``(bb) that section 1903(d) + shall apply to amounts recovered + under the program; and + ``(cc) that the State and + any such contractors under + contract with the State shall + coordinate such recovery audit + efforts with other contractors + or entities performing audits of + entities receiving payments + under the State plan or waiver + in the State, including efforts + with Federal and State law + enforcement with respect to the + Department of Justice, including + the Federal Bureau of + Investigations, the Inspector + General of the Department of + Health and Human Services, and + the State medicaid fraud control + unit; and''. + +[[Page 124 STAT. 775]] + + (2) <<NOTE: 42 USC 1396a note.>> Coordination; + regulations.-- + (A) In general.--The Secretary of Health and Human + Services, acting through the Administrator of the + Centers for Medicare & Medicaid Services, shall + coordinate the expansion of the Recovery Audit + Contractor program to Medicaid with States, particularly + with respect to each State that enters into a contract + with a recovery audit contractor for purposes of the + State's Medicaid program prior to December 31, 2010. + (B) Regulations.--The Secretary of Health and Human + Services shall promulgate regulations to carry out this + subsection and the amendments made by this subsection, + including with respect to conditions of Federal + financial participation, as specified by the Secretary. + + (b) Expansion to Medicare Parts C and D.--Section 1893(h) of the +Social Security Act (42 U.S.C. 1395ddd(h)) is amended-- + (1) in paragraph (1), in the matter preceding subparagraph + (A), by striking ``part A or B'' and inserting ``this title''; + (2) in paragraph (2), by striking ``parts A and B'' and + inserting ``this title''; + (3) in paragraph (3), by inserting ``(not later than + December 31, 2010, in the case of contracts relating to payments + made under part C or D)'' after ``2010''; + (4) in paragraph (4), in the matter preceding subparagraph + (A), by striking ``part A or B'' and inserting ``this title''; + and + (5) by adding at the end the following: + ``(9) Special rules relating to parts c and d.--The + Secretary shall enter into contracts under paragraph (1) to + require recovery audit contractors to-- + ``(A) ensure that each MA plan under part C has an + anti-fraud plan in effect and to review the + effectiveness of each such anti-fraud plan; + ``(B) ensure that each prescription drug plan under + part D has an anti-fraud plan in effect and to review + the effectiveness of each such anti-fraud plan; + ``(C) examine claims for reinsurance payments under + section 1860D-15(b) to determine whether prescription + drug plans submitting such claims incurred costs in + excess of the allowable reinsurance costs permitted + under paragraph (2) of that section; and + ``(D) review estimates submitted by prescription + drug plans by private plans with respect to the + enrollment of high cost beneficiaries (as defined by the + Secretary) and to compare such estimates with the + numbers of such beneficiaries actually enrolled by such + plans.''. + + (c) <<NOTE: 42 USC 1396a note.>> Annual Report.--The Secretary of +Health and Human Services, acting through the Administrator of the +Centers for Medicare & Medicaid Services, shall submit an annual report +to Congress concerning the effectiveness of the Recovery Audit +Contractor program under Medicaid and Medicare and shall include such +reports recommendations for expanding or improving the program. + +[[Page 124 STAT. 776]] + + Subtitle F--Additional Medicaid Program Integrity Provisions + +SEC. 6501. TERMINATION OF PROVIDER PARTICIPATION UNDER MEDICAID IF + TERMINATED UNDER MEDICARE OR OTHER STATE PLAN. + + Section 1902(a)(39) of the Social Security Act (42 U.S.C. 42 U.S.C. +1396a(a)) is amended by inserting after ``1128A,'' the following: +``terminate the participation of any individual or entity in such +program if (subject to such exceptions as are permitted with respect to +exclusion under sections 1128(c)(3)(B) and 1128(d)(3)(B)) participation +of such individual or entity is terminated under title XVIII or any +other State plan under this title,''. + +SEC. 6502. MEDICAID EXCLUSION FROM PARTICIPATION RELATING TO CERTAIN + OWNERSHIP, CONTROL, AND MANAGEMENT AFFILIATIONS. + + Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), as +amended by section 6401(b), is amended by inserting after paragraph (77) +the following: + ``(78) provide that the State agency described in paragraph + (9) exclude, with respect to a period, any individual or entity + from participation in the program under the State plan if such + individual or entity owns, controls, or manages an entity that + (or if such entity is owned, controlled, or managed by an + individual or entity that)-- + ``(A) has unpaid overpayments (as defined by the + Secretary) under this title during such period + determined by the Secretary or the State agency to be + delinquent; + ``(B) is suspended or excluded from participation + under or whose participation is terminated under this + title during such period; or + ``(C) is affiliated with an individual or entity + that has been suspended or excluded from participation + under this title or whose participation is terminated + under this title during such period;''. + +SEC. 6503. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE PAYEES + REQUIRED TO REGISTER UNDER MEDICAID. + + (a) In General.--Section 1902(a) of the Social Security Act (42 +U.S.C. 42 U.S.C. 1396a(a)), as amended by section 6502(a), is amended by +inserting after paragraph (78), the following: + ``(79) provide that any agent, clearinghouse, or other + alternate payee (as defined by the Secretary) that submits + claims on behalf of a health care provider must register with + the State and the Secretary in a form and manner specified by + the Secretary;''. + +SEC. 6504. REQUIREMENT TO REPORT EXPANDED SET OF DATA ELEMENTS UNDER + MMIS TO DETECT FRAUD AND ABUSE. + + (a) <<NOTE: Determination.>> In General.--Section 1903(r)(1)(F) of +the Social Security Act (42 U.S.C. 1396b(r)(1)(F)) is amended by +inserting after ``necessary'' the following: ``and including, for data +submitted to the Secretary on or after January 1, 2010, data elements +from the + +[[Page 124 STAT. 777]] + +automated data system that the Secretary determines to be necessary for +program integrity, program oversight, and administration, at such +frequency as the Secretary shall determine''. + + (b) Managed Care Organizations.-- + (1) In general.--Section 1903(m)(2)(A)(xi) of the Social + Security Act (42 U.S.C. 1396b(m)(2)(A)(xi)) is amended by + inserting ``and for the provision of such data to the State at a + frequency and level of detail to be specified by the Secretary'' + after ``patients''. + (2) <<NOTE: 42 USC 1396b note.>> Effective date.--The + amendment made by paragraph (1) shall apply with respect to + contract years beginning on or after January 1, 2010. + +SEC. 6505. PROHIBITION ON PAYMENTS TO INSTITUTIONS OR ENTITIES LOCATED + OUTSIDE OF THE UNITED STATES. + + Section 1902(a) of the Social Security Act <<NOTE: 42 USC +1396a.>> (42 U.S.C. 1396b(a)), as amended by section 6503, is amended by +inserting after paragraph (79) the following new paragraph: + ``(80) provide that the State shall not provide any payments + for items or services provided under the State plan or under a + waiver to any financial institution or entity located outside of + the United States;''. + +SEC. 6506. OVERPAYMENTS. + + (a) Extension of Period for Collection of Overpayments Due to +Fraud.-- + (1) In general.--Section 1903(d)(2) of the Social Security + Act (42 U.S.C. 1396b(d)(2)) is amended-- + (A) in subparagraph (C)-- + (i) in the first sentence, by striking ``60 + days'' and inserting ``1 year''; and + (ii) in the second sentence, by striking ``60 + days'' and inserting ``1-year period''; and + (B) in subparagraph (D)-- + (i) in inserting ``(i)'' after ``(D)''; and + (ii) by adding at the end the following: + + ``(ii) In any case where the State is unable to recover a debt which +represents an overpayment (or any portion thereof) made to a person or +other entity due to fraud within 1 year of discovery because there is +not a final determination of the amount of the overpayment under an +administrative or judicial process (as applicable), including as a +result of a judgment being under appeal, no adjustment shall be made in +the Federal payment to such State on account of such overpayment (or +portion thereof) before the date that is 30 days after the date on which +a final judgment (including, if applicable, a final determination on an +appeal) is made.''. + (2) <<NOTE: 42 USC 1396b note.>> Effective date.--The + amendments made by this subsection take effect on the date of + enactment of this Act and apply to overpayments discovered on or + after that date. + + (b) <<NOTE: Regulations. 42 USC 1396b note.>> Corrective Action.-- +The Secretary shall promulgate regulations that require States to +correct Federally identified claims overpayments, of an ongoing or +recurring nature, with new Medicaid Management Information System (MMIS) +edits, audits, or other appropriate corrective action. + +[[Page 124 STAT. 778]] + +SEC. 6507. MANDATORY STATE USE OF NATIONAL CORRECT CODING INITIATIVE. + + Section 1903(r) of the Social Security Act (42 U.S.C. 1396b(r)) is +amended-- + (1) in paragraph (1)(B)-- + (A) in clause (ii), by striking ``and'' at the end; + (B) in clause (iii), by adding ``and'' after the + semi-colon; and + (C) by adding at the end the following new clause: + ``(iv) <<NOTE: Effective date.>> effective for + claims filed on or after October 1, 2010, + incorporate compatible methodologies of the + National Correct Coding Initiative administered by + the Secretary (or any successor initiative to + promote correct coding and to control improper + coding leading to inappropriate payment) and such + other methodologies of that Initiative (or such + other national correct coding methodologies) as + the Secretary identifies in accordance with + paragraph (4);''; and + (2) by adding at the end the following new paragraph: + + ``(4) <<NOTE: Deadlines.>> For purposes of paragraph (1)(B)(iv), the +Secretary shall do the following: + ``(A) Not later than September 1, 2010: + ``(i) Identify those methodologies of the National + Correct Coding Initiative administered by the Secretary + (or any successor initiative to promote correct coding + and to control improper coding leading to inappropriate + payment) which are compatible to claims filed under this + title. + ``(ii) Identify those methodologies of such + Initiative (or such other national correct coding + methodologies) that should be incorporated into claims + filed under this title with respect to items or services + for which States provide medical assistance under this + title and no national correct coding methodologies have + been established under such Initiative with respect to + title XVIII. + ``(iii) <<NOTE: Notification.>> Notify States of-- + ``(I) the methodologies identified under + subparagraphs (A) and (B) (and of any other + national correct coding methodologies identified + under subparagraph (B)); and + ``(II) how States are to incorporate such + methodologies into claims filed under this title. + ``(B) Not later than March 1, 2011, submit a report to + Congress that includes the notice to States under clause (iii) + of subparagraph (A) and an analysis supporting the + identification of the methodologies made under clauses (i) and + (ii) of subparagraph (A).''. + +SEC. 6508. <<NOTE: 42 USC 1396a note.>> GENERAL EFFECTIVE DATE. + + (a) In General.--Except as otherwise provided in this subtitle, this +subtitle and the amendments made by this subtitle take effect on January +1, 2011, without regard to whether final regulations to carry out such +amendments and subtitle have been promulgated by that date. + (b) <<NOTE: Determination. Plan.>> Delay if State Legislation +Required.--In the case of a State plan for medical assistance under +title XIX of the Social Security Act or a child health plan under title +XXI of such Act which the Secretary of Health and Human Services +determines + +[[Page 124 STAT. 779]] + +requires State legislation (other than legislation appropriating funds) +in order for the plan to meet the additional requirement imposed by the +amendments made by this subtitle, the State plan or child health plan +shall not be regarded as failing to comply with the requirements of such +title solely on the basis of its failure to meet this additional +requirement before the first day of the first calendar quarter beginning +after the close of the first regular session of the State legislature +that begins after the date of the enactment of this Act. For purposes of +the previous sentence, in the case of a State that has a 2-year +legislative session, each year of such session shall be deemed to be a +separate regular session of the State legislature. + + Subtitle G--Additional Program Integrity Provisions + +SEC. 6601. PROHIBITION ON FALSE STATEMENTS AND REPRESENTATIONS. + + (a) Prohibition.--Part 5 of subtitle B of title I of the Employee +Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.) is +amended by adding at the end the following: + +``SEC. 519. <<NOTE: 29 USC 1149.>> PROHIBITION ON FALSE STATEMENTS AND + REPRESENTATIONS. + + ``No person, in connection with a plan or other arrangement that is +multiple employer welfare arrangement described in section 3(40), shall +make a false statement or false representation of fact, knowing it to be +false, in connection with the marketing or sale of such plan or +arrangement, to any employee, any member of an employee organization, +any beneficiary, any employer, any employee organization, the Secretary, +or any State, or the representative or agent of any such person, State, +or the Secretary, concerning-- + ``(1) the financial condition or solvency of such plan or + arrangement; + ``(2) the benefits provided by such plan or arrangement; + ``(3) the regulatory status of such plan or other + arrangement under any Federal or State law governing collective + bargaining, labor management relations, or intern union affairs; + or + ``(4) the regulatory status of such plan or other + arrangement regarding exemption from state regulatory authority + under this Act. + +This section shall not apply to any plan or arrangement that does not +fall within the meaning of the term `multiple employer welfare +arrangement' under section 3(40)(A).''. + (b) Criminal Penalties.--Section 501 of the Employee Retirement +Income Security Act of 1974 (29 U.S.C. 1131) is amended-- + (1) by inserting ``(a)'' before ``Any person''; and + (2) by adding at the end the following: + + ``(b) Any person that violates section 519 shall upon conviction be +imprisoned not more than 10 years or fined under title 18, United States +Code, or both.''. + (c) Conforming Amendment.--The table of sections for part 5 of +subtitle B of title I of the Employee Retirement Income Security Act of +1974 is amended by adding at the end the following: + +``Sec. 519. Prohibition on false statement and representations.''. + +[[Page 124 STAT. 780]] + +SEC. 6602. CLARIFYING DEFINITION. + + Section 24(a)(2) of title 18, United States Code, is amended by +inserting ``or section 411, 518, or 511 of the Employee Retirement +Income Security Act of 1974,'' after ``1954 of this title''. + +SEC. 6603. DEVELOPMENT OF MODEL UNIFORM REPORT FORM. + + Part C of title XXVII of the Public Health Service Act (42 U.S.C. +300gg-91 et seq.) is amended by adding at the end the following: + +``SEC. 2794. <<NOTE: 42 USC 300gg-95.>> UNIFORM FRAUD AND ABUSE REFERRAL + FORMAT. + + ``The Secretary shall request the National Association of Insurance +Commissioners to develop a model uniform report form for private health +insurance issuer seeking to refer suspected fraud and abuse to State +insurance departments or other responsible State agencies for +investigation. The Secretary shall request that the National Association +of Insurance Commissioners develop recommendations for uniform reporting +standards for such referrals.''. + +SEC. 6604. APPLICABILITY OF STATE LAW TO COMBAT FRAUD AND ABUSE. + + (a) In General.--Part 5 of subtitle B of title I of the Employee +Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.), as +amended by section 6601, is further amended by adding at the end the +following: + +``SEC. 520. <<NOTE: 29 USC 1150.>> APPLICABILITY OF STATE LAW TO COMBAT + FRAUD AND ABUSE. + + ``The Secretary may, for the purpose of identifying, preventing, or +prosecuting fraud and abuse, adopt regulatory standards establishing, or +issue an order relating to a specific person establishing, that a person +engaged in the business of providing insurance through a multiple +employer welfare arrangement described in section 3(40) is subject to +the laws of the States in which such person operates which regulate +insurance in such State, notwithstanding section 514(b)(6) of this Act +or the Liability Risk Retention Act of 1986, and regardless of whether +the law of the State is otherwise preempted under any of such +provisions. This section shall not apply to any plan or arrangement that +does not fall within the meaning of the term `multiple employer welfare +arrangement' under section 3(40)(A).''. + (b) Conforming Amendment.--The table of sections for part 5 of +subtitle B of title I of the Employee Retirement Income Security Act of +1974, as amended by section 6601, is further amended by adding at the +end the following: + +``Sec. 520. Applicability of State law to combat fraud and abuse.''. + +SEC. 6605. ENABLING THE DEPARTMENT OF LABOR TO ISSUE ADMINISTRATIVE + SUMMARY CEASE AND DESIST ORDERS AND SUMMARY SEIZURES ORDERS + AGAINST PLANS THAT ARE IN FINANCIALLY HAZARDOUS CONDITION. + + (a) In General.--Part 5 of subtitle B of title I of the Employee +Retirement Income Security Act of 1974 (29 U.S.C. 1131 et seq.), as +amended by section 6604, is further amended by adding at the end the +following: + +[[Page 124 STAT. 781]] + +``SEC. 521. <<NOTE: 29 USC 1151.>> ADMINISTRATIVE SUMMARY CEASE AND + DESIST ORDERS AND SUMMARY SEIZURE ORDERS AGAINST MULTIPLE + EMPLOYER WELFARE ARRANGEMENTS IN FINANCIALLY HAZARDOUS + CONDITION. + + ``(a) In General.--The Secretary may issue a cease and desist (ex +parte) order under this title if it appears to the Secretary that the +alleged conduct of a multiple employer welfare arrangement described in +section 3(40), other than a plan or arrangement described in subsection +(g), is fraudulent, or creates an immediate danger to the public safety +or welfare, or is causing or can be reasonably expected to cause +significant, imminent, and irreparable public injury. + ``(b) Hearing.--A person that is adversely affected by the issuance +of a cease and desist order under subsection (a) may request a hearing +by the Secretary regarding such order. The Secretary may require that a +proceeding under this section, including all related information and +evidence, be conducted in a confidential manner. + ``(c) Burden of Proof.--The burden of proof in any hearing conducted +under subsection (b) shall be on the party requesting the hearing to +show cause why the cease and desist order should be set aside. + ``(d) Determination.--Based upon the evidence presented at a hearing +under subsection (b), the cease and desist order involved may be +affirmed, modified, or set aside by the Secretary in whole or in part. + ``(e) Seizure.--The Secretary may issue a summary seizure order +under this title if it appears that a multiple employer welfare +arrangement is in a financially hazardous condition. + ``(f) Regulations.--The Secretary may promulgate such regulations or +other guidance as may be necessary or appropriate to carry out this +section. + ``(g) Exception.--This section shall not apply to any plan or +arrangement that does not fall within the meaning of the term `multiple +employer welfare arrangement' under section 3(40)(A).''. + (b) Conforming Amendment.--The table of sections for part 5 of +subtitle B of title I of the Employee Retirement Income Security Act of +1974, as amended by section 6604, is further amended by adding at the +end the following: + +``Sec. 521. Administrative summary cease and desist orders and summary + seizure orders against health plans in financially hazardous + condition.''. + +SEC. 6606. MEWA PLAN REGISTRATION WITH DEPARTMENT OF LABOR. + + Section 101(g) of the Employee Retirement Income Security Act of +1974 (29 U.S.C. 1021(g)) is amended-- + (1) by striking ``Secretary may'' and inserting ``Secretary + shall''; and + (2) by inserting ``to register with the Secretary prior to + operating in a State and may, by regulation, require such + multiple employer welfare arrangements'' after ``not group + health plans''. + +SEC. 6607. PERMITTING EVIDENTIARY PRIVILEGE AND CONFIDENTIAL + COMMUNICATIONS. + + Section 504 of the Employee Retirement Income Security Act of 1974 +(29 U.S.C. 1134) is amended by adding at the end the following: + +[[Page 124 STAT. 782]] + + ``(d) The Secretary may promulgate a regulation that provides an +evidentiary privilege for, and provides for the confidentiality of +communications between or among, any of the following entities or their +agents, consultants, or employees: + ``(1) A State insurance department. + ``(2) A State attorney general. + ``(3) The National Association of Insurance Commissioners. + ``(4) The Department of Labor. + ``(5) The Department of the Treasury. + ``(6) The Department of Justice. + ``(7) The Department of Health and Human Services. + ``(8) Any other Federal or State authority that the + Secretary determines is appropriate for the purposes of + enforcing the provisions of this title. + + ``(e) <<NOTE: Applicability.>> The privilege established under +subsection (d) shall apply to communications related to any +investigation, audit, examination, or inquiry conducted or coordinated +by any of the agencies. A communication that is privileged under +subsection (d) shall not waive any privilege otherwise available to the +communicating agency or to any person who provided the information that +is communicated.''. + +Subtitle H <<NOTE: Elder Justice Act of 2009.>> --Elder Justice Act + +SEC. 6701. <<NOTE: 42 USC 1305 note.>> SHORT TITLE OF SUBTITLE. + + This subtitle may be cited as the ``Elder Justice Act of 2009''. + +SEC. 6702. <<NOTE: 42 USC 1395i-3a note.>> DEFINITIONS. + + Except as otherwise specifically provided, any term that is defined +in section 2011 of the Social Security Act (as added by section 6703(a)) +and is used in this subtitle has the meaning given such term by such +section. + +SEC. 6703. ELDER JUSTICE. + + (a) Elder Justice.-- + (1) In general.--Title XX of the Social Security Act (42 + U.S.C. 1397 et seq.) is amended-- + (A) in the heading, by inserting ``AND ELDER + JUSTICE'' after ``SOCIAL SERVICES''; + (B) by inserting before section 2001 the following: + + ``Subtitle A--Block Grants to States for Social Services''; + + and + (C) by adding at the end the following: + + ``Subtitle B--Elder Justice + +``SEC. 2011. <<NOTE: 42 USC 1397j.>> DEFINITIONS. + + ``In this subtitle: + ``(1) Abuse.--The term `abuse' means the knowing infliction + of physical or psychological harm or the knowing deprivation of + goods or services that are necessary to meet essential needs or + to avoid physical or psychological harm. + +[[Page 124 STAT. 783]] + + ``(2) Adult protective services.--The term `adult protective + services' means such services provided to adults as the + Secretary may specify and includes services such as-- + ``(A) receiving reports of adult abuse, neglect, or + exploitation; + ``(B) investigating the reports described in + subparagraph (A); + ``(C) case planning, monitoring, evaluation, and + other case work and services; and + ``(D) providing, arranging for, or facilitating the + provision of medical, social service, economic, legal, + housing, law enforcement, or other protective, + emergency, or support services. + ``(3) Caregiver.--The term `caregiver' means an individual + who has the responsibility for the care of an elder, either + voluntarily, by contract, by receipt of payment for care, or as + a result of the operation of law, and means a family member or + other individual who provides (on behalf of such individual or + of a public or private agency, organization, or institution) + compensated or uncompensated care to an elder who needs + supportive services in any setting. + ``(4) Direct care.--The term `direct care' means care by an + employee or contractor who provides assistance or long-term care + services to a recipient. + ``(5) Elder.--The term `elder' means an individual age 60 or + older. + ``(6) Elder justice.--The term `elder justice' means-- + ``(A) from a societal perspective, efforts to-- + ``(i) prevent, detect, treat, intervene in, + and prosecute elder abuse, neglect, and + exploitation; and + ``(ii) protect elders with diminished capacity + while maximizing their autonomy; and + ``(B) from an individual perspective, the + recognition of an elder's rights, including the right to + be free of abuse, neglect, and exploitation. + ``(7) Eligible entity.--The term `eligible entity' means a + State or local government agency, Indian tribe or tribal + organization, or any other public or private entity that is + engaged in and has expertise in issues relating to elder justice + or in a field necessary to promote elder justice efforts. + ``(8) Exploitation.--The term `exploitation' means the + fraudulent or otherwise illegal, unauthorized, or improper act + or process of an individual, including a caregiver or fiduciary, + that uses the resources of an elder for monetary or personal + benefit, profit, or gain, or that results in depriving an elder + of rightful access to, or use of, benefits, resources, + belongings, or assets. + ``(9) Fiduciary.--The term `fiduciary'-- + ``(A) means a person or entity with the legal + responsibility-- + ``(i) to make decisions on behalf of and for + the benefit of another person; and + ``(ii) to act in good faith and with fairness; + and + ``(B) includes a trustee, a guardian, a conservator, + an executor, an agent under a financial power of + attorney or health care power of attorney, or a + representative payee. + +[[Page 124 STAT. 784]] + + ``(10) Grant.--The term `grant' includes a contract, + cooperative agreement, or other mechanism for providing + financial assistance. + ``(11) Guardianship.--The term `guardianship' means-- + ``(A) the process by which a State court determines + that an adult individual lacks capacity to make + decisions about self-care or property, and appoints + another individual or entity known as a guardian, as a + conservator, or by a similar term, as a surrogate + decisionmaker; + ``(B) the manner in which the court-appointed + surrogate decisionmaker carries out duties to the + individual and the court; or + ``(C) the manner in which the court exercises + oversight of the surrogate decisionmaker. + ``(12) Indian tribe.-- + ``(A) In general.--The term `Indian tribe' has the + meaning given such term in section 4 of the Indian Self- + Determination and Education Assistance Act (25 U.S.C. + 450b). + ``(B) Inclusion of pueblo and rancheria.--The term + `Indian tribe' includes any Pueblo or Rancheria. + ``(13) Law enforcement.--The term `law enforcement' means + the full range of potential responders to elder abuse, neglect, + and exploitation including-- + ``(A) police, sheriffs, detectives, public safety + officers, and corrections personnel; + ``(B) prosecutors; + ``(C) medical examiners; + ``(D) investigators; and + ``(E) coroners. + ``(14) Long-term care.-- + ``(A) In general.--The term `long-term care' means + supportive and health services specified by the + Secretary for individuals who need assistance because + the individuals have a loss of capacity for self-care + due to illness, disability, or vulnerability. + ``(B) Loss of capacity for self-care.--For purposes + of subparagraph (A), the term `loss of capacity for + self-care' means an inability to engage in 1 or more + activities of daily living, including eating, dressing, + bathing, management of one's financial affairs, and + other activities the Secretary determines appropriate. + ``(15) Long-term care facility.--The term `long-term care + facility' means a residential care provider that arranges for, + or directly provides, long-term care. + ``(16) Neglect.--The term `neglect' means-- + ``(A) the failure of a caregiver or fiduciary to + provide the goods or services that are necessary to + maintain the health or safety of an elder; or + ``(B) self-neglect. + ``(17) Nursing facility.-- + ``(A) In general.--The term `nursing facility' has + the meaning given such term under section 1919(a). + ``(B) Inclusion of skilled nursing facility.--The + term `nursing facility' includes a skilled nursing + facility (as defined in section 1819(a)). + +[[Page 124 STAT. 785]] + + ``(18) Self-neglect.--The term `self-neglect' means an + adult's inability, due to physical or mental impairment or + diminished capacity, to perform essential self-care tasks + including-- + ``(A) obtaining essential food, clothing, shelter, + and medical care; + ``(B) obtaining goods and services necessary to + maintain physical health, mental health, or general + safety; or + ``(C) managing one's own financial affairs. + ``(19) Serious bodily injury.-- + ``(A) In general.--The term `serious bodily injury' + means an injury-- + ``(i) involving extreme physical pain; + ``(ii) involving substantial risk of death; + ``(iii) involving protracted loss or + impairment of the function of a bodily member, + organ, or mental faculty; or + ``(iv) requiring medical intervention such as + surgery, hospitalization, or physical + rehabilitation. + ``(B) Criminal sexual abuse.--Serious bodily injury + shall be considered to have occurred if the conduct + causing the injury is conduct described in section 2241 + (relating to aggravated sexual abuse) or 2242 (relating + to sexual abuse) of title 18, United States Code, or any + similar offense under State law. + ``(20) Social.--The term `social', when used with respect to + a service, includes adult protective services. + ``(21) State legal assistance developer.--The term `State + legal assistance developer' means an individual described in + section 731 of the Older Americans Act of 1965. + ``(22) State long-term care ombudsman.--The term `State + Long-Term Care Ombudsman' means the State Long-Term Care + Ombudsman described in section 712(a)(2) of the Older Americans + Act of 1965. + +``SEC. 2012. <<NOTE: 42 USC 1397j-1.>> GENERAL PROVISIONS. + + ``(a) Protection of Privacy.--In pursuing activities under this +subtitle, the Secretary shall ensure the protection of individual health +privacy consistent with the regulations promulgated under section 264(c) +of the Health Insurance Portability and Accountability Act of 1996 and +applicable State and local privacy regulations. + ``(b) Rule of Construction.--Nothing in this subtitle shall be +construed to interfere with or abridge an elder's right to practice his +or her religion through reliance on prayer alone for healing when this +choice-- + ``(1) is contemporaneously expressed, either orally or in + writing, with respect to a specific illness or injury which the + elder has at the time of the decision by an elder who is + competent at the time of the decision; + ``(2) is previously set forth in a living will, health care + proxy, or other advance directive document that is validly + executed and applied under State law; or + ``(3) may be unambiguously deduced from the elder's life + history. + +[[Page 124 STAT. 786]] + +``PART I--NATIONAL COORDINATION OF ELDER JUSTICE ACTIVITIES AND RESEARCH + + ``Subpart A--Elder Justice Coordinating Council and Advisory Board on + Elder Abuse, Neglect, and Exploitation + +``SEC. 2021. <<NOTE: 42 USC 1397k.>> ELDER JUSTICE COORDINATING COUNCIL. + + ``(a) Establishment.--There is established within the Office of the +Secretary an Elder Justice Coordinating Council (in this section +referred to as the `Council'). + ``(b) Membership.-- + ``(1) In general.--The Council shall be composed of the + following members: + ``(A) The Secretary (or the Secretary's designee). + ``(B) The Attorney General (or the Attorney + General's designee). + ``(C) The head of each Federal department or agency + or other governmental entity identified by the Chair + referred to in subsection (d) as having + responsibilities, or administering programs, relating to + elder abuse, neglect, and exploitation. + ``(2) Requirement.--Each member of the Council shall be an + officer or employee of the Federal Government. + + ``(c) Vacancies.--Any vacancy in the Council shall not affect its +powers, but shall be filled in the same manner as the original +appointment was made. + ``(d) Chair.--The member described in subsection (b)(1)(A) shall be +Chair of the Council. + ``(e) Meetings.--The Council shall meet at least 2 times per year, +as determined by the Chair. + ``(f) Duties.-- + ``(1) <<NOTE: Recommenda- tions.>> In general.--The Council + shall make recommendations to the Secretary for the coordination + of activities of the Department of Health and Human Services, + the Department of Justice, and other relevant Federal, State, + local, and private agencies and entities, relating to elder + abuse, neglect, and exploitation and other crimes against + elders. + ``(2) Report.--Not later than the date that is 2 years after + the date of enactment of the Elder Justice Act of 2009 and every + 2 years thereafter, the Council shall submit to the Committee on + Finance of the Senate and the Committee on Ways and Means and + the Committee on Energy and Commerce of the House of + Representatives a report that-- + ``(A) describes the activities and accomplishments + of, and challenges faced by-- + ``(i) the Council; and + ``(ii) the entities represented on the + Council; and + ``(B) makes such recommendations for legislation, + model laws, or other action as the Council determines to + be appropriate. + + ``(g) Powers of the Council.-- + ``(1) Information from federal agencies.--Subject to the + requirements of section 2012(a), the Council may secure directly + from any Federal department or agency such information as the + Council considers necessary to carry out this section. Upon + +[[Page 124 STAT. 787]] + + request of the Chair of the Council, the head of such department + or agency shall furnish such information to the Council. + ``(2) Postal services.--The Council may use the United + States mails in the same manner and under the same conditions as + other departments and agencies of the Federal Government. + + ``(h) Travel Expenses.--The members of the Council shall not receive +compensation for the performance of services for the Council. The +members shall be allowed travel expenses, including per diem in lieu of +subsistence, at rates authorized for employees of agencies under +subchapter I of chapter 57 of title 5, United States Code, while away +from their homes or regular places of business in the performance of +services for the Council. Notwithstanding section 1342 of title 31, +United States Code, the Secretary may accept the voluntary and +uncompensated services of the members of the Council. + ``(i) Detail of Government Employees.--Any Federal Government +employee may be detailed to the Council without reimbursement, and such +detail shall be without interruption or loss of civil service status or +privilege. + ``(j) Status as Permanent Council.--Section 14 of the Federal +Advisory Committee Act (5 U.S.C. App.) shall not apply to the Council. + ``(k) Authorization of Appropriations.--There are authorized to be +appropriated such sums as are necessary to carry out this section. + +``SEC. 2022. <<NOTE: 42 USC 1397k-1.>> ADVISORY BOARD ON ELDER ABUSE, + NEGLECT, AND EXPLOITATION. + + ``(a) Establishment.--There is established a board to be known as +the `Advisory Board on Elder Abuse, Neglect, and Exploitation' (in this +section referred to as the `Advisory Board') to create short- and long- +term multidisciplinary strategic plans for the development of the field +of elder justice and to make recommendations to the Elder Justice +Coordinating Council established under section 2021. + ``(b) Composition.--The Advisory Board shall be composed of 27 +members appointed by the Secretary from among members of the general +public who are individuals with experience and expertise in elder abuse, +neglect, and exploitation prevention, detection, treatment, +intervention, or prosecution. + ``(c) <<NOTE: Notice. Federal Register, publication.>> Solicitation +of Nominations.--The Secretary shall publish a notice in the Federal +Register soliciting nominations for the appointment of members of the +Advisory Board under subsection (b). + + ``(d) Terms.-- + ``(1) In general.--Each member of the Advisory Board shall + be appointed for a term of 3 years, except that, of the members + first appointed-- + ``(A) 9 shall be appointed for a term of 3 years; + ``(B) 9 shall be appointed for a term of 2 years; + and + ``(C) 9 shall be appointed for a term of 1 year. + ``(2) Vacancies.-- + ``(A) In general.--Any vacancy on the Advisory Board + shall not affect its powers, but shall be filled in the + same manner as the original appointment was made. + ``(B) Filling unexpired term.--An individual chosen + to fill a vacancy shall be appointed for the unexpired + term of the member replaced. + +[[Page 124 STAT. 788]] + + ``(3) Expiration of terms.--The term of any member shall not + expire before the date on which the member's successor takes + office. + + ``(e) Election of Officers.--The Advisory Board shall elect a Chair +and Vice Chair from among its members. The Advisory Board shall elect +its initial Chair and Vice Chair at its initial meeting. + ``(f) Duties.-- + ``(1) Enhance communication on promoting quality of, and + preventing abuse, neglect, and exploitation in, long-term + care.--The Advisory Board shall develop collaborative and + innovative approaches to improve the quality of, including + preventing abuse, neglect, and exploitation in, long-term care. + ``(2) Collaborative efforts to develop consensus around the + management of certain quality-related factors.-- + ``(A) <<NOTE: Panels.>> In general.--The Advisory + Board shall establish multidisciplinary panels to + address, and develop consensus on, subjects relating to + improving the quality of long-term care. At least 1 such + panel shall address, and develop consensus on, methods + for managing resident-to-resident abuse in long-term + care. + ``(B) Activities conducted.--The multidisciplinary + panels established under subparagraph (A) shall examine + relevant research and data, identify best practices with + respect to the subject of the panel, determine the best + way to carry out those best practices in a practical and + feasible manner, and determine an effective manner of + distributing information on such subject. + ``(3) Report.--Not later than the date that is 18 months + after the date of enactment of the Elder Justice Act of 2009, + and annually thereafter, the Advisory Board shall prepare and + submit to the Elder Justice Coordinating Council, the Committee + on Finance of the Senate, and the Committee on Ways and Means + and the Committee on Energy and Commerce of the House of + Representatives a report containing-- + ``(A) information on the status of Federal, State, + and local public and private elder justice activities; + ``(B) recommendations (including recommended + priorities) regarding-- + ``(i) elder justice programs, research, + training, services, practice, enforcement, and + coordination; + ``(ii) coordination between entities pursuing + elder justice efforts and those involved in + related areas that may inform or overlap with + elder justice efforts, such as activities to + combat violence against women and child abuse and + neglect; and + ``(iii) activities relating to adult fiduciary + systems, including guardianship and other + fiduciary arrangements; + ``(C) recommendations for specific modifications + needed in Federal and State laws (including regulations) + or for programs, research, and training to enhance + prevention, detection, and treatment (including + diagnosis) of, intervention in (including investigation + of), and prosecution of elder abuse, neglect, and + exploitation; + +[[Page 124 STAT. 789]] + + ``(D) recommendations on methods for the most + effective coordinated national data collection with + respect to elder justice, and elder abuse, neglect, and + exploitation; and + ``(E) recommendations for a multidisciplinary + strategic plan to guide the effective and efficient + development of the field of elder justice. + + ``(g) Powers of the Advisory Board.-- + ``(1) Information from federal agencies.--Subject to the + requirements of section 2012(a), the Advisory Board may secure + directly from any Federal department or agency such information + as the Advisory Board considers necessary to carry out this + section. Upon request of the Chair of the Advisory Board, the + head of such department or agency shall furnish such information + to the Advisory Board. + ``(2) Sharing of data and reports.--The Advisory Board may + request from any entity pursuing elder justice activities under + the Elder Justice Act of 2009 or an amendment made by that Act, + any data, reports, or recommendations generated in connection + with such activities. + ``(3) Postal services.--The Advisory Board may use the + United States mails in the same manner and under the same + conditions as other departments and agencies of the Federal + Government. + + ``(h) Travel Expenses.--The members of the Advisory Board shall not +receive compensation for the performance of services for the Advisory +Board. The members shall be allowed travel expenses for up to 4 meetings +per year, including per diem in lieu of subsistence, at rates authorized +for employees of agencies under subchapter I of chapter 57 of title 5, +United States Code, while away from their homes or regular places of +business in the performance of services for the Advisory Board. +Notwithstanding section 1342 of title 31, United States Code, the +Secretary may accept the voluntary and uncompensated services of the +members of the Advisory Board. + ``(i) Detail of Government Employees.--Any Federal Government +employee may be detailed to the Advisory Board without reimbursement, +and such detail shall be without interruption or loss of civil service +status or privilege. + ``(j) Status as Permanent Advisory Committee.--Section 14 of the +Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to the +advisory board. + ``(k) Authorization of Appropriations.--There are authorized to be +appropriated such sums as are necessary to carry out this section. + +``SEC. 2023. <<NOTE: 42 USC 1397k-2.>> RESEARCH PROTECTIONS. + + ``(a) Guidelines.--The Secretary shall promulgate guidelines to +assist researchers working in the area of elder abuse, neglect, and +exploitation, with issues relating to human subject protections. + ``(b) Definition of Legally Authorized Representative for +Application of Regulations.--For purposes of the application of subpart +A of part 46 of title 45, Code of Federal Regulations, to research +conducted under this subpart, the term `legally authorized +representative' means, unless otherwise provided by law, the individual +or judicial or other body authorized under the applicable law to consent +to medical treatment on behalf of another person. + +[[Page 124 STAT. 790]] + +``SEC. 2024. <<NOTE: 42 USC 1397k-3.>> AUTHORIZATION OF APPROPRIATIONS. + + ``There are authorized to be appropriated to carry out this +subpart-- + ``(1) for fiscal year 2011, $6,500,000; and + ``(2) for each of fiscal years 2012 through 2014, + $7,000,000. + + ``Subpart B--Elder Abuse, Neglect, and Exploitation Forensic Centers + +``SEC. 2031. <<NOTE: Grants. 42 USC 1397l.>> ESTABLISHMENT AND SUPPORT + OF ELDER ABUSE, NEGLECT, AND EXPLOITATION FORENSIC CENTERS. + + ``(a) In General.--The Secretary, in consultation with the Attorney +General, shall make grants to eligible entities to establish and operate +stationary and mobile forensic centers, to develop forensic expertise +regarding, and provide services relating to, elder abuse, neglect, and +exploitation. + ``(b) Stationary Forensic Centers.--The Secretary shall make 4 of +the grants described in subsection (a) to institutions of higher +education with demonstrated expertise in forensics or commitment to +preventing or treating elder abuse, neglect, or exploitation, to +establish and operate stationary forensic centers. + ``(c) Mobile Centers.--The Secretary shall make 6 of the grants +described in subsection (a) to appropriate entities to establish and +operate mobile forensic centers. + ``(d) Authorized Activities.-- + ``(1) Development of forensic markers and methodologies.--An + eligible entity that receives a grant under this section shall + use funds made available through the grant to assist in + determining whether abuse, neglect, or exploitation occurred and + whether a crime was committed and to conduct research to + describe and disseminate information on-- + ``(A) forensic markers that indicate a case in which + elder abuse, neglect, or exploitation may have occurred; + and + ``(B) methodologies for determining, in such a case, + when and how health care, emergency service, social and + protective services, and legal service providers should + intervene and when the providers should report the case + to law enforcement authorities. + ``(2) Development of forensic expertise.--An eligible entity + that receives a grant under this section shall use funds made + available through the grant to develop forensic expertise + regarding elder abuse, neglect, and exploitation in order to + provide medical and forensic evaluation, therapeutic + intervention, victim support and advocacy, case review, and case + tracking. + ``(3) Collection of evidence.--The Secretary, in + coordination with the Attorney General, shall use data made + available by grant recipients under this section to develop the + capacity of geriatric health care professionals and law + enforcement to collect forensic evidence, including collecting + forensic evidence relating to a potential determination of elder + abuse, neglect, or exploitation. + + ``(e) Application.--To be eligible to receive a grant under this +section, an entity shall submit an application to the Secretary + +[[Page 124 STAT. 791]] + +at such time, in such manner, and containing such information as the +Secretary may require. + ``(f) Authorization of Appropriations.--There are authorized to be +appropriated to carry out this section-- + ``(1) for fiscal year 2011, $4,000,000; + ``(2) for fiscal year 2012, $6,000,000; and + ``(3) for each of fiscal years 2013 and 2014, $8,000,000. + + ``PART II--PROGRAMS TO PROMOTE ELDER JUSTICE + +``SEC. 2041. <<NOTE: 42 USC 1397m.>> ENHANCEMENT OF LONG-TERM CARE. + + ``(a) Grants and Incentives for Long-Term Care Staffing.-- + ``(1) In general.--The Secretary shall carry out activities, + including activities described in paragraphs (2) and (3), to + provide incentives for individuals to train for, seek, and + maintain employment providing direct care in long-term care. + ``(2) Specific programs to enhance training, recruitment, + and retention of staff.-- + ``(A) Coordination with secretary of labor to + recruit and train long-term care staff.--The Secretary + shall coordinate activities under this subsection with + the Secretary of Labor in order to provide incentives + for individuals to train for and seek employment + providing direct care in long-term care. + ``(B) <<NOTE: Grants.>> Career ladders and wage or + benefit increases to increase staffing in long-term + care.-- + ``(i) In general.--The Secretary shall make + grants to eligible entities to carry out programs + through which the entities-- + ``(I) offer, to employees who + provide direct care to residents of an + eligible entity or individuals receiving + community-based long-term care from an + eligible entity, continuing training and + varying levels of certification, based + on observed clinical care practices and + the amount of time the employees spend + providing direct care; and + ``(II) provide, or make arrangements + to provide, bonuses or other increased + compensation or benefits to employees + who achieve certification under such a + program. + ``(ii) Application.--To be eligible to receive + a grant under this subparagraph, an eligible + entity shall submit an application to the + Secretary at such time, in such manner, and + containing such information as the Secretary may + require (which may include evidence of + consultation with the State in which the eligible + entity is located with respect to carrying out + activities funded under the grant). + ``(iii) Authority to limit number of + applicants.--Nothing in this subparagraph shall be + construed as prohibiting the Secretary from + limiting the number of applicants for a grant + under this subparagraph. + ``(3) <<NOTE: Grants.>> Specific programs to improve + management practices.-- + +[[Page 124 STAT. 792]] + + ``(A) In general.--The Secretary shall make grants + to eligible entities to enable the entities to provide + training and technical assistance. + ``(B) Authorized activities.--An eligible entity + that receives a grant under subparagraph (A) shall use + funds made available through the grant to provide + training and technical assistance regarding management + practices using methods that are demonstrated to promote + retention of individuals who provide direct care, such + as-- + ``(i) the establishment of standard human + resource policies that reward high performance, + including policies that provide for improved wages + and benefits on the basis of job reviews; + ``(ii) the establishment of motivational and + thoughtful work organization practices; + ``(iii) the creation of a workplace culture + that respects and values caregivers and their + needs; + ``(iv) the promotion of a workplace culture + that respects the rights of residents of an + eligible entity or individuals receiving + community-based long-term care from an eligible + entity and results in improved care for the + residents or the individuals; and + ``(v) the establishment of other programs that + promote the provision of high quality care, such + as a continuing education program that provides + additional hours of training, including on-the-job + training, for employees who are certified nurse + aides. + ``(C) Application.--To be eligible to receive a + grant under this paragraph, an eligible entity shall + submit an application to the Secretary at such time, in + such manner, and containing such information as the + Secretary may require (which may include evidence of + consultation with the State in which the eligible entity + is located with respect to carrying out activities + funded under the grant). + ``(D) Authority to limit number of applicants.-- + Nothing in this paragraph shall be construed as + prohibiting the Secretary from limiting the number of + applicants for a grant under this paragraph. + ``(4) Accountability measures.--The Secretary shall develop + accountability measures to ensure that the activities conducted + using funds made available under this subsection benefit + individuals who provide direct care and increase the stability + of the long-term care workforce. + ``(5) Definitions.--In this subsection: + ``(A) Community-based long-term care.--The term + `community-based long-term care' has the meaning given + such term by the Secretary. + ``(B) Eligible entity.--The term `eligible entity' + means the following: + ``(i) A long-term care facility. + ``(ii) A community-based long-term care entity + (as defined by the Secretary). + + ``(b) Certified EHR Technology Grant Program.-- + ``(1) Grants authorized.--The Secretary is authorized to + make grants to long-term care facilities for the purpose of + assisting such entities in offsetting the costs related to + purchasing, leasing, developing, and implementing certified EHR + +[[Page 124 STAT. 793]] + + technology (as defined in section 1848(o)(4)) designed to + improve patient safety and reduce adverse events and health care + complications resulting from medication errors. + ``(2) Use of grant funds.--Funds provided under grants under + this subsection may be used for any of the following: + ``(A) Purchasing, leasing, and installing computer + software and hardware, including handheld computer + technologies. + ``(B) Making improvements to existing computer + software and hardware. + ``(C) Making upgrades and other improvements to + existing computer software and hardware to enable e- + prescribing. + ``(D) Providing education and training to eligible + long-term care facility staff on the use of such + technology to implement the electronic transmission of + prescription and patient information. + ``(3) Application.-- + ``(A) In general.--To be eligible to receive a grant + under this subsection, a long-term care facility shall + submit an application to the Secretary at such time, in + such manner, and containing such information as the + Secretary may require (which may include evidence of + consultation with the State in which the long-term care + facility is located with respect to carrying out + activities funded under the grant). + ``(B) Authority to limit number of applicants.-- + Nothing in this subsection shall be construed as + prohibiting the Secretary from limiting the number of + applicants for a grant under this subsection. + ``(4) Participation in state health exchanges.--A long-term + care facility that receives a grant under this subsection shall, + where available, participate in activities conducted by a State + or a qualified State-designated entity (as defined in section + 3013(f) of the Public Health Service Act) under a grant under + section 3013 of the Public Health Service Act to coordinate care + and for other purposes determined appropriate by the Secretary. + ``(5) Accountability measures.--The Secretary shall develop + accountability measures to ensure that the activities conducted + using funds made available under this subsection help improve + patient safety and reduce adverse events and health care + complications resulting from medication errors. + + ``(c) Adoption of Standards for Transactions Involving Clinical Data +by Long-Term Care Facilities.-- + ``(1) Standards and compatibility.--The Secretary shall + adopt electronic standards for the exchange of clinical data by + long-term care facilities, including, where available, standards + for messaging and nomenclature. Standards adopted by the + Secretary under the preceding sentence shall be compatible with + standards established under part C of title XI, standards + established under subsections (b)(2)(B)(i) and (e)(4) of section + 1860D-4, standards adopted under section 3004 of the Public + Health Service Act, and general health information technology + standards. + ``(2) Electronic submission of data to the secretary.-- + +[[Page 124 STAT. 794]] + + ``(A) <<NOTE: Deadline. Procedures.>> In general.-- + Not later than 10 years after the date of enactment of + the Elder Justice Act of 2009, the Secretary shall have + procedures in place to accept the optional electronic + submission of clinical data by long-term care facilities + pursuant to the standards adopted under paragraph (1). + ``(B) Rule of construction.--Nothing in this + subsection shall be construed to require a long-term + care facility to submit clinical data electronically to + the Secretary. + ``(3) Regulations.--The Secretary shall promulgate + regulations to carry out this subsection. Such regulations shall + require a State, as a condition of the receipt of funds under + this part, to conduct such data collection and reporting as the + Secretary determines are necessary to satisfy the requirements + of this subsection. + + ``(d) Authorization of Appropriations.--There are authorized to be +appropriated to carry out this section-- + ``(1) for fiscal year 2011, $20,000,000; + ``(2) for fiscal year 2012, $17,500,000; and + ``(3) for each of fiscal years 2013 and 2014, $15,000,000. + +``SEC. 2042. <<NOTE: 42 USC 1397m-1.>> ADULT PROTECTIVE SERVICES + FUNCTIONS AND GRANT PROGRAMS. + + ``(a) Secretarial Responsibilities.-- + ``(1) In general.--The Secretary shall ensure that the + Department of Health and Human Services-- + ``(A) provides funding authorized by this part to + State and local adult protective services offices that + investigate reports of the abuse, neglect, and + exploitation of elders; + ``(B) collects and disseminates data annually + relating to the abuse, exploitation, and neglect of + elders in coordination with the Department of Justice; + ``(C) develops and disseminates information on best + practices regarding, and provides training on, carrying + out adult protective services; + ``(D) conducts research related to the provision of + adult protective services; and + ``(E) provides technical assistance to States and + other entities that provide or fund the provision of + adult protective services, including through grants made + under subsections (b) and (c). + ``(2) Authorization of appropriations.--There are authorized + to be appropriated to carry out this subsection, $3,000,000 for + fiscal year 2011 and $4,000,000 for each of fiscal years 2012 + through 2014. + + ``(b) Grants To Enhance the Provision of Adult Protective +Services.-- + ``(1) Establishment.--There is established an adult + protective services grant program under which the Secretary + shall annually award grants to States in the amounts calculated + under paragraph (2) for the purposes of enhancing adult + protective services provided by States and local units of + government. + ``(2) Amount of payment.-- + ``(A) In general.--Subject to the availability of + appropriations and subparagraphs (B) and (C), the amount + paid to a State for a fiscal year under the program + under this + +[[Page 124 STAT. 795]] + + subsection shall equal the amount appropriated for that + year to carry out this subsection multiplied by the + percentage of the total number of elders who reside in + the United States who reside in that State. + ``(B) Guaranteed minimum payment amount.-- + ``(i) 50 states.--Subject to clause (ii), if + the amount determined under subparagraph (A) for a + State for a fiscal year is less than 0.75 percent + of the amount appropriated for such year, the + Secretary shall increase such determined amount so + that the total amount paid under this subsection + to the State for the year is equal to 0.75 percent + of the amount so appropriated. + ``(ii) + Territories. <<NOTE: Applicability.>> --In the + case of a State other than 1 of the 50 States, + clause (i) shall be applied as if each reference + to `0.75' were a reference to `0.1'. + ``(C) Pro rata reductions.--The Secretary shall make + such pro rata reductions to the amounts described in + subparagraph (A) as are necessary to comply with the + requirements of subparagraph (B). + ``(3) Authorized activities.-- + ``(A) Adult protective services.--Funds made + available pursuant to this subsection may only be used + by States and local units of government to provide adult + protective services and may not be used for any other + purpose. + ``(B) Use by agency.--Each State receiving funds + pursuant to this subsection shall provide such funds to + the agency or unit of State government having legal + responsibility for providing adult protective services + within the State. + ``(C) Supplement not supplant.--Each State or local + unit of government shall use funds made available + pursuant to this subsection to supplement and not + supplant other Federal, State, and local public funds + expended to provide adult protective services in the + State. + ``(4) State reports.--Each State receiving funds under this + subsection shall submit to the Secretary, at such time and in + such manner as the Secretary may require, a report on the number + of elders served by the grants awarded under this subsection. + ``(5) Authorization of appropriations.--There are authorized + to be appropriated to carry out this subsection, $100,000,000 + for each of fiscal years 2011 through 2014. + + ``(c) State Demonstration Programs.-- + ``(1) Establishment.--The Secretary shall award grants to + States for the purposes of conducting demonstration programs in + accordance with paragraph (2). + ``(2) Demonstration programs.--Funds made available pursuant + to this subsection may be used by States and local units of + government to conduct demonstration programs that test-- + ``(A) training modules developed for the purpose of + detecting or preventing elder abuse; + ``(B) methods to detect or prevent financial + exploitation of elders; + ``(C) methods to detect elder abuse; + +[[Page 124 STAT. 796]] + + ``(D) whether training on elder abuse forensics + enhances the detection of elder abuse by employees of + the State or local unit of government; or + ``(E) other matters relating to the detection or + prevention of elder abuse. + ``(3) Application.--To be eligible to receive a grant under + this subsection, a State shall submit an application to the + Secretary at such time, in such manner, and containing such + information as the Secretary may require. + ``(4) State reports.--Each State that receives funds under + this subsection shall submit to the Secretary a report at such + time, in such manner, and containing such information as the + Secretary may require on the results of the demonstration + program conducted by the State using funds made available under + this subsection. + ``(5) Authorization of appropriations.--There are authorized + to be appropriated to carry out this subsection, $25,000,000 for + each of fiscal years 2011 through 2014. + +``SEC. 2043. <<NOTE: 42 USC 1397m-2.>> LONG-TERM CARE OMBUDSMAN PROGRAM + GRANTS AND TRAINING. + + ``(a) Grants To Support the Long-Term Care Ombudsman Program.-- + ``(1) In general.--The Secretary shall make grants to + eligible entities with relevant expertise and experience in + abuse and neglect in long-term care facilities or long-term care + ombudsman programs and responsibilities, for the purpose of-- + ``(A) improving the capacity of State long-term care + ombudsman programs to respond to and resolve complaints + about abuse and neglect; + ``(B) conducting pilot programs with State long-term + care ombudsman offices or local ombudsman entities; and + ``(C) providing support for such State long-term + care ombudsman programs and such pilot programs (such as + through the establishment of a national long-term care + ombudsman resource center). + ``(2) Authorization of appropriations.--There are authorized + to be appropriated to carry out this subsection-- + ``(A) for fiscal year 2011, $5,000,000; + ``(B) for fiscal year 2012, $7,500,000; and + ``(C) for each of fiscal years 2013 and 2014, + $10,000,000. + + ``(b) Ombudsman Training Programs.-- + ``(1) In general.--The Secretary shall establish programs to + provide and improve ombudsman training with respect to elder + abuse, neglect, and exploitation for national organizations and + State long-term care ombudsman programs. + ``(2) Authorization of appropriations.--There are authorized + to be appropriated to carry out this subsection, for each of + fiscal years 2011 through 2014, $10,000,000. + +``SEC. 2044. <<NOTE: 42 USC 1397m-3.>> PROVISION OF INFORMATION + REGARDING, AND EVALUATIONS OF, ELDER JUSTICE PROGRAMS. + + ``(a) Provision of Information.--To be eligible to receive a grant +under this part, an applicant shall agree-- + ``(1) except as provided in paragraph (2), to provide the + eligible entity conducting an evaluation under subsection (b) of + the activities funded through the grant with such information + +[[Page 124 STAT. 797]] + + as the eligible entity may require in order to conduct such + evaluation; or + ``(2) in the case of an applicant for a grant under section + 2041(b), to provide the Secretary with such information as the + Secretary may require to conduct an evaluation or audit under + subsection (c). + + ``(b) Use of Eligible Entities To Conduct Evaluations.-- + ``(1) Evaluations required.--Except as provided in paragraph + (2), the Secretary shall-- + ``(A) reserve a portion (not less than 2 percent) of + the funds appropriated with respect to each program + carried out under this part; and + ``(B) use the funds reserved under subparagraph (A) + to provide assistance to eligible entities to conduct + evaluations of the activities funded under each program + carried out under this part. + ``(2) Certified ehr technology grant program not included.-- + The provisions of this subsection shall not apply to the + certified EHR technology grant program under section 2041(b). + ``(3) Authorized activities.--A recipient of assistance + described in paragraph (1)(B) shall use the funds made available + through the assistance to conduct a validated evaluation of the + effectiveness of the activities funded under a program carried + out under this part. + ``(4) Applications.--To be eligible to receive assistance + under paragraph (1)(B), an entity shall submit an application to + the Secretary at such time, in such manner, and containing such + information as the Secretary may require, including a proposal + for the evaluation. + ``(5) Reports.--Not later than a date specified by the + Secretary, an eligible entity receiving assistance under + paragraph (1)(B) shall submit to the Secretary, the Committee on + Ways and Means and the Committee on Energy and Commerce of the + House of Representatives, and the Committee on Finance of the + Senate a report containing the results of the evaluation + conducted using such assistance together with such + recommendations as the entity determines to be appropriate. + + ``(c) Evaluations and Audits of Certified EHR Technology Grant +Program by the Secretary.-- + ``(1) Evaluations.--The Secretary shall conduct an + evaluation of the activities funded under the certified EHR + technology grant program under section 2041(b). Such evaluation + shall include an evaluation of whether the funding provided + under the grant is expended only for the purposes for which it + is made. + ``(2) Audits.--The Secretary shall conduct appropriate + audits of grants made under section 2041(b). + +``SEC. 2045. <<NOTE: 42 USC 1397m-4.>> REPORT. + + ``Not later than October 1, 2014, the Secretary shall submit to the +Elder Justice Coordinating Council established under section 2021, the +Committee on Ways and Means and the Committee on Energy and Commerce of +the House of Representatives, and the Committee on Finance of the Senate +a report-- + +[[Page 124 STAT. 798]] + + ``(1) compiling, summarizing, and analyzing the information + contained in the State reports submitted under subsections + (b)(4) and (c)(4) of section 2042; and + ``(2) containing such recommendations for legislative or + administrative action as the Secretary determines to be + appropriate. + +``SEC. 2046. <<NOTE: 42 USC 1397m-5.>> RULE OF CONSTRUCTION. + + ``Nothing in this subtitle shall be construed as-- + ``(1) limiting any cause of action or other relief related + to obligations under this subtitle that is available under the + law of any State, or political subdivision thereof; or + ``(2) creating a private cause of action for a violation of + this subtitle.''. + (2) Option for state plan under program for temporary + assistance for needy families.-- + (A) In general.--Section 402(a)(1)(B) of the Social + Security Act (42 U.S.C. 602(a)(1)(B)) is amended by + adding at the end the following new clause: + ``(v) The document shall indicate whether the + State intends to assist individuals to train for, + seek, and maintain employment-- + ``(I) providing direct care in a + long-term care facility (as such terms + are defined under section 2011); or + ``(II) in other occupations related + to elder care determined appropriate by + the State for which the State identifies + an unmet need for service personnel, + and, if so, shall include an overview of such + assistance.''. + (B) <<NOTE: 42 USC 602 note.>> Effective date.--The + amendment made by subparagraph (A) shall take effect on + January 1, 2011. + + (b) <<NOTE: 42 USC 1395i-3a.>> Protecting Residents of Long-Term +Care Facilities.-- + (1) National training institute for surveyors.-- + (A) In general. <<NOTE: Contracts.>> --The Secretary + of Health and Human Services shall enter into a contract + with an entity for the purpose of establishing and + operating a National Training Institute for Federal and + State surveyors. Such Institute shall provide and + improve the training of surveyors with respect to + investigating allegations of abuse, neglect, and + misappropriation of property in programs and long-term + care facilities that receive payments under title XVIII + or XIX of the Social Security Act. + (B) Activities carried out by the institute.--The + contract entered into under subparagraph (A) shall + require the Institute established and operated under + such contract to carry out the following activities: + (i) Assess the extent to which State agencies + use specialized surveyors for the investigation of + reported allegations of abuse, neglect, and + misappropriation of property in such programs and + long-term care facilities. + (ii) Evaluate how the competencies of + surveyors may be improved to more effectively + investigate reported allegations of such abuse, + neglect, and misappropriation of property, and + provide feedback to Federal and State agencies on + the evaluations conducted. + +[[Page 124 STAT. 799]] + + (iii) Provide a national program of training, + tools, and technical assistance to Federal and + State surveyors on investigating reports of such + abuse, neglect, and misappropriation of property. + (iv) Develop and disseminate information on + best practices for the investigation of such + abuse, neglect, and misappropriation of property. + (v) Assess the performance of State complaint + intake systems, in order to ensure that the intake + of complaints occurs 24 hours per day, 7 days a + week (including holidays). + (vi) To the extent approved by the Secretary + of Health and Human Services, provide a national + 24 hours per day, 7 days a week (including + holidays), back-up system to State complaint + intake systems in order to ensure optimum national + responsiveness to complaints of such abuse, + neglect, and misappropriation of property. + (vii) Analyze and report annually on the + following: + (I) The total number and sources of + complaints of such abuse, neglect, and + misappropriation of property. + (II) The extent to which such + complaints are referred to law + enforcement agencies. + (III) General results of Federal and + State investigations of such complaints. + (viii) Conduct a national study of the cost to + State agencies of conducting complaint + investigations of skilled nursing facilities and + nursing facilities under sections 1819 and 1919, + respectively, of the Social Security Act (42 + U.S.C. 1395i-3; 1396r), and making recommendations + to the Secretary of Health and Human Services with + respect to options to increase the efficiency and + cost-effectiveness of such investigations. + (C) Authorization.--There are authorized to be + appropriated to carry out this paragraph, for the period + of fiscal years 2011 through 2014, $12,000,000. + (2) Grants to state survey agencies.-- + (A) In general.--The Secretary of Health and Human + Services shall make grants to State agencies that + perform surveys of skilled nursing facilities or nursing + facilities under sections 1819 or 1919, respectively, of + the Social Security Act (42 U.S.C. 1395i-3; 1395r). + (B) Use of funds.--A grant awarded under + subparagraph (A) shall be used for the purpose of + designing and implementing complaint investigations + systems that-- + (i) promptly prioritize complaints in order to + ensure a rapid response to the most serious and + urgent complaints; + (ii) respond to complaints with optimum + effectiveness and timeliness; and + (iii) optimize the collaboration between local + authorities, consumers, and providers, including-- + (I) such State agency; + (II) the State Long-Term Care + Ombudsman; + (III) local law enforcement + agencies; + (IV) advocacy and consumer + organizations; + +[[Page 124 STAT. 800]] + + (V) State aging units; + (VI) Area Agencies on Aging; and + (VII) other appropriate entities. + (C) Authorization.--There are authorized to be + appropriated to carry out this paragraph, for each of + fiscal years 2011 through 2014, $5,000,000. + (3) Reporting of crimes in federally funded long-term care + facilities.--Part A of title XI of the Social Security Act (42 + U.S.C. 1301 et seq.), as amended by section 6005, is amended by + inserting after section 1150A the following new section: + + + ``reporting to law enforcement of crimes occurring in federally funded + long-term care facilities + + + ``Sec. 1150B. <<NOTE: 42 USC 1320b-25.>> (a) Determination and +Notification.-- + ``(1) Determination.--The owner or operator of each long- + term care facility that receives Federal funds under this Act + shall annually determine whether the facility received at least + $10,000 in such Federal funds during the preceding year. + ``(2) Notification.--If the owner or operator determines + under paragraph (1) that the facility received at least $10,000 + in such Federal funds during the preceding year, such owner or + operator shall annually notify each covered individual (as + defined in paragraph (3)) of that individual's obligation to + comply with the reporting requirements described in subsection + (b). + ``(3) Covered individual defined.--In this section, the term + `covered individual' means each individual who is an owner, + operator, employee, manager, agent, or contractor of a long-term + care facility that is the subject of a determination described + in paragraph (1). + + ``(b) Reporting Requirements.-- + ``(1) In general.--Each covered individual shall report to + the Secretary and 1 or more law enforcement entities for the + political subdivision in which the facility is located any + reasonable suspicion of a crime (as defined by the law of the + applicable political subdivision) against any individual who is + a resident of, or is receiving care from, the facility. + ``(2) Timing.--If the events that cause the suspicion-- + ``(A) result in serious bodily injury, the + individual shall report the suspicion immediately, but + not later than 2 hours after forming the suspicion; and + ``(B) do not result in serious bodily injury, the + individual shall report the suspicion not later than 24 + hours after forming the suspicion. + + ``(c) Penalties.-- + ``(1) In general.--If a covered individual violates + subsection (b)-- + ``(A) the covered individual shall be subject to a + civil money penalty of not more than $200,000; and + ``(B) the Secretary may make a determination in the + same proceeding to exclude the covered individual from + participation in any Federal health care program (as + defined in section 1128B(f)). + ``(2) Increased harm.--If a covered individual violates + subsection (b) and the violation exacerbates the harm to the + victim of the crime or results in harm to another individual-- + +[[Page 124 STAT. 801]] + + ``(A) the covered individual shall be subject to a + civil money penalty of not more than $300,000; and + ``(B) the Secretary may make a determination in the + same proceeding to exclude the covered individual from + participation in any Federal health care program (as + defined in section 1128B(f)). + ``(3) Excluded individual.--During any period for which a + covered individual is classified as an excluded individual under + paragraph (1)(B) or (2)(B), a long-term care facility that + employs such individual shall be ineligible to receive Federal + funds under this Act. + ``(4) Extenuating circumstances.-- + ``(A) In general.--The Secretary may take into + account the financial burden on providers with + underserved populations in determining any penalty to be + imposed under this subsection. + ``(B) Underserved population defined.--In this + paragraph, the term `underserved population' means the + population of an area designated by the Secretary as an + area with a shortage of elder justice programs or a + population group designated by the Secretary as having a + shortage of such programs. Such areas or groups + designated by the Secretary may include-- + ``(i) areas or groups that are geographically + isolated (such as isolated in a rural area); + ``(ii) racial and ethnic minority populations; + and + ``(iii) populations underserved because of + special needs (such as language barriers, + disabilities, alien status, or age). + + ``(d) Additional Penalties for Retaliation.-- + ``(1) In general.--A long-term care facility may not-- + ``(A) discharge, demote, suspend, threaten, harass, + or deny a promotion or other employment-related benefit + to an employee, or in any other manner discriminate + against an employee in the terms and conditions of + employment because of lawful acts done by the employee; + or + ``(B) file a complaint or a report against a nurse + or other employee with the appropriate State + professional disciplinary agency because of lawful acts + done by the nurse or employee, + for making a report, causing a report to be made, or for taking + steps in furtherance of making a report pursuant to subsection + (b)(1). + ``(2) Penalties for retaliation.--If a long-term care + facility violates subparagraph (A) or (B) of paragraph (1) the + facility shall be subject to a civil money penalty of not more + than $200,000 or the Secretary may classify the entity as an + excluded entity for a period of 2 years pursuant to section + 1128(b), or both. + ``(3) Requirement to post notice.--Each long-term care + facility shall post conspicuously in an appropriate location a + sign (in a form specified by the Secretary) specifying the + rights of employees under this section. Such sign shall include + a statement that an employee may file a complaint with the + Secretary against a long-term care facility that violates the + provisions of this subsection and information with respect to + the manner of filing such a complaint. + +[[Page 124 STAT. 802]] + + ``(e) Procedure. <<NOTE: Applicability.>> --The provisions of +section 1128A (other than subsections (a) and (b) and the second +sentence of subsection (f)) shall apply to a civil money penalty or +exclusion under this section in the same manner as such provisions apply +to a penalty or proceeding under section 1128A(a). + + ``(f) Definitions.--In this section, the terms `elder justice', +`long-term care facility', and `law enforcement' have the meanings given +those terms in section 2011.''. + (c) National Nurse Aide Registry.-- + (1) Definition of nurse aide.--In this subsection, the term + ``nurse aide'' has the meaning given that term in sections + 1819(b)(5)(F) and 1919(b)(5)(F) of the Social Security Act (42 + U.S.C. 1395i-3(b)(5)(F); 1396r(b)(5)(F)). + (2) Study and report.-- + (A) In general.--The Secretary, in consultation with + appropriate government agencies and private sector + organizations, shall conduct a study on establishing a + national nurse aide registry. + (B) Areas evaluated.--The study conducted under this + subsection shall include an evaluation of-- + (i) who should be included in the registry; + (ii) how such a registry would comply with + Federal and State privacy laws and regulations; + (iii) how data would be collected for the + registry; + (iv) what entities and individuals would have + access to the data collected; + (v) how the registry would provide appropriate + information regarding violations of Federal and + State law by individuals included in the registry; + (vi) how the functions of a national nurse + aide registry would be coordinated with the + nationwide program for national and State + background checks on direct patient access + employees of long-term care facilities and + providers under section 4301; and + (vii) how the information included in State + nurse aide registries developed and maintained + under sections 1819(e)(2) and 1919(e)(2) of the + Social Security Act (42 U.S.C. 1395i-3(e)(2); + 1396r(e)(2)(2)) would be provided as part of a + national nurse aide registry. + (C) Considerations.--In conducting the study and + preparing the report required under this subsection, the + Secretary shall take into consideration the findings and + conclusions of relevant reports and other relevant + resources, including the following: + (i) The Department of Health and Human + Services Office of Inspector General Report, Nurse + Aide Registries: State Compliance and Practices + (February 2005). + (ii) The General Accounting Office (now known + as the Government Accountability Office) Report, + Nursing Homes: More Can Be Done to Protect + Residents from Abuse (March 2002). + (iii) The Department of Health and Human + Services Office of the Inspector General Report, + Nurse Aide Registries: Long-Term Care Facility + Compliance and Practices (July 2005). + +[[Page 124 STAT. 803]] + + (iv) The Department of Health and Human + Services Health Resources and Services + Administration Report, Nursing Aides, Home Health + Aides, and Related Health Care Occupations-- + National and Local Workforce Shortages and + Associated Data Needs (2004) (in particular with + respect to chapter 7 and appendix F). + (v) The 2001 Report to CMS from the School of + Rural Public Health, Texas A&M University, + Preventing Abuse and Neglect in Nursing Homes: The + Role of Nurse Aide Registries. + (vi) Information included in State nurse aide + registries developed and maintained under sections + 1819(e)(2) and 1919(e)(2) of the Social Security + Act (42 U.S.C. 1395i-3(e)(2); 1396r(e)(2)(2)). + (D) Report.--Not later than 18 months after the date + of enactment of this Act, the Secretary shall submit to + the Elder Justice Coordinating Council established under + section 2021 of the Social Security Act, as added by + section 1805(a), the Committee on Finance of the Senate, + and the Committee on Ways and Means and the Committee on + Energy and Commerce of the House of Representatives a + report containing the findings and recommendations of + the study conducted under this paragraph. + (E) Funding limitation.--Funding for the study + conducted under this subsection shall not exceed + $500,000. + (3) Congressional action.--After receiving the report + submitted by the Secretary under paragraph (2)(D), the Committee + on Finance of the Senate and the Committee on Ways and Means and + the Committee on Energy and Commerce of the House of + Representatives shall, as they deem appropriate, take action + based on the recommendations contained in the report. + (4) Authorization of appropriations.--There are authorized + to be appropriated such sums as are necessary for the purpose of + carrying out this subsection. + + (d) Conforming Amendments.-- + (1) Title xx.--Title XX of the Social Security Act (42 + U.S.C. 1397 et seq.), as amended by section 6703(a), is + amended-- + (A) in the heading of section 2001, <<NOTE: 42 USC + 1397.>> by striking ``title'' and inserting + ``subtitle''; and + (B) in subtitle 1, <<NOTE: 42 USC 1397, 1397a, + 1397c-1397e, 1397g.>> by striking ``this title'' each + place it appears and inserting ``this subtitle''. + (2) Title iv.--Title IV of the Social Security Act (42 + U.S.C. 601 et seq.) is amended-- + (A) in section 404(d) <<NOTE: 42 USC 604.>> -- + (i) in paragraphs (1)(A), (2)(A), and (3)(B), + by inserting ``subtitle 1 of'' before ``title XX'' + each place it appears; + (ii) in the heading of paragraph (2), by + inserting ``subtitle 1 of'' before ``title xx''; + and + (iii) in the heading of paragraph (3)(B), by + inserting ``subtitle 1 of'' before ``title xx''; + and + (B) in sections 422(b), 471(a)(4), 472(h)(1), and + 473(b)(2), <<NOTE: 42 USC 622, 671-673.>> by inserting + ``subtitle 1 of'' before ``title XX'' each place it + appears. + +[[Page 124 STAT. 804]] + + (3) Title xi.--Title XI of the Social Security Act (42 + U.S.C. 1301 et seq.) is amended-- + (A) in section 1128(h)(3) <<NOTE: 42 USC 1320a- + 7.>> -- + (i) by inserting ``subtitle 1 of'' before + ``title XX''; and + (ii) by striking ``such title'' and inserting + ``such subtitle''; and + (B) in section 1128A(i)(1), <<NOTE: 42 USC 1320a- + 7a.>> by inserting ``subtitle 1 of'' before ``title + XX''. + + Subtitle I--Sense of the Senate Regarding Medical Malpractice + +SEC. 6801. SENSE OF THE SENATE REGARDING MEDICAL MALPRACTICE. + + It is the sense of the Senate that-- + (1) health care reform presents an opportunity to address + issues related to medical malpractice and medical liability + insurance; + (2) States should be encouraged to develop and test + alternatives to the existing civil litigation system as a way of + improving patient safety, reducing medical errors, encouraging + the efficient resolution of disputes, increasing the + availability of prompt and fair resolution of disputes, and + improving access to liability insurance, while preserving an + individual's right to seek redress in court; and + (3) Congress should consider establishing a State + demonstration program to evaluate alternatives to the existing + civil litigation system with respect to the resolution of + medical malpractice claims. + + TITLE VII--IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES + + Subtitle A <<NOTE: Biologics Price Competition and Innovation Act of +2009.>> --Biologics Price Competition and Innovation + +SEC. 7001. <<NOTE: 42 USC 201 note.>> SHORT TITLE. + + (a) In General.--This subtitle may be cited as the ``Biologics Price +Competition and Innovation Act of 2009''. + (b) Sense of the Senate.--It is the sense of the Senate that a +biosimilars pathway balancing innovation and consumer interests should +be established. + +SEC. 7002. APPROVAL PATHWAY FOR BIOSIMILAR BIOLOGICAL PRODUCTS. + + (a) Licensure of Biological Products as Biosimilar or +Interchangeable.--Section 351 of the Public Health Service Act (42 +U.S.C. 262) is amended-- + (1) in subsection (a)(1)(A), by inserting ``under this + subsection or subsection (k)'' after ``biologics license''; and + (2) by adding at the end the following: + +[[Page 124 STAT. 805]] + + ``(k) Licensure of Biological Products as Biosimilar or +Interchangeable.-- + ``(1) In general.--Any person may submit an application for + licensure of a biological product under this subsection. + ``(2) Content.-- + ``(A) In general.-- + ``(i) Required information.--An application + submitted under this subsection shall include + information demonstrating that-- + ``(I) the biological product is + biosimilar to a reference product based + upon data derived from-- + ``(aa) analytical studies + that demonstrate that the + biological product is highly + similar to the reference product + notwithstanding minor + differences in clinically + inactive components; + ``(bb) animal studies + (including the assessment of + toxicity); and + ``(cc) a clinical study or + studies (including the + assessment of immunogenicity and + pharmacokinetics or + pharmacodynamics) that are + sufficient to demonstrate + safety, purity, and potency in 1 + or more appropriate conditions + of use for which the reference + product is licensed and intended + to be used and for which + licensure is sought for the + biological product; + ``(II) the biological product and + reference product utilize the same + mechanism or mechanisms of action for + the condition or conditions of use + prescribed, recommended, or suggested in + the proposed labeling, but only to the + extent the mechanism or mechanisms of + action are known for the reference + product; + ``(III) the condition or conditions + of use prescribed, recommended, or + suggested in the labeling proposed for + the biological product have been + previously approved for the reference + product; + ``(IV) the route of administration, + the dosage form, and the strength of the + biological product are the same as those + of the reference product; and + ``(V) the facility in which the + biological product is manufactured, + processed, packed, or held meets + standards designed to assure that the + biological product continues to be safe, + pure, and potent. + ``(ii) Determination by secretary.--The + Secretary may determine, in the Secretary's + discretion, that an element described in clause + (i)(I) is unnecessary in an application submitted + under this subsection. + ``(iii) Additional information.--An + application submitted under this subsection-- + ``(I) <<NOTE: Public + information.>> shall include publicly- + available information regarding the + Secretary's previous determination that + the reference product is safe, pure, and + potent; and + +[[Page 124 STAT. 806]] + + ``(II) may include any additional + information in support of the + application, including publicly- + available information with respect to + the reference product or another + biological product. + ``(B) Interchangeability.--An application (or a + supplement to an application) submitted under this + subsection may include information demonstrating that + the biological product meets the standards described in + paragraph (4). + ``(3) Evaluation by secretary.--Upon review of an + application (or a supplement to an application) submitted under + this subsection, the Secretary shall license the biological + product under this subsection if-- + ``(A) <<NOTE: Determination.>> the Secretary + determines that the information submitted in the + application (or the supplement) is sufficient to show + that the biological product-- + ``(i) is biosimilar to the reference product; + or + ``(ii) meets the standards described in + paragraph (4), and therefore is interchangeable + with the reference product; and + ``(B) the applicant (or other appropriate person) + consents to the inspection of the facility that is the + subject of the application, in accordance with + subsection (c). + ``(4) Safety standards for determining interchangeability.-- + Upon review of an application submitted under this subsection or + any supplement to such application, the Secretary shall + determine the biological product to be interchangeable with the + reference product if the Secretary determines that the + information submitted in the application (or a supplement to + such application) is sufficient to show that-- + ``(A) the biological product-- + ``(i) is biosimilar to the reference product; + and + ``(ii) can be expected to produce the same + clinical result as the reference product in any + given patient; and + ``(B) for a biological product that is administered + more than once to an individual, the risk in terms of + safety or diminished efficacy of alternating or + switching between use of the biological product and the + reference product is not greater than the risk of using + the reference product without such alternation or + switch. + ``(5) General rules.-- + ``(A) One reference product per application.--A + biological product, in an application submitted under + this subsection, may not be evaluated against more than + 1 reference product. + ``(B) Review.--An application submitted under this + subsection shall be reviewed by the division within the + Food and Drug Administration that is responsible for the + review and approval of the application under which the + reference product is licensed. + ``(C) Risk evaluation and mitigation + strategies. <<NOTE: Applicability.>> --The authority of + the Secretary with respect to risk evaluation and + mitigation strategies under the Federal Food, Drug, and + Cosmetic Act shall apply to biological products licensed + under this subsection in the same manner as + +[[Page 124 STAT. 807]] + + such authority applies to biological products licensed + under subsection (a). + ``(6) Exclusivity for first interchangeable biological + product.--Upon review of an application submitted under this + subsection relying on the same reference product for which a + prior biological product has received a determination of + interchangeability for any condition of use, the Secretary shall + not make a determination under paragraph (4) that the second or + subsequent biological product is interchangeable for any + condition of use until the earlier of-- + ``(A) 1 year after the first commercial marketing of + the first interchangeable biosimilar biological product + to be approved as interchangeable for that reference + product; + ``(B) 18 months after-- + ``(i) a final court decision on all patents in + suit in an action instituted under subsection + (l)(6) against the applicant that submitted the + application for the first approved interchangeable + biosimilar biological product; or + ``(ii) the dismissal with or without prejudice + of an action instituted under subsection (l)(6) + against the applicant that submitted the + application for the first approved interchangeable + biosimilar biological product; or + ``(C)(i) 42 months after approval of the first + interchangeable biosimilar biological product if the + applicant that submitted such application has been sued + under subsection (l)(6) and such litigation is still + ongoing within such 42-month period; or + ``(ii) 18 months after approval of the first + interchangeable biosimilar biological product if the + applicant that submitted such application has not been + sued under subsection (l)(6). + <<NOTE: Definition.>> For purposes of this paragraph, the term + `final court decision' means a final decision of a court from + which no appeal (other than a petition to the United States + Supreme Court for a writ of certiorari) has been or can be + taken. + ``(7) Exclusivity for reference product.-- + ``(A) Effective date of biosimilar application + approval.--Approval of an application under this + subsection may not be made effective by the Secretary + until the date that is 12 years after the date on which + the reference product was first licensed under + subsection (a). + ``(B) Filing period.--An application under this + subsection may not be submitted to the Secretary until + the date that is 4 years after the date on which the + reference product was first licensed under subsection + (a). + ``(C) First licensure.--Subparagraphs (A) and (B) + shall not apply to a license for or approval of-- + ``(i) a supplement for the biological product + that is the reference product; or + ``(ii) a subsequent application filed by the + same sponsor or manufacturer of the biological + product that is the reference product (or a + licensor, predecessor in interest, or other + related entity) for-- + ``(I) a change (not including a + modification to the structure of the + biological product) that results + +[[Page 124 STAT. 808]] + + in a new indication, route of + administration, dosing schedule, dosage + form, delivery system, delivery device, + or strength; or + ``(II) a modification to the + structure of the biological product that + does not result in a change in safety, + purity, or potency. + ``(8) Guidance documents.-- + ``(A) In general.--The Secretary may, after + opportunity for public comment, issue guidance in + accordance, except as provided in subparagraph (B)(i), + with section 701(h) of the Federal Food, Drug, and + Cosmetic Act with respect to the licensure of a + biological product under this subsection. Any such + guidance may be general or specific. + ``(B) Public comment.-- + ``(i) In general.--The Secretary shall provide + the public an opportunity to comment on any + proposed guidance issued under subparagraph (A) + before issuing final guidance. + ``(ii) Input regarding most valuable + guidance.--The Secretary shall establish a process + through which the public may provide the Secretary + with input regarding priorities for issuing + guidance. + ``(C) No requirement for application + consideration.--The issuance (or non-issuance) of + guidance under subparagraph (A) shall not preclude the + review of, or action on, an application submitted under + this subsection. + ``(D) Requirement for product class-specific + guidance.--If the Secretary issues product class- + specific guidance under subparagraph (A), such guidance + shall include a description of-- + <<NOTE: Criteria.>> ``(i) the criteria that + the Secretary will use to determine whether a + biological product is highly similar to a + reference product in such product class; and + ``(ii) the criteria, if available, that the + Secretary will use to determine whether a + biological product meets the standards described + in paragraph (4). + ``(E) Certain product classes.-- + ``(i) Guidance.--The Secretary may indicate in + a guidance document that the science and + experience, as of the date of such guidance, with + respect to a product or product class (not + including any recombinant protein) does not allow + approval of an application for a license as + provided under this subsection for such product or + product class. + ``(ii) Modification or reversal.--The + Secretary may issue a subsequent guidance document + under subparagraph (A) to modify or reverse a + guidance document under clause (i). + ``(iii) No effect on ability to deny + license.--Clause (i) shall not be construed to + require the Secretary to approve a product with + respect to which the Secretary has not indicated + in a guidance document that the science and + experience, as described in clause (i), does not + allow approval of such an application. + + ``(l) Patents.-- + ``(1) Confidential access to subsection (k) application.-- + +[[Page 124 STAT. 809]] + + ``(A) Application of paragraph.--Unless otherwise + agreed to by a person that submits an application under + subsection (k) (referred to in this subsection as the + `subsection (k) applicant') and the sponsor of the + application for the reference product (referred to in + this subsection as the `reference product sponsor'), the + provisions of this paragraph shall apply to the exchange + of information described in this subsection. + ``(B) In general.-- + ``(i) Provision of confidential information.-- + When a subsection (k) applicant submits an + application under subsection (k), such applicant + shall provide to the persons described in clause + (ii), subject to the terms of this paragraph, + confidential access to the information required to + be produced pursuant to paragraph (2) and any + other information that the subsection (k) + applicant determines, in its sole discretion, to + be appropriate (referred to in this subsection as + the `confidential information'). + ``(ii) Recipients of information.--The persons + described in this clause are the following: + ``(I) Outside counsel.--One or more + attorneys designated by the reference + product sponsor who are employees of an + entity other than the reference product + sponsor (referred to in this paragraph + as the `outside counsel'), provided that + such attorneys do not engage, formally + or informally, in patent prosecution + relevant or related to the reference + product. + ``(II) In-house counsel.--One + attorney that represents the reference + product sponsor who is an employee of + the reference product sponsor, provided + that such attorney does not engage, + formally or informally, in patent + prosecution relevant or related to the + reference product. + ``(iii) Patent owner access.--A representative + of the owner of a patent exclusively licensed to a + reference product sponsor with respect to the + reference product and who has retained a right to + assert the patent or participate in litigation + concerning the patent may be provided the + confidential information, provided that the + representative informs the reference product + sponsor and the subsection (k) applicant of his or + her agreement to be subject to the confidentiality + provisions set forth in this paragraph, including + those under clause (ii). + ``(C) Limitation on disclosure.--No person that + receives confidential information pursuant to + subparagraph (B) shall disclose any confidential + information to any other person or entity, including the + reference product sponsor employees, outside scientific + consultants, or other outside counsel retained by the + reference product sponsor, without the prior written + consent of the subsection (k) applicant, which shall not + be unreasonably withheld. + ``(D) Use of confidential information.--Confidential + information shall be used for the sole and exclusive + purpose of determining, with respect to each patent + assigned to + +[[Page 124 STAT. 810]] + + or exclusively licensed by the reference product + sponsor, whether a claim of patent infringement could + reasonably be asserted if the subsection (k) applicant + engaged in the manufacture, use, offering for sale, + sale, or importation into the United States of the + biological product that is the subject of the + application under subsection (k). + ``(E) Ownership of confidential information.--The + confidential information disclosed under this paragraph + is, and shall remain, the property of the subsection (k) + applicant. By providing the confidential information + pursuant to this paragraph, the subsection (k) applicant + does not provide the reference product sponsor or the + outside counsel any interest in or license to use the + confidential information, for purposes other than those + specified in subparagraph (D). + ``(F) Effect of infringement action.--In the event + that the reference product sponsor files a patent + infringement suit, the use of confidential information + shall continue to be governed by the terms of this + paragraph until such time as a court enters a protective + order regarding the information. Upon entry of such + order, the subsection (k) applicant may redesignate + confidential information in accordance with the terms of + that order. No confidential information shall be + included in any publicly-available complaint or other + pleading. In the event that the reference product + sponsor does not file an infringement action by the date + specified in paragraph (6), the reference product + sponsor shall return or destroy all confidential + information received under this paragraph, provided that + if the reference product sponsor opts to destroy such + information, it will confirm destruction in writing to + the subsection (k) applicant. + ``(G) Rule of construction.--Nothing in this + paragraph shall be construed-- + ``(i) as an admission by the subsection (k) + applicant regarding the validity, enforceability, + or infringement of any patent; or + ``(ii) as an agreement or admission by the + subsection (k) applicant with respect to the + competency, relevance, or materiality of any + confidential information. + ``(H) Effect of violation.--The disclosure of any + confidential information in violation of this paragraph + shall be deemed to cause the subsection (k) applicant to + suffer irreparable harm for which there is no adequate + legal remedy and the court shall consider immediate + injunctive relief to be an appropriate and necessary + remedy for any violation or threatened violation of this + paragraph. + ``(2) Subsection (k) application information.-- + <<NOTE: Deadline. Notification.>> Not later than 20 days after + the Secretary notifies the subsection (k) applicant that the + application has been accepted for review, the subsection (k) + applicant-- + ``(A) shall provide to the reference product sponsor + a copy of the application submitted to the Secretary + under subsection (k), and such other information that + describes the process or processes used to manufacture + the biological product that is the subject of such + application; and + +[[Page 124 STAT. 811]] + + ``(B) may provide to the reference product sponsor + additional information requested by or on behalf of the + reference product sponsor. + ``(3) <<NOTE: Deadlines.>> List and description of + patents.-- + ``(A) List by reference product sponsor.--Not later + than 60 days after the receipt of the application and + information under paragraph (2), the reference product + sponsor shall provide to the subsection (k) applicant-- + ``(i) a list of patents for which the + reference product sponsor believes a claim of + patent infringement could reasonably be asserted + by the reference product sponsor, or by a patent + owner that has granted an exclusive license to the + reference product sponsor with respect to the + reference product, if a person not licensed by the + reference product sponsor engaged in the making, + using, offering to sell, selling, or importing + into the United States of the biological product + that is the subject of the subsection (k) + application; and + ``(ii) an identification of the patents on + such list that the reference product sponsor would + be prepared to license to the subsection (k) + applicant. + ``(B) List and description by subsection (k) + applicant.--Not later than 60 days after receipt of the + list under subparagraph (A), the subsection (k) + applicant-- + ``(i) may provide to the reference product + sponsor a list of patents to which the subsection + (k) applicant believes a claim of patent + infringement could reasonably be asserted by the + reference product sponsor if a person not licensed + by the reference product sponsor engaged in the + making, using, offering to sell, selling, or + importing into the United States of the biological + product that is the subject of the subsection (k) + application; + ``(ii) shall provide to the reference product + sponsor, with respect to each patent listed by the + reference product sponsor under subparagraph (A) + or listed by the subsection (k) applicant under + clause (i)-- + ``(I) a detailed statement that + describes, on a claim by claim basis, + the factual and legal basis of the + opinion of the subsection (k) applicant + that such patent is invalid, + unenforceable, or will not be infringed + by the commercial marketing of the + biological product that is the subject + of the subsection (k) application; or + ``(II) a statement that the + subsection (k) applicant does not intend + to begin commercial marketing of the + biological product before the date that + such patent expires; and + ``(iii) shall provide to the reference product + sponsor a response regarding each patent + identified by the reference product sponsor under + subparagraph (A)(ii). + ``(C) Description by reference product sponsor.--Not + later than 60 days after receipt of the list and + statement under subparagraph (B), the reference product + sponsor shall provide to the subsection (k) applicant a + detailed statement that describes, with respect to each + patent described in subparagraph (B)(ii)(I), on a claim + by + +[[Page 124 STAT. 812]] + + claim basis, the factual and legal basis of the opinion + of the reference product sponsor that such patent will + be infringed by the commercial marketing of the + biological product that is the subject of the subsection + (k) application and a response to the statement + concerning validity and enforceability provided under + subparagraph (B)(ii)(I). + ``(4) Patent resolution negotiations.-- + ``(A) In general.--After receipt by the subsection + (k) applicant of the statement under paragraph (3)(C), + the reference product sponsor and the subsection (k) + applicant shall engage in good faith negotiations to + agree on which, if any, patents listed under paragraph + (3) by the subsection (k) applicant or the reference + product sponsor shall be the subject of an action for + patent infringement under paragraph (6). + ``(B) Failure to reach agreement. <<NOTE: Time + period. Applicability.>> --If, within 15 days of + beginning negotiations under subparagraph (A), the + subsection (k) applicant and the reference product + sponsor fail to agree on a final and complete list of + which, if any, patents listed under paragraph (3) by the + subsection (k) applicant or the reference product + sponsor shall be the subject of an action for patent + infringement under paragraph (6), the provisions of + paragraph (5) shall apply to the parties. + ``(5) Patent resolution if no agreement.-- + <<NOTE: Notification.>> + ``(A) Number of patents.--The subsection (k) + applicant shall notify the reference product sponsor of + the number of patents that such applicant will provide + to the reference product sponsor under subparagraph + (B)(i)(I). + ``(B) Exchange of patent lists.-- + ``(i) In general. <<NOTE: Deadline.>> --On a + date agreed to by the subsection (k) applicant and + the reference product sponsor, but in no case + later than 5 days after the subsection (k) + applicant notifies the reference product sponsor + under subparagraph (A), the subsection (k) + applicant and the reference product sponsor shall + simultaneously exchange-- + ``(I) the list of patents that the + subsection (k) applicant believes should + be the subject of an action for patent + infringement under paragraph (6); and + ``(II) the list of patents, in + accordance with clause (ii), that the + reference product sponsor believes + should be the subject of an action for + patent infringement under paragraph (6). + ``(ii) Number of patents listed by reference + product sponsor.-- + ``(I) In general.--Subject to + subclause (II), the number of patents + listed by the reference product sponsor + under clause (i)(II) may not exceed the + number of patents listed by the + subsection (k) applicant under clause + (i)(I). + ``(II) Exception.--If a subsection + (k) applicant does not list any patent + under clause (i)(I), the reference + product sponsor may list 1 patent under + clause (i)(II). + ``(6) <<NOTE: Deadlines.>> Immediate patent infringement + action.-- + +[[Page 124 STAT. 813]] + + ``(A) Action if agreement on patent list.--If the + subsection (k) applicant and the reference product + sponsor agree on patents as described in paragraph (4), + not later than 30 days after such agreement, the + reference product sponsor shall bring an action for + patent infringement with respect to each such patent. + ``(B) Action if no agreement on patent list.--If the + provisions of paragraph (5) apply to the parties as + described in paragraph (4)(B), not later than 30 days + after the exchange of lists under paragraph (5)(B), the + reference product sponsor shall bring an action for + patent infringement with respect to each patent that is + included on such lists. + ``(C) Notification and publication of complaint.-- + ``(i) Notification to secretary.--Not later + than 30 days after a complaint is served to a + subsection (k) applicant in an action for patent + infringement described under this paragraph, the + subsection (k) applicant shall provide the + Secretary with notice and a copy of such + complaint. + ``(ii) Publication by + secretary. <<NOTE: Federal Register, + publication. Notice.>> --The Secretary shall + publish in the Federal Register notice of a + complaint received under clause (i). + ``(7) Newly issued or licensed patents.--In the case of a + patent that-- + ``(A) is issued to, or exclusively licensed by, the + reference product sponsor after the date that the + reference product sponsor provided the list to the + subsection (k) applicant under paragraph (3)(A); and + ``(B) the reference product sponsor reasonably + believes that, due to the issuance of such patent, a + claim of patent infringement could reasonably be + asserted by the reference product sponsor if a person + not licensed by the reference product sponsor engaged in + the making, using, offering to sell, selling, or + importing into the United States of the biological + product that is the subject of the subsection + (k) <<NOTE: Deadlines.>> application, + not later than 30 days after such issuance or licensing, the + reference product sponsor shall provide to the subsection (k) + applicant a supplement to the list provided by the reference + product sponsor under paragraph (3)(A) that includes such + patent, not later than 30 days after such supplement is + provided, the subsection (k) applicant shall provide a statement + to the reference product sponsor in accordance with paragraph + (3)(B), and such patent shall be subject to paragraph (8). + ``(8) Notice of commercial marketing and preliminary + injunction.-- + ``(A) Notice of commercial + marketing. <<NOTE: Deadline.>> --The subsection (k) + applicant shall provide notice to the reference product + sponsor not later than 180 days before the date of the + first commercial marketing of the biological product + licensed under subsection (k). + ``(B) Preliminary injunction.--After receiving the + notice under subparagraph (A) and before such date of + the first commercial marketing of such biological + product, the reference product sponsor may seek a + preliminary injunction prohibiting the subsection (k) + applicant from + +[[Page 124 STAT. 814]] + + engaging in the commercial manufacture or sale of such + biological product until the court decides the issue of + patent validity, enforcement, and infringement with + respect to any patent that is-- + ``(i) included in the list provided by the + reference product sponsor under paragraph (3)(A) + or in the list provided by the subsection (k) + applicant under paragraph (3)(B); and + ``(ii) not included, as applicable, on-- + ``(I) the list of patents described + in paragraph (4); or + ``(II) the lists of patents + described in paragraph (5)(B). + ``(C) Reasonable cooperation.--If the reference + product sponsor has sought a preliminary injunction + under subparagraph (B), the reference product sponsor + and the subsection (k) applicant shall reasonably + cooperate to expedite such further discovery as is + needed in connection with the preliminary injunction + motion. + ``(9) Limitation on declaratory judgment action.-- + ``(A) Subsection (k) application provided.--If a + subsection (k) applicant provides the application and + information required under paragraph (2)(A), neither the + reference product sponsor nor the subsection (k) + applicant may, prior to the date notice is received + under paragraph (8)(A), bring any action under section + 2201 of title 28, United States Code, for a declaration + of infringement, validity, or enforceability of any + patent that is described in clauses (i) and (ii) of + paragraph (8)(B). + ``(B) Subsequent failure to act by subsection (k) + applicant.--If a subsection (k) applicant fails to + complete an action required of the subsection (k) + applicant under paragraph (3)(B)(ii), paragraph (5), + paragraph (6)(C)(i), paragraph (7), or paragraph (8)(A), + the reference product sponsor, but not the subsection + (k) applicant, may bring an action under section 2201 of + title 28, United States Code, for a declaration of + infringement, validity, or enforceability of any patent + included in the list described in paragraph (3)(A), + including as provided under paragraph (7). + ``(C) Subsection (k) application not provided.--If a + subsection (k) applicant fails to provide the + application and information required under paragraph + (2)(A), the reference product sponsor, but not the + subsection (k) applicant, may bring an action under + section 2201 of title 28, United States Code, for a + declaration of infringement, validity, or enforceability + of any patent that claims the biological product or a + use of the biological product.''. + + (b) Definitions.--Section 351(i) of the Public Health Service Act +(42 U.S.C. 262(i)) is amended-- + (1) by striking ``In this section, the term `biological + product' means'' and inserting the following: ``In this section: + ``(1) The term `biological product' means''; + (2) in paragraph (1), as so designated, by inserting + ``protein (except any chemically synthesized polypeptide),'' + after ``allergenic product,''; and + (3) by adding at the end the following: + +[[Page 124 STAT. 815]] + + ``(2) The term `biosimilar' or `biosimilarity', in reference + to a biological product that is the subject of an application + under subsection (k), means-- + ``(A) that the biological product is highly similar + to the reference product notwithstanding minor + differences in clinically inactive components; and + ``(B) there are no clinically meaningful differences + between the biological product and the reference product + in terms of the safety, purity, and potency of the + product. + ``(3) The term `interchangeable' or `interchangeability', in + reference to a biological product that is shown to meet the + standards described in subsection (k)(4), means that the + biological product may be substituted for the reference product + without the intervention of the health care provider who + prescribed the reference product. + ``(4) The term `reference product' means the single + biological product licensed under subsection (a) against which a + biological product is evaluated in an application submitted + under subsection (k).''. + + (c) Conforming Amendments Relating to Patents.-- + (1) Patents.--Section 271(e) of title 35, United States + Code, is amended-- + (A) in paragraph (2)-- + (i) in subparagraph (A), by striking ``or'' at + the end; + (ii) in subparagraph (B), by adding ``or'' at + the end; and + (iii) by inserting after subparagraph (B) the + following: + ``(C)(i) with respect to a patent that is identified in the + list of patents described in section 351(l)(3) of the Public + Health Service Act (including as provided under section + 351(l)(7) of such Act), an application seeking approval of a + biological product, or + ``(ii) if the applicant for the application fails to provide + the application and information required under section + 351(l)(2)(A) of such Act, an application seeking approval of a + biological product for a patent that could be identified + pursuant to section 351(l)(3)(A)(i) of such Act,''; and + (iv) in the matter following subparagraph (C) + (as added by clause (iii)), by striking ``or + veterinary biological product'' and inserting ``, + veterinary biological product, or biological + product''; + (B) in paragraph (4)-- + (i) in subparagraph (B), by-- + (I) striking ``or veterinary + biological product'' and inserting ``, + veterinary biological product, or + biological product''; and + (II) striking ``and'' at the end; + (ii) in subparagraph (C), by-- + (I) striking ``or veterinary + biological product'' and inserting ``, + veterinary biological product, or + biological product''; and + (II) striking the period and + inserting ``, and''; + (iii) by inserting after subparagraph (C) the + following: + +[[Page 124 STAT. 816]] + + ``(D) <<NOTE: Courts.>> the court shall order a permanent + injunction prohibiting any infringement of the patent by the + biological product involved in the infringement until a date + which is not earlier than the date of the expiration of the + patent that has been infringed under paragraph (2)(C), provided + the patent is the subject of a final court decision, as defined + in section 351(k)(6) of the Public Health Service Act, in an + action for infringement of the patent under section 351(l)(6) of + such Act, and the biological product has not yet been approved + because of section 351(k)(7) of such Act.''; and + (iv) in the matter following subparagraph (D) + (as added by clause (iii)), by striking ``and + (C)'' and inserting ``(C), and (D)''; and + (C) by adding at the end the following: + + ``(6)(A) <<NOTE: Applicability.>> Subparagraph (B) applies, in lieu +of paragraph (4), in the case of a patent-- + ``(i) that is identified, as applicable, in the list of + patents described in section 351(l)(4) of the Public Health + Service Act or the lists of patents described in section + 351(l)(5)(B) of such Act with respect to a biological product; + and + ``(ii) for which an action for infringement of the patent + with respect to the biological product-- + ``(I) was brought after the expiration of the 30-day + period described in subparagraph (A) or (B), as + applicable, of section 351(l)(6) of such Act; or + ``(II) was brought before the expiration of the 30- + day period described in subclause (I), but which was + dismissed without prejudice or was not prosecuted to + judgment in good faith. + + ``(B) In an action for infringement of a patent described in +subparagraph (A), the sole and exclusive remedy that may be granted by a +court, upon a finding that the making, using, offering to sell, selling, +or importation into the United States of the biological product that is +the subject of the action infringed the patent, shall be a reasonable +royalty. + ``(C) The owner of a patent that should have been included in the +list described in section 351(l)(3)(A) of the Public Health Service Act, +including as provided under section 351(l)(7) of such Act for a +biological product, but was not timely included in such list, may not +bring an action under this section for infringement of the patent with +respect to the biological product.''. + (2) Conforming amendment under title 28.--Section 2201(b) of + title 28, United States Code, is amended by inserting before the + period the following: ``, or section 351 of the Public Health + Service Act''. + + (d) Conforming Amendments Under the Federal Food, Drug, and Cosmetic +Act.-- + (1) Content and review of applications.--Section + 505(b)(5)(B) of the Federal Food, Drug, and Cosmetic Act (21 + U.S.C. 355(b)(5)(B)) is amended by inserting before the period + at the end of the first sentence the following: ``or, with + respect to an applicant for approval of a biological product + under section 351(k) of the Public Health Service Act, any + necessary clinical study or studies''. + (2) New active ingredient.--Section 505B of the Federal + Food, Drug, and Cosmetic Act (21 U.S.C. 355c) is amended by + adding at the end the following: + +[[Page 124 STAT. 817]] + + ``(n) New Active Ingredient.-- + ``(1) Non-interchangeable biosimilar biological product.--A + biological product that is biosimilar to a reference product + under section 351 of the Public Health Service Act, and that the + Secretary has not determined to meet the standards described in + subsection (k)(4) of such section for interchangeability with + the reference product, shall be considered to have a new active + ingredient under this section. + ``(2) Interchangeable biosimilar biological product.--A + biological product that is interchangeable with a reference + product under section 351 of the Public Health Service Act shall + not be considered to have a new active ingredient under this + section.''. + + (e) <<NOTE: 42 USC 262 note.>> Products Previously Approved Under +Section 505.-- + (1) Requirement to follow section 351.--Except as provided + in paragraph (2), an application for a biological product shall + be submitted under section 351 of the Public Health Service Act + (42 U.S.C. 262) (as amended by this Act). + (2) Exception.--An application for a biological product may + be submitted under section 505 of the Federal Food, Drug, and + Cosmetic Act (21 U.S.C. 355) if-- + (A) such biological product is in a product class + for which a biological product in such product class is + the subject of an application approved under such + section 505 not later than the date of enactment of this + Act; and + (B) <<NOTE: Deadlines.>> such application-- + (i) has been submitted to the Secretary of + Health and Human Services (referred to in this + subtitle as the ``Secretary'') before the date of + enactment of this Act; or + (ii) is submitted to the Secretary not later + than the date that is 10 years after the date of + enactment of this Act. + (3) Limitation.--Notwithstanding paragraph (2), an + application for a biological product may not be submitted under + section 505 of the Federal Food, Drug, and Cosmetic Act (21 + U.S.C. 355) if there is another biological product approved + under subsection (a) of section 351 of the Public Health Service + Act that could be a reference product with respect to such + application (within the meaning of such section 351) if such + application were submitted under subsection (k) of such section + 351. + (4) Deemed approved under section 351 <<NOTE: Effective + date.>> .--An approved application for a biological product + under section 505 of the Federal Food, Drug, and Cosmetic Act + (21 U.S.C. 355) shall be deemed to be a license for the + biological product under such section 351 on the date that is 10 + years after the date of enactment of this Act. + (5) Definitions.--For purposes of this subsection, the term + ``biological product'' has the meaning given such term under + section 351 of the Public Health Service Act (42 U.S.C. 262) (as + amended by this Act). + + (f) Follow-on Biologics User Fees.-- + (1) Development of user fees for biosimilar biological + products.-- + (A) In general. <<NOTE: Deadline. Recommenda- + tions.>> --Beginning not later than October 1, 2010, the + Secretary shall develop recommendations to + +[[Page 124 STAT. 818]] + + present to Congress with respect to the goals, and plans + for meeting the goals, for the process for the review of + biosimilar biological product applications submitted + under section 351(k) of the Public Health Service Act + (as added by this Act) for the first 5 fiscal years + after fiscal year 2012. <<NOTE: Consultation.>> In + developing such recommendations, the Secretary shall + consult with-- + (i) the Committee on Health, Education, Labor, + and Pensions of the Senate; + (ii) the Committee on Energy and Commerce of + the House of Representatives; + (iii) scientific and academic experts; + (iv) health care professionals; + (v) representatives of patient and consumer + advocacy groups; and + (vi) the regulated industry. + (B) Public review of recommendations.--After + negotiations with the regulated industry, the Secretary + shall-- + (i) present the recommendations developed + under subparagraph (A) to the Congressional + committees specified in such subparagraph; + (ii) <<NOTE: Federal Register, + publication.>> publish such recommendations in the + Federal Register; + (iii) <<NOTE: Time period.>> provide for a + period of 30 days for the public to provide + written comments on such recommendations; + (iv) hold a meeting at which the public may + present its views on such recommendations; and + (v) after consideration of such public views + and comments, revise such recommendations as + necessary. + (C) Transmittal of + recommendations. <<NOTE: Deadline.>> --Not later than + January 15, 2012, the Secretary shall transmit to + Congress the revised recommendations under subparagraph + (B), a summary of the views and comments received under + such subparagraph, and any changes made to the + recommendations in response to such views and comments. + (2) <<NOTE: Effective date.>> Establishment of user fee + program.--It is the sense of the Senate that, based on the + recommendations transmitted to Congress by the Secretary + pursuant to paragraph (1)(C), Congress should authorize a + program, effective on October 1, 2012, for the collection of + user fees relating to the submission of biosimilar biological + product applications under section 351(k) of the Public Health + Service Act (as added by this Act). + (3) Transitional provisions for user fees for biosimilar + biological products.-- + (A) Application of the prescription drug user fee + provisions.--Section 735(1)(B) of the Federal Food, + Drug, and Cosmetic Act (21 U.S.C. 379g(1)(B)) is amended + by striking ``section 351'' and inserting ``subsection + (a) or (k) of section 351''. + (B) <<NOTE: 42 USC 262 note.>> Evaluation of costs + of reviewing biosimilar biological product + applications. <<NOTE: Time period.>> --During the period + beginning on the date of enactment of this Act and + ending on October 1, 2010, the Secretary shall collect + and evaluate data regarding the costs of reviewing + applications for biological products submitted under + section 351(k) of the + +[[Page 124 STAT. 819]] + + Public Health Service Act (as added by this Act) during + such period. + (C) Audit.-- + (i) <<NOTE: Time period.>> In general.--On + the date that is 2 years after first receiving a + user fee applicable to an application for a + biological product under section 351(k) of the + Public Health Service Act (as added by this Act), + and on a biennial basis thereafter until October + 1, 2013, the Secretary shall perform an audit of + the costs of reviewing such applications under + such section 351(k). Such an audit shall compare-- + (I) the costs of reviewing such + applications under such section 351(k) + to the amount of the user fee applicable + to such applications; and + (II)(aa) such ratio determined under + subclause (I); to + (bb) the ratio of the costs of + reviewing applications for biological + products under section 351(a) of such + Act (as amended by this Act) to the + amount of the user fee applicable to + such applications under such section + 351(a). + (ii) Alteration of user fee.--If the audit + performed under clause (i) indicates that the + ratios compared under subclause (II) of such + clause differ by more than 5 percent, then the + Secretary shall alter the user fee applicable to + applications submitted under such section 351(k) + to more appropriately account for the costs of + reviewing such applications. + (iii) Accounting standards.--The Secretary + shall perform an audit under clause (i) in + conformance with the accounting principles, + standards, and requirements prescribed by the + Comptroller General of the United States under + section 3511 of title 31, United State Code, to + ensure the validity of any potential variability. + (4) Authorization of appropriations.--There is authorized to + be appropriated to carry out this subsection such sums as may be + necessary for each of fiscal years 2010 through 2012. + + (g) Pediatric Studies of Biological Products.-- + (1) In general.--Section 351 of the Public Health Service + Act (42 U.S.C. 262) is amended by adding at the end the + following: + + ``(m) Pediatric Studies.-- + ``(1) Application of certain provisions.--The provisions of + subsections (a), (d), (e), (f), (i), (j), (k), (l), (p), and (q) + of section 505A of the Federal Food, Drug, and Cosmetic Act + shall apply with respect to the extension of a period under + paragraphs (2) and (3) to the same extent and in the same manner + as such provisions apply with respect to the extension of a + period under subsection (b) or (c) of section 505A of the + Federal Food, Drug, and Cosmetic Act. + ``(2) Market exclusivity for new biological products.--If, + prior <<NOTE: Determination.>> to approval of an application + that is submitted under subsection (a), the Secretary determines + that information relating to the use of a new biological product + in the pediatric population may produce health benefits in that + population, the Secretary makes a written request for pediatric + studies + +[[Page 124 STAT. 820]] + + (which shall include a timeframe for completing such studies), + the applicant agrees to the request, such studies are completed + using appropriate formulations for each age group for which the + study is requested within any such timeframe, and the reports + thereof are submitted and accepted in accordance with section + 505A(d)(3) of the Federal Food, Drug, and Cosmetic Act-- + ``(A) the periods for such biological product + referred to in subsection (k)(7) are deemed to be 4 + years and 6 months rather than 4 years and 12 years and + 6 months rather than 12 years; and + ``(B) if the biological product is designated under + section 526 for a rare disease or condition, the period + for such biological product referred to in section + 527(a) is deemed to be 7 years and 6 months rather than + 7 years. + ``(3) Market exclusivity for already-marketed biological + products.--If the Secretary <<NOTE: Determination.>> determines + that information relating to the use of a licensed biological + product in the pediatric population may produce health benefits + in that population and makes a written request to the holder of + an approved application under subsection (a) for pediatric + studies (which shall include a timeframe for completing such + studies), the holder agrees to the request, such studies are + completed using appropriate formulations for each age group for + which the study is requested within any such timeframe, and the + reports thereof are submitted and accepted in accordance with + section 505A(d)(3) of the Federal Food, Drug, and Cosmetic Act-- + ``(A) the periods for such biological product + referred to in subsection (k)(7) are deemed to be 4 + years and 6 months rather than 4 years and 12 years and + 6 months rather than 12 years; and + ``(B) if the biological product is designated under + section 526 for a rare disease or condition, the period + for such biological product referred to in section + 527(a) is deemed to be 7 years and 6 months rather than + 7 years. + ``(4) Exception.--The Secretary shall not extend a period + referred to in paragraph (2)(A), (2)(B), (3)(A), or (3)(B) if + the determination under section 505A(d)(3) is made later than 9 + months prior to the expiration of such period.''. + (2) Studies regarding pediatric research.-- + (A) Program for pediatric study of drugs.-- + Subsection (a)(1) of section 409I of the Public Health + Service Act (42 U.S.C. 284m) is amended by inserting ``, + biological products,'' after ``including drugs''. + (B) Institute of medicine study.--Section 505A(p) of + the Federal Food, Drug, and Cosmetic Act <<NOTE: 21 USC + 355a.>> (21 U.S.C. 355b(p)) is amended by striking + paragraphs (4) and (5) and inserting the following: + ``(4) review and assess the number and importance of + biological products for children that are being tested as a + result of the amendments made by the Biologics Price Competition + and Innovation Act of 2009 and the importance for children, + health care providers, parents, and others of labeling changes + made as a result of such testing; + +[[Page 124 STAT. 821]] + + ``(5) review and assess the number, importance, and + prioritization of any biological products that are not being + tested for pediatric use; and + ``(6) offer recommendations for ensuring pediatric testing + of biological products, including consideration of any + incentives, such as those provided under this section or section + 351(m) of the Public Health Service Act.''. + + (h) <<NOTE: Time periods. 42 USC 262 note.>> Orphan Products.--If a +reference product, as defined in section 351 of the Public Health +Service Act (42 U.S.C. 262) (as amended by this Act) has been designated +under section 526 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. +360bb) for a rare disease or condition, a biological product seeking +approval for such disease or condition under subsection (k) of such +section 351 as biosimilar to, or interchangeable with, such reference +product may be licensed by the Secretary only after the expiration for +such reference product of the later of-- + (1) the 7-year period described in section 527(a) of the + Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360cc(a)); and + (2) the 12-year period described in subsection (k)(7) of + such section 351. + +SEC. 7003. <<NOTE: 42 USC 262 note.>> SAVINGS. + + (a) Determination.--The Secretary of the Treasury, in consultation +with the Secretary of Health and Human Services, shall for each fiscal +year determine the amount of savings to the Federal Government as a +result of the enactment of this subtitle. + (b) Use.--Notwithstanding any other provision of this subtitle (or +an amendment made by this subtitle), the savings to the Federal +Government generated as a result of the enactment of this subtitle shall +be used for deficit reduction. + + Subtitle B--More Affordable Medicines for Children and Underserved + Communities + +SEC. 7101. EXPANDED PARTICIPATION IN 340B PROGRAM. + + (a) Expansion of Covered Entities Receiving Discounted Prices.-- +Section 340B(a)(4) of the Public Health Service Act (42 U.S.C. +256b(a)(4)) is amended by adding at the end the following: + ``(M) A children's hospital excluded from the + Medicare prospective payment system pursuant to section + 1886(d)(1)(B)(iii) of the Social Security Act, or a + free-standing cancer hospital excluded from the Medicare + prospective payment system pursuant to section + 1886(d)(1)(B)(v) of the Social Security Act, that would + meet the requirements of subparagraph (L), including the + disproportionate share adjustment percentage requirement + under clause (ii) of such subparagraph, if the hospital + were a subsection (d) hospital as defined by section + 1886(d)(1)(B) of the Social Security Act. + ``(N) An entity that is a critical access hospital + (as determined under section 1820(c)(2) of the Social + Security Act), and that meets the requirements of + subparagraph (L)(i). + ``(O) An entity that is a rural referral center, as + defined by section 1886(d)(5)(C)(i) of the Social + Security Act, or + +[[Page 124 STAT. 822]] + + a sole community hospital, as defined by section + 1886(d)(5)(C)(iii) of such Act, and that both meets the + requirements of subparagraph (L)(i) and has a + disproportionate share adjustment percentage equal to or + greater than 8 percent.''. + + (b) Extension of Discount to Inpatient Drugs.--Section 340B of the +Public Health Service Act (42 U.S.C. 256b) is amended-- + (1) in paragraphs (2), (5), (7), and (9) of subsection (a), + by striking ``outpatient'' each place it appears; and + (2) in subsection (b)-- + (A) by striking ``Other Definition'' and all that + follows through ``In this section'' and inserting the + following: ``Other Definitions.-- + ``(1) In general.--In this section''; and + (B) by adding at the end the following new + paragraph: + ``(2) Covered drug.--In this section, the term `covered + drug'-- + ``(A) means a covered outpatient drug (as defined in + section 1927(k)(2) of the Social Security Act); and + ``(B) includes, notwithstanding paragraph (3)(A) of + section 1927(k) of such Act, a drug used in connection + with an inpatient or outpatient service provided by a + hospital described in subparagraph (L), (M), (N), or (O) + of subsection (a)(4) that is enrolled to participate in + the drug discount program under this section.''. + + (c) Prohibition on Group Purchasing Arrangements.--Section 340B(a) +of the Public Health Service Act (42 U.S.C. 256b(a)) is amended-- + (1) in paragraph (4)(L)-- + (A) in clause (i), by adding ``and'' at the end; + (B) in clause (ii), by striking ``; and'' and + inserting a period; and + (C) by striking clause (iii); and + (2) in paragraph (5), as amended by subsection (b)-- + (A) by redesignating subparagraphs (C) and (D) as + subparagraphs (D) and (E); respectively; and + (B) by inserting after subparagraph (B), the + following: + ``(C) Prohibition on group purchasing + arrangements.-- + ``(i) In general.--A hospital described in + subparagraph (L), (M), (N), or (O) of paragraph + (4) shall not obtain covered outpatient drugs + through a group purchasing organization or other + group purchasing arrangement, except as permitted + or provided for pursuant to clauses (ii) or (iii). + ``(ii) Inpatient drugs.--Clause (i) shall not + apply to drugs purchased for inpatient use. + ``(iii) Exceptions.--The Secretary shall + establish reasonable exceptions to clause (i)-- + ``(I) with respect to a covered + outpatient drug that is unavailable to + be purchased through the program under + this section due to a drug shortage + problem, manufacturer noncompliance, or + any other circumstance beyond the + hospital's control; + ``(II) to facilitate generic + substitution when a generic covered + outpatient drug is available at a lower + price; or + +[[Page 124 STAT. 823]] + + ``(III) to reduce in other ways the + administrative burdens of managing both + inventories of drugs subject to this + section and inventories of drugs that + are not subject to this section, so long + as the exceptions do not create a + duplicate discount problem in violation + of subparagraph (A) or a diversion + problem in violation of subparagraph + (B). + ``(iv) Purchasing arrangements for inpatient + drugs.--The Secretary shall ensure that a hospital + described in subparagraph (L), (M), (N), or (O) of + subsection (a)(4) that is enrolled to participate + in the drug discount program under this section + shall have multiple options for purchasing covered + drugs for inpatients, including by utilizing a + group purchasing organization or other group + purchasing arrangement, establishing and utilizing + its own group purchasing program, purchasing + directly from a manufacturer, and any other + purchasing arrangements that the Secretary + determines is appropriate to ensure access to drug + discount pricing under this section for inpatient + drugs taking into account the particular needs of + small and rural hospitals.''. + + (d) Medicaid Credits on Inpatient Drugs.--Section 340B of the Public +Health Service Act (42 U.S.C. 256b) is amended by striking subsection +(c) and inserting the following: + ``(c) Medicaid Credit.--Not +later <<NOTE: Deadline. Determination.>> than 90 days after the date of +filing of the hospital's most recently filed Medicare cost report, the +hospital shall issue a credit as determined by the Secretary to the +State Medicaid program for inpatient covered drugs provided to Medicaid +recipients.''. + + (e) <<NOTE: 42 USC 256b.>> Effective Dates.-- + (1) In general.--The amendments made by this section and + section 7102 shall take effect on January 1, 2010, and shall + apply to drugs purchased on or after January 1, 2010. + (2) Effectiveness.--The amendments made by this section and + section 7102 shall be effective and shall be taken into account + in determining whether a manufacturer is deemed to meet the + requirements of section 340B(a) of the Public Health Service Act + (42 U.S.C. 256b(a)), notwithstanding any other provision of law. + +SEC. 7102. IMPROVEMENTS TO 340B PROGRAM INTEGRITY. + + (a) Integrity Improvements.--Subsection (d) of section 340B of the +Public Health Service Act (42 U.S.C. 256b) is amended to read as +follows: + ``(d) Improvements in Program Integrity.-- + ``(1) Manufacturer compliance.-- + ``(A) In general.--From amounts appropriated under + paragraph (4), the Secretary shall provide for + improvements in compliance by manufacturers with the + requirements of this section in order to prevent + overcharges and other violations of the discounted + pricing requirements specified in this section. + ``(B) Improvements.--The improvements described in + subparagraph (A) shall include the following: + +[[Page 124 STAT. 824]] + + ``(i) The development of a system to enable + the Secretary to verify the accuracy of ceiling + prices calculated by manufacturers under + subsection (a)(1) and charged to covered entities, + which shall include the following: + ``(I) Developing and publishing + through an appropriate policy or + regulatory issuance, precisely defined + standards and methodology for the + calculation of ceiling prices under such + subsection. + ``(II) Comparing regularly the + ceiling prices calculated by the + Secretary with the quarterly pricing + data that is reported by manufacturers + to the Secretary. + ``(III) Performing spot checks of + sales transactions by covered entities. + ``(IV) Inquiring into the cause of + any pricing discrepancies that may be + identified and either taking, or + requiring manufacturers to take, such + corrective action as is appropriate in + response to such price discrepancies. + ``(ii) The <<NOTE: Procedures.>> + establishment of procedures for manufacturers to + issue refunds to covered entities in the event + that there is an overcharge by the manufacturers, + including the following: + ``(I) Providing the Secretary with + an explanation of why and how the + overcharge occurred, how the refunds + will be calculated, and to whom the + refunds will be issued. + ``(II) Oversight by the Secretary to + ensure that the refunds are issued + accurately and within a reasonable + period of time, both in routine + instances of retroactive adjustment to + relevant pricing data and exceptional + circumstances such as erroneous or + intentional overcharging for covered + drugs. + ``(iii) The provision of access through the + Internet website of the Department of Health and + Human Services to the applicable ceiling prices + for covered drugs as calculated and verified by + the Secretary in accordance with this section, in + a manner (such as through the use of password + protection) that limits such access to covered + entities and adequately assures security and + protection of privileged pricing data from + unauthorized re-disclosure. + ``(iv) The development of a mechanism by + which-- + ``(I) rebates and other discounts + provided by manufacturers to other + purchasers subsequent to the sale of + covered drugs to covered entities are + reported to the Secretary; and + ``(II) appropriate credits and + refunds are issued to covered entities + if such discounts or rebates have the + effect of lowering the applicable + ceiling price for the relevant quarter + for the drugs involved. + ``(v) Selective auditing of manufacturers and + wholesalers to ensure the integrity of the drug + discount program under this section. + +[[Page 124 STAT. 825]] + + ``(vi) The imposition of sanctions in the form + of civil monetary penalties, which-- + ``(I) shall be assessed according to + standards established in regulations to + be promulgated by the Secretary not + later than 180 days after the date of + enactment of the Patient Protection and + Affordable Care Act; + ``(II) shall not exceed $5,000 for + each instance of overcharging a covered + entity that may have occurred; and + ``(III) <<NOTE: Applicability.>> + shall apply to any manufacturer with an + agreement under this section that + knowingly and intentionally charges a + covered entity a price for purchase of a + drug that exceeds the maximum applicable + price under subsection (a)(1). + ``(2) Covered entity compliance.-- + ``(A) In general.--From amounts appropriated under + paragraph (4), the Secretary shall provide for + improvements in compliance by covered entities with the + requirements of this section in order to prevent + diversion and violations of the duplicate discount + provision and other requirements specified under + subsection (a)(5). + ``(B) Improvements.--The improvements described in + subparagraph (A) shall include the following: + ``(i) <<NOTE: Procedures.>> The development + of procedures to enable and require covered + entities to regularly update (at least annually) + the information on the Internet website of the + Department of Health and Human Services relating + to this section. + ``(ii) The development of a system for the + Secretary to verify the accuracy of information + regarding covered entities that is listed on the + website described in clause (i). + ``(iii) <<NOTE: Guidance.>> The development + of more detailed guidance describing methodologies + and options available to covered entities for + billing covered drugs to State Medicaid agencies + in a manner that avoids duplicate discounts + pursuant to subsection (a)(5)(A). + ``(iv) The establishment of a single, + universal, and standardized identification system + by which each covered entity site can be + identified by manufacturers, distributors, covered + entities, and the Secretary for purposes of + facilitating the ordering, purchasing, and + delivery of covered drugs under this section, + including the processing of chargebacks for such + drugs. + ``(v) <<NOTE: Sanctions. Determination.>> The + imposition of sanctions, in appropriate cases as + determined by the Secretary, additional to those + to which covered entities are subject under + subsection (a)(5)(E), through one or more of the + following actions: + ``(I) Where a covered entity + knowingly and intentionally violates + subsection (a)(5)(B), the covered entity + shall be required to pay a monetary + penalty to a manufacturer or + manufacturers in the form of interest on + sums for which the covered entity is + found liable under subsection (a)(5)(E), + such interest to be compounded monthly + and equal + +[[Page 124 STAT. 826]] + + to the current short term interest rate + as determined by the Federal Reserve for + the time period for which the covered + entity is liable. + ``(II) Where the Secretary + determines a violation of subsection + (a)(5)(B) was systematic and egregious + as well as knowing and intentional, + removing the covered entity from the + drug discount program under this section + and disqualifying the entity from re- + entry into such program for a reasonable + period of time to be determined by the + Secretary. + ``(III) Referring matters to + appropriate Federal authorities within + the Food and Drug Administration, the + Office of Inspector General of + Department of Health and Human Services, + or other Federal agencies for + consideration of appropriate action + under other Federal statutes, such as + the Prescription Drug Marketing Act (21 + U.S.C. 353). + ``(3) Administrative dispute resolution process.-- + ``(A) In general.--Not + later <<NOTE: Deadline. Regulations.>> than 180 days + after the date of enactment of the Patient Protection + and Affordable Care Act, the Secretary shall promulgate + regulations to establish and implement an administrative + process for the resolution of claims by covered entities + that they have been overcharged for drugs purchased + under this section, and claims by manufacturers, after + the conduct of audits as authorized by subsection + (a)(5)(D), of violations of subsections (a)(5)(A) or + (a)(5)(B), including appropriate procedures for the + provision of remedies and enforcement of determinations + made pursuant to such process through mechanisms and + sanctions described in paragraphs (1)(B) and (2)(B). + ``(B) Deadlines and procedures.--Regulations + promulgated by the Secretary under subparagraph (A) + shall-- + ``(i) designate or establish a decision-making + official or decision-making body within the + Department of Health and Human Services to be + responsible for reviewing and finally resolving + claims by covered entities that they have been + charged prices for covered drugs in excess of the + ceiling price described in subsection (a)(1), and + claims by manufacturers that violations of + subsection (a)(5)(A) or (a)(5)(B) have occurred; + ``(ii) establish such deadlines and procedures + as may be necessary to ensure that claims shall be + resolved fairly, efficiently, and expeditiously; + ``(iii) establish procedures by which a + covered entity may discover and obtain such + information and documents from manufacturers and + third parties as may be relevant to demonstrate + the merits of a claim that charges for a + manufacturer's product have exceeded the + applicable ceiling price under this section, and + may submit such documents and information to the + administrative official or body responsible for + adjudicating such claim; + ``(iv) <<NOTE: Audits.>> require that a + manufacturer conduct an audit of a covered entity + pursuant to subsection (a)(5)(D) + +[[Page 124 STAT. 827]] + + as a prerequisite to initiating administrative + dispute resolution proceedings against a covered + entity; + ``(v) permit the official or body designated + under clause (i), at the request of a manufacturer + or manufacturers, to consolidate claims brought by + more than one manufacturer against the same + covered entity where, in the judgment of such + official or body, consolidation is appropriate and + consistent with the goals of fairness and economy + of resources; and + ``(vi) include provisions and procedures to + permit multiple covered entities to jointly assert + claims of overcharges by the same manufacturer for + the same drug or drugs in one administrative + proceeding, and permit such claims to be asserted + on behalf of covered entities by associations or + organizations representing the interests of such + covered entities and of which the covered entities + are members. + ``(C) Finality of administrative resolution.--The + administrative resolution of a claim or claims under the + regulations promulgated under subparagraph (A) shall be + a final agency decision and shall be binding upon the + parties involved, unless invalidated by an order of a + court of competent jurisdiction. + ``(4) Authorization of appropriations.--There are authorized + to be appropriated to carry out this subsection, such sums as + may be necessary for fiscal year 2010 and each succeeding fiscal + year.''. + + (b) Conforming Amendments.--Section 340B(a) of the Public Health +Service Act (42 U.S.C. 256b(a)) is amended-- + (1) in subsection (a)(1), by adding at the end the + following: ``Each such + agreement <<NOTE: Contracts. Reports. Deadlines.>> shall + require that the manufacturer furnish the Secretary with + reports, on a quarterly basis, of the price for each covered + drug subject to the agreement that, according to the + manufacturer, represents the maximum price that covered entities + may permissibly be required to pay for the drug (referred to in + this section as the `ceiling price'), and shall require that the + manufacturer offer each covered entity covered drugs for + purchase at or below the applicable ceiling price if such drug + is made available to any other purchaser at any price.''; and + (2) in the first sentence of subsection (a)(5)(E), as + redesignated by section 7101(c), by inserting ``after audit as + described in subparagraph (D) and'' after ``finds,''. + +SEC. 7103. GAO STUDY TO MAKE RECOMMENDATIONS ON IMPROVING THE 340B + PROGRAM. + + (a) Report.--Not later than 18 months after the date of enactment of +this Act, the Comptroller General of the United States shall submit to +Congress a report that examines whether those individuals served by the +covered entities under the program under section 340B of the Public +Health Service Act (42 U.S.C. 256b) (referred to in this section as the +``340B program'') are receiving optimal health care services. + (b) Recommendations.--The report under subsection (a) shall include +recommendations on the following: + +[[Page 124 STAT. 828]] + + (1) Whether the 340B program should be expanded since it is + anticipated that the 47,000,000 individuals who are uninsured as + of the date of enactment of this Act will have health care + coverage once this Act is implemented. + (2) Whether mandatory sales of certain products by the 340B + program could hinder patients access to those therapies through + any provider. + (3) Whether income from the 340B program is being used by + the covered entities under the program to further the program + objectives. + + TITLE VIII--CLASS ACT <<NOTE: Community Living Assistance Services and +Supports Act. 42 USC 201 note.>> + +SEC. 8001. SHORT TITLE OF TITLE. + + This title may be cited as the ``Community Living Assistance +Services and Supports Act'' or the ``CLASS Act''. + +SEC. 8002. ESTABLISHMENT OF NATIONAL VOLUNTARY INSURANCE PROGRAM FOR + PURCHASING COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORT. + + (a) Establishment of CLASS Program.-- + (1) In general.--The Public Health Service Act (42 U.S.C. + 201 et seq.), as amended by section 4302(a), is amended by + adding at the end the following: + + ``TITLE XXXII--COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS + +``SEC. 3201. <<NOTE: 42 USC 300ll.>> PURPOSE. + + ``The purpose of this title is to establish a national voluntary +insurance program for purchasing community living assistance services +and supports in order to-- + ``(1) provide individuals with functional limitations with + tools that will allow them to maintain their personal and + financial independence and live in the community through a new + financing strategy for community living assistance services and + supports; + ``(2) establish an infrastructure that will help address the + Nation's community living assistance services and supports + needs; + ``(3) alleviate burdens on family caregivers; and + ``(4) address institutional bias by providing a financing + mechanism that supports personal choice and independence to live + in the community. + +``SEC. 3202. <<NOTE: 42 USC 300ll-1.>> DEFINITIONS. + + ``In this title: + ``(1) Active enrollee.--The term `active enrollee' means an + individual who is enrolled in the CLASS program in accordance + with section 3204 and who has paid any premiums due to maintain + such enrollment. + ``(2) Actively employed.--The term `actively employed' means + an individual who-- + ``(A) is reporting for work at the individual's + usual place of employment or at another location to + which the + +[[Page 124 STAT. 829]] + + individual is required to travel because of the + individual's employment (or in the case of an individual + who is a member of the uniformed services, is on active + duty and is physically able to perform the duties of the + individual's position); and + ``(B) is able to perform all the usual and customary + duties of the individual's employment on the + individual's regular work schedule. + ``(3) Activities of daily living.--The term `activities of + daily living' means each of the following activities specified + in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986: + ``(A) Eating. + ``(B) Toileting. + ``(C) Transferring. + ``(D) Bathing. + ``(E) Dressing. + ``(F) Continence. + ``(4) CLASS program.--The term `CLASS program' means the + program established under this title. + ``(5) Eligibility assessment system.--The term `Eligibility + Assessment System' means the entity established by the Secretary + under section 3205(a)(2) to make functional eligibility + determinations for the CLASS program. + ``(6) Eligible beneficiary.-- + ``(A) In general.--The term `eligible beneficiary' + means any individual who is an active enrollee in the + CLASS program and, as of the date described in + subparagraph (B)-- + ``(i) has paid premiums for enrollment in such + program for at least 60 months; + ``(ii) has earned, with respect to at least 3 + calendar years that occur during the first 60 + months for which the individual has paid premiums + for enrollment in the program, at least an amount + equal to the amount of wages and self-employment + income which an individual must have in order to + be credited with a quarter of coverage under + section 213(d) of the Social Security Act for the + year; and + ``(iii) has paid premiums for enrollment in + such program for at least 24 consecutive months, + if a lapse in premium payments of more than 3 + months has occurred during the period that begins + on the date of the individual's enrollment and + ends on the date of such determination. + ``(B) Date described.--For purposes of subparagraph + (A), the date described in this subparagraph is the date + on which the individual is determined to have a + functional limitation described in section 3203(a)(1)(C) + that is expected to last for a continuous period of more + than 90 days. + ``(C) Regulations.--The Secretary shall promulgate + regulations specifying exceptions to the minimum + earnings requirements under subparagraph (A)(ii) for + purposes of being considered an eligible beneficiary for + certain populations. + ``(7) Hospital; nursing facility; intermediate care facility + for the mentally retarded; institution for + +[[Page 124 STAT. 830]] + + mental diseases.--The terms `hospital', `nursing facility', + `intermediate care facility for the mentally retarded', and + `institution for mental diseases' have the meanings given such + terms for purposes of Medicaid. + ``(8) CLASS independence advisory council.--The term `CLASS + Independence Advisory Council' or `Council' means the Advisory + Council established under section 3207 to advise the Secretary. + ``(9) CLASS independence benefit plan.--The term `CLASS + Independence Benefit Plan' means the benefit plan developed and + designated by the Secretary in accordance with section 3203. + ``(10) CLASS independence fund.--The term `CLASS + Independence Fund' or `Fund' means the fund established under + section 3206. + ``(11) Medicaid.--The term `Medicaid' means the program + established under title XIX of the Social Security Act (42 + U.S.C. 1396 et seq.). + ``(12) Poverty line.--The term `poverty line' has the + meaning given that term in section 2110(c)(5) of the Social + Security Act (42 U.S.C. 1397jj(c)(5)). + ``(13) Protection and advocacy system.--The term `Protection + and Advocacy System' means the system for each State established + under section 143 of the Developmental Disabilities Assistance + and Bill of Rights Act of 2000 (42 U.S.C. 15043). + +``SEC. 3203. <<NOTE: 42 USC 300ll-2.>> CLASS INDEPENDENCE BENEFIT PLAN. + + ``(a) Process for Development.-- + ``(1) In general.--The Secretary, in consultation with + appropriate actuaries and other experts, shall develop at least + 3 actuarially sound benefit plans as alternatives for + consideration for designation by the Secretary as the CLASS + Independence Benefit Plan under which eligible beneficiaries + shall receive benefits under this title. Each of the plan + alternatives developed shall be designed to provide eligible + beneficiaries with the benefits described in section 3205 + consistent with the following requirements: + ``(A) Premiums.-- + ``(i) In general.--Beginning with the first + year of the CLASS program, and for each year + thereafter, subject to clauses (ii) and (iii), the + Secretary shall establish all premiums to be paid + by enrollees for the year based on an actuarial + analysis of the 75-year costs of the program that + ensures solvency throughout such 75-year period. + ``(ii) Nominal premium for poorest individuals + and full-time students.-- + ``(I) In general.--The monthly + premium for enrollment in the CLASS + program shall not exceed the applicable + dollar amount per month determined under + subclause (II) for-- + ``(aa) any individual whose + income does not exceed the + poverty line; and + ``(bb) any individual who + has not attained age 22, and is + actively employed during any + +[[Page 124 STAT. 831]] + + period in which the individual + is a full-time student (as + determined by the Secretary). + ``(II) Applicable dollar amount.-- + The applicable dollar amount described + in this subclause is the amount equal to + $5, increased by the percentage increase + in the consumer price index for all + urban consumers (U.S. city average) for + each year occurring after 2009 and + before such year. + ``(iii) Class independence fund reserves.--At + such time as the CLASS program has been in + operation for 10 years, the Secretary shall + establish all premiums to be paid by enrollees for + the year based on an actuarial analysis that + accumulated reserves in the CLASS Independence + Fund would not decrease in that year. At such + time <<NOTE: Determination.>> as the Secretary + determines the CLASS program demonstrates a + sustained ability to finance expected yearly + expenses with expected yearly premiums and + interest credited to the CLASS Independence Fund, + the Secretary may decrease the required amount of + CLASS Independence Fund reserves. + ``(B) Vesting period.--A 5-year vesting period for + eligibility for benefits. + ``(C) Benefit triggers.--A benefit trigger for + provision of benefits that requires a determination that + an individual has a functional limitation, as certified + by a licensed health care practitioner, described in any + of the following clauses that is expected to last for a + continuous period of more than 90 days: + ``(i) The individual is determined to be + unable to perform at least the minimum number + (which may be 2 or 3) of activities of daily + living as are required under the plan for the + provision of benefits without substantial + assistance (as defined by the Secretary) from + another individual. + ``(ii) The individual requires substantial + supervision to protect the individual from threats + to health and safety due to substantial cognitive + impairment. + ``(iii) <<NOTE: Regulations.>> The individual + has a level of functional limitation similar (as + determined under regulations prescribed by the + Secretary) to the level of functional limitation + described in clause (i) or (ii). + ``(D) Cash benefit.--Payment of a cash benefit that + satisfies the following requirements: + ``(i) Minimum required amount.--The benefit + amount provides an eligible beneficiary with not + less than an average of $50 per day (as determined + based on the reasonably expected distribution of + beneficiaries receiving benefits at various + benefit levels). + ``(ii) Amount scaled to functional ability.-- + The benefit amount is varied based on a scale of + functional ability, with not less than 2, and not + more than 6, benefit level amounts. + ``(iii) Daily or weekly.--The benefit is paid + on a daily or weekly basis. + ``(iv) No lifetime or aggregate limit.--The + benefit is not subject to any lifetime or + aggregate limit. + +[[Page 124 STAT. 832]] + + ``(E) Coordination with supplemental coverage + obtained through the exchange.--The benefits allow for + coordination with any supplemental coverage purchased + through an Exchange established under section 1311 of + the Patient Protection and Affordable Care Act. + ``(2) Review and recommendation by the class independence + advisory council.--The CLASS Independence Advisory Council + shall-- + ``(A) evaluate the alternative benefit plans + developed under paragraph (1); and + ``(B) recommend for designation as the CLASS + Independence Benefit Plan for offering to the public the + plan that the Council determines best balances price and + benefits to meet enrollees' needs in an actuarially + sound manner, while optimizing the probability of the + long-term sustainability of the CLASS program. + ``(3) Designation by the secretary.--Not + later <<NOTE: Deadline.>> than October 1, 2012, the Secretary, + taking into consideration the recommendation of the CLASS + Independence Advisory Council under paragraph (2)(B), shall + designate a benefit plan as the CLASS Independence Benefit + Plan. <<NOTE: Publication. Regulations. Public information.>> + The Secretary shall publish such designation, along with details + of the plan and the reasons for the selection by the Secretary, + in a final rule that allows for a period of public comment. + + ``(b) Additional Premium Requirements.-- + ``(1) Adjustment of premiums.-- + ``(A) In general.--Except as provided in + subparagraphs (B), (C), (D), and (E), the amount of the + monthly premium determined for an individual upon such + individual's enrollment in the CLASS program shall + remain the same for as long as the individual is an + active enrollee in the program. + ``(B) Recalculated premium if required for program + solvency.-- + ``(i) <<NOTE: Determination.>> In general.-- + Subject to clause (ii), if the Secretary + determines, based on the most recent report of the + Board of Trustees of the CLASS Independence Fund, + the advice of the CLASS Independence Advisory + Council, and the annual report of the Inspector + General of the Department of Health and Human + Services, and waste, fraud, and abuse, or such + other information as the Secretary determines + appropriate, that the monthly premiums and income + to the CLASS Independence Fund for a year are + projected to be insufficient with respect to the + 20-year period that begins with that year, the + Secretary shall adjust the monthly premiums for + individuals enrolled in the CLASS program as + necessary (but maintaining a nominal premium for + enrollees whose income is below the poverty line + or who are full-time students actively employed). + ``(ii) Exemption from increase.--Any increase + in a monthly premium imposed as result of a + determination described in clause (i) shall not + apply with respect to the monthly premium of any + active enrollee who-- + ``(I) has attained age 65; + +[[Page 124 STAT. 833]] + + ``(II) has paid premiums for + enrollment in the program for at least + 20 years; and + ``(III) is not actively employed. + ``(C) Recalculated premium if reenrollment after + more than a 3-month lapse.-- + ``(i) In general.--The reenrollment of an + individual after a 90-day period during which the + individual failed to pay the monthly premium + required to maintain the individual's enrollment + in the CLASS program shall be treated as an + initial enrollment for purposes of age-adjusting + the premium for enrollment in the program. + ``(ii) Credit for prior months if reenrolled + within 5 years.--An individual who reenrolls in + the CLASS program after such a 90-day period and + before the end of the 5-year period that begins + with the first month for which the individual + failed to pay the monthly premium required to + maintain the individual's enrollment in the + program shall be-- + ``(I) credited with any months of + paid premiums that accrued prior to the + individual's lapse in enrollment; and + ``(II) notwithstanding the total + amount of any such credited months, + required to satisfy section + 3202(6)(A)(ii) before being eligible to + receive benefits. + ``(D) No longer status as a full-time student.--An + individual subject to a nominal premium on the basis of + being described in subsection (a)(1)(A)(ii)(I)(bb) who + ceases to be described in that subsection, beginning + with the first month following the month in which the + individual ceases to be so described, shall be subject + to the same monthly premium as the monthly premium that + applies to an individual of the same age who first + enrolls in the program under the most similar + circumstances as the individual (such as the first year + of eligibility for enrollment in the program or in a + subsequent year). + ``(E) Penalty for reenollment after 5-year lapse.-- + In the case of an individual who reenrolls in the CLASS + program after the end of the 5-year period described in + subparagraph (C)(ii), the monthly premium required for + the individual shall be the age-adjusted premium that + would be applicable to an initially enrolling individual + who is the same age as the reenrolling individual, + increased by the greater of-- + ``(i) an amount that the Secretary determines + is actuarially sound for each month that occurs + during the period that begins with the first month + for which the individual failed to pay the monthly + premium required to maintain the individual's + enrollment in the CLASS program and ends with the + month preceding the month in which the reenollment + is effective; or + ``(ii) 1 percent of the applicable age- + adjusted premium for each such month occurring in + such period. + ``(2) Administrative expenses.--In determining the monthly + premiums for the CLASS program the Secretary may + +[[Page 124 STAT. 834]] + + factor in costs for administering the program, not to exceed for + any year in which the program is in effect under this title, an + amount equal to 3 percent of all premiums paid during the year. + ``(3) No underwriting requirements.--No underwriting (other + than on the basis of age in accordance with subparagraphs (D) + and (E) of paragraph (1)) shall be used to-- + ``(A) determine the monthly premium for enrollment + in the CLASS program; or + ``(B) prevent an individual from enrolling in the + program. + + ``(c) <<NOTE: Procedures.>> Self-attestation and Verification of +Income.--The Secretary shall establish procedures to-- + ``(1) permit an individual who is eligible for the nominal + premium required under subsection (a)(1)(A)(ii), as part of + their automatic enrollment in the CLASS program, to self-attest + that their income does not exceed the poverty line or that their + status as a full-time student who is actively employed; + ``(2) verify, using procedures similar to the procedures + used by the Commissioner of Social Security under section + 1631(e)(1)(B)(ii) of the Social Security Act and consistent with + the requirements applicable to the conveyance of data and + information under section 1942 of such Act, the validity of such + self-attestation; and + ``(3) require an individual to confirm, on at least an + annual basis, that their income does not exceed the poverty line + or that they continue to maintain such status. + +``SEC. 3204. <<NOTE: 42 USC 300ll-3.>> ENROLLMENT AND DISENROLLMENT + REQUIREMENTS. + + ``(a) <<NOTE: Procedures.>> Automatic Enrollment.-- + ``(1) In general.--Subject to paragraph (2), the Secretary, + in coordination with the Secretary of the Treasury, shall + establish procedures under which each individual described in + subsection (c) may be automatically enrolled in the CLASS + program by an employer of such individual in the same manner as + an employer may elect to automatically enroll employees in a + plan under section 401(k), 403(b), or 457 of the Internal + Revenue Code of 1986. + ``(2) Alternative enrollment procedures.--The procedures + established under paragraph (1) shall provide for an alternative + enrollment process for an individual described in subsection (c) + in the case of such an individual-- + ``(A) who is self-employed; + ``(B) who has more than 1 employer; or + ``(C) whose employer does not elect to participate + in the automatic enrollment process established by the + Secretary. + ``(3) Administration.-- + ``(A) <<NOTE: Regulations.>> In general.--The + Secretary and the Secretary of the Treasury shall, by + regulation, establish procedures to ensure that an + individual is not automatically enrolled in the CLASS + program by more than 1 employer. + ``(B) Form.--Enrollment in the CLASS program shall + be made in such manner as the Secretary may prescribe in + order to ensure ease of administration. + + ``(b) Election to Opt-Out.--An individual described in subsection +(c) may elect to waive enrollment in the CLASS program + +[[Page 124 STAT. 835]] + +at any time in such form and manner as the Secretary and the Secretary +of the Treasury shall prescribe. + ``(c) Individual Described.--For purposes of enrolling in the CLASS +program, an individual described in this paragraph is an individual-- + ``(1) who has attained age 18; + ``(2) who-- + ``(A) receives wages on which there is imposed a tax + under section 3201(a) of the Internal Revenue Code of + 1986; or + ``(B) derives self-employment income on which there + is imposed a tax under section 1401(a) of the Internal + Revenue Code of 1986; + ``(3) who is actively employed; and + ``(4) who is not-- + ``(A) a patient in a hospital or nursing facility, + an intermediate care facility for the mentally retarded, + or an institution for mental diseases and receiving + medical assistance under Medicaid; or + ``(B) confined in a jail, prison, other penal + institution or correctional facility, or by court order + pursuant to conviction of a criminal offense or in + connection with a verdict or finding described in + section 202(x)(1)(A)(ii) of the Social Security Act (42 + U.S.C. 402(x)(1)(A)(ii)). + + ``(d) Rule of Construction.--Nothing in this title shall be +construed as requiring an active enrollee to continue to satisfy +subparagraph (B) or (C) of subsection (c)(1) in order to maintain +enrollment in the CLASS program. + ``(e) Payment.-- + ``(1) Payroll deduction.--An amount equal to the monthly + premium for the enrollment in the CLASS program of an individual + shall be deducted from the wages or self-employment income of + such individual in accordance with such procedures as the + Secretary, in coordination with the Secretary of the Treasury, + shall establish for employers who elect to deduct and withhold + such premiums on behalf of enrolled employees. + ``(2) Alternative payment mechanism.--The Secretary, in + coordination with the Secretary of the Treasury, shall establish + alternative procedures for the payment of monthly premiums by an + individual enrolled in the CLASS program-- + ``(A) who does not have an employer who elects to + deduct and withhold premiums in accordance with + subparagraph (A); or + ``(B) who does not earn wages or derive self- + employment income. + + ``(f) Transfer of Premiums Collected.-- + ``(1) In general.--During each calendar year the Secretary + of the Treasury shall deposit into the CLASS Independence Fund a + total amount equal, in the aggregate, to 100 percent of the + premiums collected during that year. + ``(2) Transfers based on estimates.--The amount deposited + pursuant to paragraph (1) shall be transferred in at least + monthly payments to the CLASS Independence Fund on the basis of + estimates by the Secretary and certified to the Secretary of the + Treasury of the amounts collected in accordance with + subparagraphs (A) and (B) of paragraph (5). Proper adjustments + shall be made in amounts subsequently transferred to + +[[Page 124 STAT. 836]] + + the Fund to the extent prior estimates were in excess of, or + were less than, actual amounts collected. + + ``(g) Other Enrollment and Disenrollment Opportunities.--The +Secretary, <<NOTE: Procedures.>> in coordination with the Secretary of +the Treasury, shall establish procedures under which-- + ``(1) an individual who, in the year of the individual's + initial eligibility to enroll in the CLASS program, has elected + to waive enrollment in the program, is eligible to elect to + enroll in the program, in such form and manner as the + Secretaries shall establish, only during an open enrollment + period established by the Secretaries that is specific to the + individual and that may not occur more frequently than + biennially after the date on which the individual first elected + to waive enrollment in the program; and + ``(2) an individual shall only be permitted to disenroll + from the program (other than for nonpayment of premiums) during + an annual disenrollment period established by the Secretaries + and in such form and manner as the Secretaries shall establish. + +``SEC. 3205. <<NOTE: 42 USC 300ll-4.>> BENEFITS. + + ``(a) Determination of Eligibility.-- + ``(1) Application for receipt of benefits.--The Secretary + shall establish procedures under which an active enrollee shall + apply for receipt of benefits under the CLASS Independence + Benefit Plan. + ``(2) Eligibility assessments.-- + ``(A) In general.--Not + later <<NOTE: Deadline. Contracts.>> than January 1, + 2012, the Secretary shall-- + ``(i) establish an Eligibility Assessment + System (other than a service with which the + Commissioner of Social Security has entered into + an agreement, with respect to any State, to make + disability determinations for purposes of title II + or XVI of the Social Security Act) to provide for + eligibility assessments of active enrollees who + apply for receipt of benefits; + ``(ii) enter into an agreement with the + Protection and Advocacy System for each State to + provide advocacy services in accordance with + subsection (d); and + ``(iii) enter into an agreement with public + and private entities to provide advice and + assistance counseling in accordance with + subsection (e). + ``(B) Regulations.--The Secretary shall promulgate + regulations to develop an expedited nationally equitable + eligibility determination process, as certified by a + licensed health care practitioner, an appeals process, + and a redetermination process, as certified by a + licensed health care practitioner, including whether an + active enrollee is eligible for a cash benefit under the + program and if so, the amount of the cash benefit (in + accordance the sliding scale established under the + plan). + ``(C) Presumptive eligibility for certain + institutionalized enrollees planning to discharge.--An + active enrollee shall be deemed presumptively eligible + if the enrollee-- + ``(i) has applied for, and attests is eligible + for, the maximum cash benefit available under the + sliding + +[[Page 124 STAT. 837]] + + scale established under the CLASS Independence + Benefit Plan; + ``(ii) is a patient in a hospital (but only if + the hospitalization is for long-term care), + nursing facility, intermediate care facility for + the mentally retarded, or an institution for + mental diseases; and + ``(iii) <<NOTE: Deadline.>> is in the process + of, or about to begin the process of, planning to + discharge from the hospital, facility, or + institution, or within 60 days from the date of + discharge from the hospital, facility, or + institution. + ``(D) Appeals.--The Secretary <<NOTE: Procedures.>> + shall establish procedures under which an applicant for + benefits under the CLASS Independence Benefit Plan shall + be guaranteed the right to appeal an adverse + determination. + + ``(b) Benefits.--An eligible beneficiary shall receive the following +benefits under the CLASS Independence Benefit Plan: + ``(1) Cash benefit.--A cash benefit established by the + Secretary in accordance with the requirements of section + 3203(a)(1)(D) that-- + ``(A) the first year in which beneficiaries receive + the benefits under the plan, is not less than the + average dollar amount specified in clause (i) of such + section; and + ``(B) for any subsequent year, is not less than the + average per day dollar limit applicable under this + subparagraph for the preceding year, increased by the + percentage increase in the consumer price index for all + urban consumers (U.S. city average) over the previous + year. + ``(2) Advocacy services.--Advocacy services in accordance + with subsection (d). + ``(3) Advice and assistance counseling.--Advice and + assistance counseling in accordance with subsection (e). + ``(4) Administrative expenses.--Advocacy services and advise + and assistance counseling services under paragraphs (2) and (3) + of this subsection shall be included as administrative expenses + under section 3203(b)(3). + + ``(c) Payment of Benefits.-- + ``(1) Life independence account.-- + ``(A) In general.--The + Secretary <<NOTE: Procedures.>> shall establish + procedures for administering the provision of benefits + to eligible beneficiaries under the CLASS Independence + Benefit Plan, including the payment of the cash benefit + for the beneficiary into a Life Independence Account + established by the Secretary on behalf of each eligible + beneficiary. + ``(B) Use of cash benefits.--Cash benefits paid into + a Life Independence Account of an eligible beneficiary + shall be used to purchase nonmedical services and + supports that the beneficiary needs to maintain his or + her independence at home or in another residential + setting of their choice in the community, including (but + not limited to) home modifications, assistive + technology, accessible transportation, homemaker + services, respite care, personal assistance services, + home care aides, and nursing support. Nothing in the + preceding sentence shall prevent an eligible beneficiary + from using cash benefits paid into a Life Independence + Account for obtaining assistance with decision making + concerning medical care, including the right to accept + or refuse medical or surgical treatment and the + +[[Page 124 STAT. 838]] + + right to formulate advance directives or other written + instructions recognized under State law, such as a + living will or durable power of attorney for health + care, in the case that an injury or illness causes the + individual to be unable to make health care decisions. + ``(C) <<NOTE: Procedures.>> Electronic management + of funds.--The Secretary shall establish procedures + for-- + ``(i) crediting an account established on + behalf of a beneficiary with the beneficiary's + cash daily benefit; + ``(ii) allowing the beneficiary to access such + account through debit cards; and + ``(iii) accounting for withdrawals by the + beneficiary from such account. + ``(D) Primary payor rules for beneficiaries who are + enrolled in medicaid.--In the case of an eligible + beneficiary who is enrolled in Medicaid, the following + payment rules shall apply: + ``(i) Institutionalized beneficiary.--If the + beneficiary is a patient in a hospital, nursing + facility, intermediate care facility for the + mentally retarded, or an institution for mental + diseases, the beneficiary shall retain an amount + equal to 5 percent of the beneficiary's daily or + weekly cash benefit (as applicable) (which shall + be in addition to the amount of the beneficiary's + personal needs allowance provided under Medicaid), + and the remainder of such benefit shall be applied + toward the facility's cost of providing the + beneficiary's care, and Medicaid shall provide + secondary coverage for such care. + ``(ii) Beneficiaries receiving home and + community-based services.-- + ``(I) 50 percent of benefit retained + by beneficiary.--Subject to subclause + (II), if a beneficiary is receiving + medical assistance under Medicaid for + home and community based services, the + beneficiary shall retain an amount equal + to 50 percent of the beneficiary's daily + or weekly cash benefit (as applicable), + and the remainder of the daily or weekly + cash benefit shall be applied toward the + cost to the State of providing such + assistance (and shall not be used to + claim Federal matching funds under + Medicaid), and Medicaid shall provide + secondary coverage for the remainder of + any costs incurred in providing such + assistance. + ``(II) Requirement for state + offset.--A State shall be paid the + remainder of a beneficiary's daily or + weekly cash benefit under subclause (I) + only if the State home and community- + based waiver under section 1115 of the + Social Security Act (42 U.S.C. 1315) or + subsection (c) or (d) of section 1915 of + such Act (42 U.S.C. 1396n), or the State + plan amendment under subsection (i) of + such section does not include a waiver + of the requirements of section + 1902(a)(1) of the Social Security Act + (relating to statewideness) or of + section 1902(a)(10)(B) of such Act + (relating to comparability) and the + State offers at a minimum + +[[Page 124 STAT. 839]] + + case management services, personal care + services, habilitation services, and + respite care under such a waiver or + State plan amendment. + ``(III) Definition of home and + community-based services.--In this + clause, the term `home and community- + based services' means any services which + may be offered under a home and + community-based waiver authorized for a + State under section 1115 of the Social + Security Act (42 U.S.C. 1315) or + subsection (c) or (d) of section 1915 of + such Act (42 U.S.C. 1396n) or under a + State plan amendment under subsection + (i) of such section. + ``(iii) Beneficiaries enrolled in programs of + all-inclusive care for the elderly (pace).-- + ``(I) In general.--Subject to + subclause (II), if a beneficiary is + receiving medical assistance under + Medicaid for PACE program services under + section 1934 of the Social Security Act + (42 U.S.C. 1396u-4), the beneficiary + shall retain an amount equal to 50 + percent of the beneficiary's daily or + weekly cash benefit (as applicable), and + the remainder of the daily or weekly + cash benefit shall be applied toward the + cost to the State of providing such + assistance (and shall not be used to + claim Federal matching funds under + Medicaid), and Medicaid shall provide + secondary coverage for the remainder of + any costs incurred in providing such + assistance. + ``(II) Institutionalized recipients + of pace program services.--If a + beneficiary receiving assistance under + Medicaid for PACE program services is a + patient in a hospital, nursing facility, + intermediate care facility for the + mentally retarded, or an institution for + mental diseases, the beneficiary shall + be treated as in institutionalized + beneficiary under clause (i). + ``(2) Authorized representatives.-- + ``(A) In general.--The + Secretary <<NOTE: Procedures.>> shall establish + procedures to allow access to a beneficiary's cash + benefits by an authorized representative of the eligible + beneficiary on whose behalf such benefits are paid. + ``(B) Quality assurance and protection against fraud + and abuse.--The procedures established under + subparagraph (A) shall ensure that authorized + representatives of eligible beneficiaries comply with + standards of conduct established by the Secretary, + including standards requiring that such representatives + provide quality services on behalf of such + beneficiaries, do not have conflicts of interest, and do + not misuse benefits paid on behalf of such beneficiaries + or otherwise engage in fraud or abuse. + ``(3) Commencement of benefits.--Benefits shall be paid to, + or on behalf of, an eligible beneficiary beginning with the + first month in which an application for such benefits is + approved. + ``(4) Rollover option for lump-sum payment.--An eligible + beneficiary may elect to-- + +[[Page 124 STAT. 840]] + + ``(A) defer payment of their daily or weekly benefit + and to rollover any such deferred benefits from month- + to-month, but not from year-to-year; and + ``(B) receive a lump-sum payment of such deferred + benefits in an amount that may not exceed the lesser + of-- + ``(i) the total amount of the accrued deferred + benefits; or + ``(ii) the applicable annual benefit. + ``(5) Period for determination of annual benefits.-- + ``(A) In general.--The applicable period for + determining with respect to an eligible beneficiary the + applicable annual benefit and the amount of any accrued + deferred benefits is the 12-month period that commences + with the first month in which the beneficiary began to + receive such benefits, and each 12-month period + thereafter. + ``(B) Inclusion of increased benefits.--The + Secretary shall establish procedures under which cash + benefits paid to an eligible beneficiary that increase + or decrease as a result of a change in the functional + status of the beneficiary before the end of a 12-month + benefit period shall be included in the determination of + the applicable annual benefit paid to the eligible + beneficiary. + ``(C) Recoupment of unpaid, accrued benefits.-- + ``(i) In general.--The Secretary, in + coordination with the Secretary of the Treasury, + shall recoup any accrued benefits in the event + of-- + ``(I) the death of a beneficiary; or + ``(II) the failure of a beneficiary + to elect under paragraph (4)(B) to + receive such benefits as a lump-sum + payment before the end of the 12-month + period in which such benefits accrued. + ``(ii) Payment into class independence fund.-- + Any benefits recouped in accordance with clause + (i) shall be paid into the CLASS Independence Fund + and used in accordance with section 3206. + ``(6) Requirement to recertify eligibility for receipt of + benefits.--An eligible beneficiary shall periodically, as + determined by the Secretary-- + ``(A) recertify by submission of medical evidence + the beneficiary's continued eligibility for receipt of + benefits; and + ``(B) submit records of expenditures attributable to + the aggregate cash benefit received by the beneficiary + during the preceding year. + ``(7) Supplement, not supplant other health care benefits.-- + Subject to the Medicaid payment rules under paragraph (1)(D), + benefits received by an eligible beneficiary shall supplement, + but not supplant, other health care benefits for which the + beneficiary is eligible under Medicaid or any other Federally + funded program that provides health care benefits or assistance. + + ``(d) <<NOTE: Contracts.>> Advocacy Services.--An agreement entered +into under subsection (a)(2)(A)(ii) shall require the Protection and +Advocacy System for the State to-- + ``(1) assign, as needed, an advocacy counselor to each + eligible beneficiary that is covered by such agreement and who + shall provide an eligible beneficiary with-- + +[[Page 124 STAT. 841]] + + ``(A) information regarding how to access the + appeals process established for the program; + ``(B) assistance with respect to the annual + recertification and notification required under + subsection (c)(6); and + ``(C) <<NOTE: Regulations.>> such other assistance + with obtaining services as the Secretary, by regulation, + shall require; and + ``(2) ensure that the System and such counselors comply with + the requirements of subsection (h). + + ``(e) <<NOTE: Contracts.>> Advice and Assistance Counseling.--An +agreement entered into under subsection (a)(2)(A)(iii) shall require the +entity to assign, as requested by an eligible beneficiary that is +covered by such agreement, an advice and assistance counselor who shall +provide an eligible beneficiary with information regarding-- + ``(1) accessing and coordinating long-term services and + supports in the most integrated setting; + ``(2) possible eligibility for other benefits and services; + ``(3) development of a service and support plan; + ``(4) information about programs established under the + Assistive Technology Act of 1998 and the services offered under + such programs; + ``(5) available assistance with decision making concerning + medical care, including the right to accept or refuse medical or + surgical treatment and the right to formulate advance directives + or other written instructions recognized under State law, such + as a living will or durable power of attorney for health care, + in the case that an injury or illness causes the individual to + be unable to make health care decisions; and + ``(6) such other services as the Secretary, by regulation, + may require. + + ``(f) No Effect on Eligibility for Other Benefits.--Benefits paid to +an eligible beneficiary under the CLASS program shall be disregarded for +purposes of determining or continuing the beneficiary's eligibility for +receipt of benefits under any other Federal, State, or locally funded +assistance program, including benefits paid under titles II, XVI, XVIII, +XIX, or XXI of the Social Security Act (42 U.S.C. 401 et seq., 1381 et +seq., 1395 et seq., 1396 et seq., 1397aa et seq.), under the laws +administered by the Secretary of Veterans Affairs, under low-income +housing assistance programs, or under the supplemental nutrition +assistance program established under the Food and Nutrition Act of 2008 +(7 U.S.C. 2011 et seq.). + ``(g) Rule of Construction.--Nothing in this title shall be +construed as prohibiting benefits paid under the CLASS Independence +Benefit Plan from being used to compensate a family caregiver for +providing community living assistance services and supports to an +eligible beneficiary. + ``(h) <<NOTE: Procedures.>> Protection Against Conflict of +Interests.--The Secretary shall establish procedures to ensure that the +Eligibility Assessment System, the Protection and Advocacy System for a +State, advocacy counselors for eligible beneficiaries, and any other +entities that provide services to active enrollees and eligible +beneficiaries under the CLASS program comply with the following: + ``(1) If the entity provides counseling or planning + services, such services are provided in a manner that fosters + the best interests of the active enrollee or beneficiary. + +[[Page 124 STAT. 842]] + + ``(2) The entity has established operating procedures that + are designed to avoid or minimize conflicts of interest between + the entity and an active enrollee or beneficiary. + ``(3) The entity provides information about all services and + options available to the active enrollee or beneficiary, to the + best of its knowledge, including services available through + other entities or providers. + ``(4) The entity assists the active enrollee or beneficiary + to access desired services, regardless of the provider. + ``(5) The entity reports the number of active enrollees and + beneficiaries provided with assistance by age, disability, and + whether such enrollees and beneficiaries received services from + the entity or another entity. + ``(6) If the entity provides counseling or planning + services, the entity ensures that an active enrollee or + beneficiary is informed of any financial interest that the + entity has in a service provider. + ``(7) The entity provides an active enrollee or beneficiary + with a list of available service providers that can meet the + needs of the active enrollee or beneficiary. + +``SEC. 3206. <<NOTE: 42 USC 300ll-5.>> CLASS INDEPENDENCE FUND. + + ``(a) Establishment of CLASS Independence Fund.--There is +established in the Treasury of the United States a trust fund to be +known as the `CLASS Independence Fund'. The Secretary of the Treasury +shall serve as Managing Trustee of such Fund. The Fund shall consist of +all amounts derived from payments into the Fund under sections 3204(f) +and 3205(c)(5)(C)(ii), and remaining after investment of such amounts +under subsection (b), including additional amounts derived as income +from such investments. The amounts held in the Fund are appropriated and +shall remain available without fiscal year limitation-- + ``(1) to be held for investment on behalf of individuals + enrolled in the CLASS program; + ``(2) to pay the administrative expenses related to the Fund + and to investment under subsection (b); and + ``(3) to pay cash benefits to eligible beneficiaries under + the CLASS Independence Benefit Plan. + + ``(b) Investment of Fund Balance.--The Secretary of the Treasury +shall invest and manage the CLASS Independence Fund in the same manner, +and to the same extent, as the Federal Supplementary Medical Insurance +Trust Fund may be invested and managed under subsections (c), (d), and +(e) of section 1841(d) of the Social Security Act (42 U.S.C. 1395t). + ``(c) Board of Trustees.-- + ``(1) <<NOTE: Establishment.>> In general.--With respect to + the CLASS Independence Fund, there is hereby created a body to + be known as the Board of Trustees of the CLASS Independence Fund + (hereinafter in this section referred to as the `Board of + Trustees') composed of the Secretary of the Treasury, the + Secretary of Labor, and the Secretary of Health and Human + Services, all ex officio, and of two members of the public (both + of whom may not be from the same political party), who shall be + nominated by the President for a term of 4 years and subject to + confirmation by the Senate. A member of the Board of Trustees + serving as a member of the public and nominated and confirmed to + fill a vacancy occurring during a term shall + +[[Page 124 STAT. 843]] + + be nominated and confirmed only for the remainder of such term. + An individual nominated and confirmed as a member of the public + may serve in such position after the expiration of such member's + term until the earlier of the time at which the member's + successor takes office or the time at which a report of the + Board is first issued under paragraph (2) after the expiration + of the member's term. The Secretary of the Treasury shall be the + Managing Trustee of the Board of Trustees. The Board of Trustees + shall meet not less frequently than once each calendar year. A + person serving on the Board of Trustees shall not be considered + to be a fiduciary and shall not be personally liable for actions + taken in such capacity with respect to the Trust Fund. + ``(2) Duties.-- + ``(A) In general.--It shall be the duty of the Board + of Trustees to do the following: + ``(i) Hold the CLASS Independence Fund. + ``(ii) <<NOTE: Reports. Deadline.>> Report to + the Congress not later than the first day of April + of each year on the operation and status of the + CLASS Independence Fund during the preceding + fiscal year and on its expected operation and + status during the current fiscal year and the next + 2 fiscal years. + ``(iii) <<NOTE: Reports.>> Report immediately + to the Congress whenever the Board is of the + opinion that the amount of the CLASS Independence + Fund is not actuarially sound in regards to the + projection under section 3203(b)(1)(B)(i). + ``(iv) Review the general policies followed in + managing the CLASS Independence Fund, and + recommend changes in such policies, including + necessary changes in the provisions of law which + govern the way in which the CLASS Independence + Fund is to be managed. + ``(B) Report.--The report provided for in + subparagraph (A)(ii) shall-- + ``(i) include-- + ``(I) a statement of the assets of, + and the disbursements made from, the + CLASS Independence Fund during the + preceding fiscal year; + ``(II) an estimate of the expected + income to, and disbursements to be made + from, the CLASS Independence Fund during + the current fiscal year and each of the + next 2 fiscal years; + ``(III) a statement of the actuarial + status of the CLASS Independence Fund + for the current fiscal year, each of the + next 2 fiscal years, and as projected + over the 75-year period beginning with + the current fiscal year; and + ``(IV) an actuarial opinion by the + Chief Actuary of the Centers for + Medicare & Medicaid Services certifying + that the techniques and methodologies + used are generally accepted within the + actuarial profession and that the + assumptions and cost estimates used are + reasonable; and + ``(ii) <<NOTE: Publication.>> be printed as a + House document of the session of the Congress to + which the report is made. + +[[Page 124 STAT. 844]] + + ``(C) <<NOTE: Determination.>> Recommendations.--If + the Board of Trustees determines that enrollment trends + and expected future benefit claims on the CLASS + Independence Fund are not actuarially sound in regards + to the projection under section 3203(b)(1)(B)(i) and are + unlikely to be resolved with reasonable premium + increases or through other means, the Board of Trustees + shall include in the report provided for in subparagraph + (A)(ii) recommendations for such legislative action as + the Board of Trustees determine to be appropriate, + including whether to adjust monthly premiums or impose a + temporary moratorium on new enrollments. + +``SEC. 3207. <<NOTE: 42 USC 300ll-6.>> CLASS INDEPENDENCE ADVISORY + COUNCIL. + + ``(a) Establishment.--There is hereby created an Advisory Committee +to be known as the `CLASS Independence Advisory Council'. + ``(b) Membership.-- + ``(1) In general.--The CLASS Independence Advisory Council + shall be composed of not more than 15 individuals, not otherwise + in the employ of the United States-- + ``(A) <<NOTE: Appointment. President.>> who shall + be appointed by the President without regard to the + civil service laws and regulations; and + ``(B) a majority of whom shall be representatives of + individuals who participate or are likely to participate + in the CLASS program, and shall include representatives + of older and younger workers, individuals with + disabilities, family caregivers of individuals who + require services and supports to maintain their + independence at home or in another residential setting + of their choice in the community, individuals with + expertise in long-term care or disability insurance, + actuarial science, economics, and other relevant + disciplines, as determined by the Secretary. + ``(2) Terms.-- + ``(A) In general.--The members of the CLASS + Independence Advisory Council shall serve overlapping + terms of 3 years (unless appointed to fill a vacancy + occurring prior to the expiration of a term, in which + case the individual shall serve for the remainder of the + term). + ``(B) Limitation.--A member shall not be eligible to + serve for more than 2 consecutive terms. + ``(3) <<NOTE: President. Appointment.>> Chair.--The + President shall, from time to time, appoint one of the members + of the CLASS Independence Advisory Council to serve as the + Chair. + + ``(c) Duties.--The CLASS Independence Advisory Council shall advise +the Secretary on matters of general policy in the administration of the +CLASS program established under this title and in the formulation of +regulations under this title including with respect to-- + ``(1) the development of the CLASS Independence Benefit Plan + under section 3203; + ``(2) the determination of monthly premiums under such plan; + and + ``(3) the financial solvency of the program. + + ``(d) Application of FACA.--The Federal Advisory Committee Act (5 +U.S.C. App.), other than section 14 of that Act, shall apply to the +CLASS Independence Advisory Council. + ``(e) Authorization of Appropriations.-- + +[[Page 124 STAT. 845]] + + ``(1) In general.--There are authorized to be appropriated + to the CLASS Independence Advisory Council to carry out its + duties under this section, such sums as may be necessary for + fiscal year 2011 and for each fiscal year thereafter. + ``(2) Availability.--Any sums appropriated under the + authorization contained in this section shall remain available, + without fiscal year limitation, until expended. + +``SEC. 3208. <<NOTE: 42 USC 300ll-7.>> SOLVENCY AND FISCAL + INDEPENDENCE; REGULATIONS; ANNUAL REPORT. + + ``(a) <<NOTE: Consultation.>> Solvency.--The Secretary shall +regularly consult with the Board of Trustees of the CLASS Independence +Fund and the CLASS Independence Advisory Council, for purposes of +ensuring that enrollees premiums are adequate to ensure the financial +solvency of the CLASS program, both with respect to fiscal years +occurring in the near-term and fiscal years occurring over 20- and 75- +year periods, taking into account the projections required for such +periods under subsections (a)(1)(A)(i) and (b)(1)(B)(i) of section 3202. + + ``(b) No Taxpayer Funds Used To Pay Benefits.--No taxpayer funds +shall be used for payment of benefits under a CLASS Independent Benefit +Plan. <<NOTE: Definitions.>> For purposes of this subsection, the term +`taxpayer funds' means any Federal funds from a source other than +premiums deposited by CLASS program participants in the CLASS +Independence Fund and any associated interest earnings. + + ``(c) Regulations.--The Secretary shall promulgate such regulations +as are necessary to carry out the CLASS program in accordance with this +title. Such regulations shall include provisions to prevent fraud and +abuse under the program. + ``(d) <<NOTE: Effective date.>> Annual Report.--Beginning January +1, 2014, the Secretary shall submit an annual report to Congress on the +CLASS program. Each report shall include the following: + ``(1) The total number of enrollees in the program. + ``(2) The total number of eligible beneficiaries during the + fiscal year. + ``(3) The total amount of cash benefits provided during the + fiscal year. + ``(4) A description of instances of fraud or abuse + identified during the fiscal year. + ``(5) Recommendations for such administrative or legislative + action as the Secretary determines is necessary to improve the + program, ensure the solvency of the program, or to prevent the + occurrence of fraud or abuse. + +``SEC. 3209. <<NOTE: 42 USC 300ll-8.>> INSPECTOR GENERAL'S REPORT. + + ``The Inspector General of the Department of Health and Human +Services shall submit an annual report to the Secretary and Congress +relating to the overall progress of the CLASS program and of the +existence of waste, fraud, and abuse in the CLASS program. Each such +report shall include findings in the following areas: + ``(1) The eligibility determination process. + ``(2) The provision of cash benefits. + ``(3) Quality assurance and protection against waste, fraud, + and abuse. + ``(4) Recouping of unpaid and accrued benefits. + +[[Page 124 STAT. 846]] + +``SEC. 3210. <<NOTE: 42 USC 300ll-9.>> TAX TREATMENT OF PROGRAM. + + ``The CLASS program shall be treated for purposes of the Internal +Revenue Code of 1986 in the same manner as a qualified long-term care +insurance contract for qualified long-term care services.''. + (2) Conforming amendments to medicaid.--Section 1902(a) of + the Social Security Act (42 U.S.C. 1396a(a)), as amended by + section 6505, is amended by inserting after paragraph (80) the + following: + ``(81) <<NOTE: Regulations.>> provide that the State will + comply with such regulations regarding the application of + primary and secondary payor rules with respect to individuals + who are eligible for medical assistance under this title and are + eligible beneficiaries under the CLASS program established under + title XXXII of the Public Health Service Act as the Secretary + shall establish; and''. + + (b) Assurance of Adequate Infrastructure for the Provision of +Personal Care Attendant Workers.--Section 1902(a) of the Social Security +Act (42 U.S.C. 1396a(a)), as amended by subsection (a)(2), is amended by +inserting after paragraph (81) the following: + ``(82) <<NOTE: Deadline.>> provide that, not later than 2 + years after the date of enactment of the Community Living + Assistance Services and Supports Act, each State shall-- + ``(A) assess the extent to which entities such as + providers of home care, home health services, home and + community service providers, public authorities created + to provide personal care services to individuals + eligible for medical assistance under the State plan, + and nonprofit organizations, are serving or have the + capacity to serve as fiscal agents for, employers of, + and providers of employment-related benefits for, + personal care attendant workers who provide personal + care services to individuals receiving benefits under + the CLASS program established under title XXXII of the + Public Health Service Act, including in rural and + underserved areas; + ``(B) <<NOTE: Designation.>> designate or create + such entities to serve as fiscal agents for, employers + of, and providers of employment-related benefits for, + such workers to ensure an adequate supply of the workers + for individuals receiving benefits under the CLASS + program, including in rural and underserved areas; and + ``(C) ensure that the designation or creation of + such entities will not negatively alter or impede + existing programs, models, methods, or administration of + service delivery that provide for consumer controlled or + self-directed home and community services and further + ensure that such entities will not impede the ability of + individuals to direct and control their home and + community services, including the ability to select, + manage, dismiss, co-employ, or employ such workers or + inhibit such individuals from relying on family members + for the provision of personal care services.''. + + (c) <<NOTE: 42 USC 300ll note.>> Personal Care Attendants Workforce +Advisory Panel.-- + (1) <<NOTE: Deadline.>> Establishment.--Not later than 90 + days after the date of enactment of this Act, the Secretary of + Health and Human Services shall establish a Personal Care + Attendants Workforce + +[[Page 124 STAT. 847]] + + Advisory Panel for the purpose of examining and advising the + Secretary and Congress on workforce issues related to personal + care attendant workers, including with respect to the adequacy + of the number of such workers, the salaries, wages, and benefits + of such workers, and access to the services provided by such + workers. + (2) Membership.--In appointing members to the Personal Care + Attendants Workforce Advisory Panel, the Secretary shall ensure + that such members include the following: + (A) Individuals with disabilities of all ages. + (B) Senior individuals. + (C) Representatives of individuals with + disabilities. + (D) Representatives of senior individuals. + (E) Representatives of workforce and labor + organizations. + (F) Representatives of home and community-based + service providers. + (G) Representatives of assisted living providers. + + (d) Inclusion of Information on Supplemental Coverage in the +National Clearinghouse for Long-term Care Information; Extension of +Funding.--Section 6021(d) of the Deficit Reduction Act of 2005 (42 +U.S.C. 1396p note) is amended-- + (1) in paragraph (2)(A)-- + (A) in clause (ii), by striking ``and'' at the end; + (B) in clause (iii), by striking the period at the + end and inserting ``; and''; and + (C) by adding at the end the following: + ``(iv) include information regarding the CLASS + program established under title XXXII of the + Public Health Service Act and coverage available + for purchase through a Exchange established under + section 1311 of the Patient Protection and + Affordable Care Act that is supplemental coverage + to the benefits provided under a CLASS + Independence Benefit Plan under that program, and + information regarding how benefits provided under + a CLASS Independence Benefit Plan differ from + disability insurance benefits.''; and + (2) in paragraph (3), by striking ``2010'' and inserting + ``2015''. + + (e) <<NOTE: 42 USC 300ll note.>> Effective Date.--The amendments +made by subsections (a), (b), and (d) take effect on January 1, 2011. + + (f) <<NOTE: 42 USC 300ll note.>> Rule of Construction.--Nothing in +this title or the amendments made by this title are intended to replace +or displace public or private disability insurance benefits, including +such benefits that are for income replacement. + + TITLE IX--REVENUE PROVISIONS + + Subtitle A--Revenue Offset Provisions + +SEC. 9001. EXCISE TAX ON HIGH COST EMPLOYER-SPONSORED HEALTH COVERAGE. + + (a) In General.--Chapter 43 of the Internal Revenue Code of 1986, as +amended by section 1513, is amended by adding at the end the following: + +[[Page 124 STAT. 848]] + +``SEC. 4980I. <<NOTE: 26 USC 4980I.>> EXCISE TAX ON HIGH COST EMPLOYER- + SPONSORED HEALTH COVERAGE. + + ``(a) Imposition of Tax.--If-- + ``(1) an employee is covered under any applicable employer- + sponsored coverage of an employer at any time during a taxable + period, and + ``(2) there is any excess benefit with respect to the + coverage, + +there is hereby imposed a tax equal to 40 percent of the excess benefit. + ``(b) Excess Benefit.--For purposes of this section-- + ``(1) <<NOTE: Definition.>> In general.--The term `excess + benefit' means, with respect to any applicable employer- + sponsored coverage made available by an employer to an employee + during any taxable period, the sum of the excess amounts + determined under paragraph (2) for months during the taxable + period. + ``(2) Monthly excess amount.--The excess amount determined + under this paragraph for any month is the excess (if any) of-- + ``(A) the aggregate cost of the applicable employer- + sponsored coverage of the employee for the month, over + ``(B) an amount equal to \1/12\ of the annual + limitation under paragraph (3) for the calendar year in + which the month occurs. + ``(3) Annual limitation.--For purposes of this subsection-- + ``(A) In general.--The annual limitation under this + paragraph for any calendar year is the dollar limit + determined under subparagraph (C) for the calendar year. + ``(B) Applicable annual limitation.--The annual + limitation which applies for any month shall be + determined on the basis of the type of coverage (as + determined under subsection (f)(1)) provided to the + employee by the employer as of the beginning of the + month. + ``(C) Applicable dollar limit.--Except as provided + in subparagraph (D)-- + ``(i) 2013.--In the case of 2013, the dollar + limit under this subparagraph is-- + ``(I) in the case of an employee + with self-only coverage, $8,500, and + ``(II) in the case of an employee + with coverage other than self-only + coverage, $23,000. + ``(ii) Exception for certain individuals.--In + the case of an individual who is a qualified + retiree or who participates in a plan sponsored by + an employer the majority of whose employees are + engaged in a high-risk profession or employed to + repair or install electrical or telecommunications + lines-- + ``(I) the dollar amount in clause + (i)(I) (determined after the application + of subparagraph (D)) shall be increased + by $1,350, and + ``(II) the dollar amount in clause + (i)(II) (determined after the + application of subparagraph (D)) shall + be increased by $3,000. + ``(iii) Subsequent years.--In the case of any + calendar year after 2013, each of the dollar + amounts under clauses (i) and (ii) shall be + increased to the amount equal to such amount as in + effect for the + +[[Page 124 STAT. 849]] + + calendar year preceding such year, increased by an + amount equal to the product of-- + ``(I) such amount as so in effect, + multiplied by + ``(II) the cost-of-living adjustment + determined under section 1(f)(3) for + such year (determined by substituting + the calendar year that is 2 years before + such year for `1992' in subparagraph (B) + thereof), increased by 1 percentage + point. + If any amount determined under this clause is not + a multiple of $50, such amount shall be rounded to + the nearest multiple of $50. + ``(D) Transition rule for states with highest + coverage costs.-- + ``(i) In general.--If an employee is a + resident of a high cost State on the first day of + any month beginning in 2013, 2014, or 2015, the + annual limitation under this paragraph for such + month with respect to such employee shall be an + amount equal to the applicable percentage of the + annual limitation (determined without regard to + this subparagraph or subparagraph (C)(ii)). + ``(ii) Applicable percentage.--The applicable + percentage is 120 percent for 2013, 110 percent + for 2014, and 105 percent for 2015. + ``(iii) <<NOTE: Definition.>> High cost + state.--The term `high cost State' means each of + the 17 States which the Secretary of Health and + Human Services, in consultation with the + Secretary, estimates had the highest average cost + during 2012 for employer-sponsored coverage under + health plans. The Secretary's estimate shall be + made on the basis of aggregate premiums paid in + the State for such health plans, determined using + the most recent data available as of August 31, + 2012. + + ``(c) Liability To Pay Tax.-- + ``(1) In general.--Each coverage provider shall pay the tax + imposed by subsection (a) on its applicable share of the excess + benefit with respect to an employee for any taxable period. + ``(2) <<NOTE: Definitions.>> Coverage provider.--For + purposes of this subsection, the term `coverage provider' means + each of the following: + ``(A) Health insurance coverage.--If the applicable + employer-sponsored coverage consists of coverage under a + group health plan which provides health insurance + coverage, the health insurance issuer. + ``(B) HSA and msa contributions.--If the applicable + employer-sponsored coverage consists of coverage under + an arrangement under which the employer makes + contributions described in subsection (b) or (d) of + section 106, the employer. + ``(C) Other coverage.--In the case of any other + applicable employer-sponsored coverage, the person that + administers the plan benefits. + ``(3) Applicable share.--For purposes of this subsection, a + coverage provider's applicable share of an excess benefit for + any taxable period is the amount which bears the same ratio to + the amount of such excess benefit as-- + +[[Page 124 STAT. 850]] + + ``(A) the cost of the applicable employer-sponsored + coverage provided by the provider to the employee during + such period, bears to + ``(B) the aggregate cost of all applicable employer- + sponsored coverage provided to the employee by all + coverage providers during such period. + ``(4) Responsibility to calculate tax and applicable + shares.-- + ``(A) In general.--Each employer shall-- + ``(i) calculate for each taxable period the + amount of the excess benefit subject to the tax + imposed by subsection (a) and the applicable share + of such excess benefit for each coverage provider, + and + ``(ii) <<NOTE: Notification.>> notify, at + such time and in such manner as the Secretary may + prescribe, the Secretary and each coverage + provider of the amount so determined for the + provider. + ``(B) Special rule for multiemployer plans.--In the + case of applicable employer-sponsored coverage made + available to employees through a multiemployer plan (as + defined in section 414(f)), the plan sponsor shall make + the calculations, and provide the notice, required under + subparagraph (A). + + ``(d) Applicable Employer-Sponsored Coverage; Cost.--For purposes of +this section-- + ``(1) Applicable employer-sponsored coverage.-- + ``(A) <<NOTE: Definitions.>> In general.--The term + `applicable employer-sponsored coverage' means, with + respect to any employee, coverage under any group health + plan made available to the employee by an employer which + is excludable from the employee's gross income under + section 106, or would be so excludable if it were + employer-provided coverage (within the meaning of such + section 106). + ``(B) Exceptions.--The term `applicable employer- + sponsored coverage' shall not include-- + ``(i) any coverage (whether through insurance + or otherwise) described in section 9832(c)(1)(A) + or for long-term care, or + ``(ii) any coverage described in section + 9832(c)(3) the payment for which is not excludable + from gross income and for which a deduction under + section 162(l) is not allowable. + ``(C) Coverage includes employee paid portion.-- + Coverage shall be treated as applicable employer- + sponsored coverage without regard to whether the + employer or employee pays for the coverage. + ``(D) Self-employed individual.--In the case of an + individual who is an employee within the meaning of + section 401(c)(1), coverage under any group health plan + providing health insurance coverage shall be treated as + applicable employer-sponsored coverage if a deduction is + allowable under section 162(l) with respect to all or + any portion of the cost of the coverage. + ``(E) Governmental plans included.--Applicable + employer-sponsored coverage shall include coverage under + any group health plan established and maintained + primarily for its civilian employees by the Government + of + +[[Page 124 STAT. 851]] + + the United States, by the government of any State or + political subdivision thereof, or by any agency or + instrumentality of any such government. + ``(2) Determination of cost.-- + ``(A) In general.--The cost of applicable employer- + sponsored coverage shall be determined under rules + similar to the rules of section 4980B(f)(4), except that + in determining such cost, any portion of the cost of + such coverage which is attributable to the tax imposed + under this section shall not be taken into account and + the amount of such cost shall be calculated separately + for self-only coverage and other coverage. In the case + of applicable employer-sponsored coverage which provides + coverage to retired employees, the plan may elect to + treat a retired employee who has not attained the age of + 65 and a retired employee who has attained the age of 65 + as similarly situated beneficiaries. + ``(B) Health fsas.--In the case of applicable + employer-sponsored coverage consisting of coverage under + a flexible spending arrangement (as defined in section + 106(c)(2)), the cost of the coverage shall be equal to + the sum of-- + ``(i) the amount of employer contributions + under any salary reduction election under the + arrangement, plus + ``(ii) the amount determined under + subparagraph (A) with respect to any reimbursement + under the arrangement in excess of the + contributions described in clause (i). + ``(C) Archer msas and hsas.--In the case of + applicable employer-sponsored coverage consisting of + coverage under an arrangement under which the employer + makes contributions described in subsection (b) or (d) + of section 106, the cost of the coverage shall be equal + to the amount of employer contributions under the + arrangement. + ``(D) Allocation on a monthly basis.--If cost is + determined on other than a monthly basis, the cost shall + be allocated to months in a taxable period on such basis + as the Secretary may prescribe. + + ``(e) Penalty for Failure To Properly Calculate Excess Benefit.-- + ``(1) In general.--If, for any taxable period, the tax + imposed by subsection (a) exceeds the tax determined under such + subsection with respect to the total excess benefit calculated + by the employer or plan sponsor under subsection (c)(4)-- + ``(A) each coverage provider shall pay the tax on + its applicable share (determined in the same manner as + under subsection (c)(4)) of the excess, but no penalty + shall be imposed on the provider with respect to such + amount, and + ``(B) the employer or plan sponsor shall, in + addition to any tax imposed by subsection (a), pay a + penalty in an amount equal to such excess, plus interest + at the underpayment rate determined under section 6621 + for the period beginning on the due date for the payment + of tax imposed by subsection (a) to which the excess + relates and ending on the date of payment of the + penalty. + +[[Page 124 STAT. 852]] + + ``(2) Limitations on penalty.-- + ``(A) Penalty not to apply where failure not + discovered exercising reasonable diligence.--No penalty + shall be imposed by paragraph (1)(B) on any failure to + properly calculate the excess benefit during any period + for which it is established to the satisfaction of the + Secretary that the employer or plan sponsor neither + knew, nor exercising reasonable diligence would have + known, that such failure existed. + ``(B) Penalty not to apply to failures corrected + within 30 days.--No penalty shall be imposed by + paragraph (1)(B) on any such failure if-- + ``(i) such failure was due to reasonable cause + and not to willful neglect, and + ``(ii) such failure is corrected during the + 30-day period beginning on the 1st date that the + employer knew, or exercising reasonable diligence + would have known, that such failure existed. + ``(C) Waiver by secretary.--In the case of any such + failure which is due to reasonable cause and not to + willful neglect, the Secretary may waive part or all of + the penalty imposed by paragraph (1), to the extent that + the payment of such penalty would be excessive or + otherwise inequitable relative to the failure involved. + + ``(f) Other Definitions and Special Rules.--For purposes of this +section-- + ``(1) Coverage determinations.-- + ``(A) In general.--Except as provided in + subparagraph (B), an employee shall be treated as having + self-only coverage with respect to any applicable + employer-sponsored coverage of an employer. + ``(B) Minimum essential coverage.--An employee shall + be treated as having coverage other than self-only + coverage only if the employee is enrolled in coverage + other than self-only coverage in a group health plan + which provides minimum essential coverage (as defined in + section 5000A(f)) to the employee and at least one other + beneficiary, and the benefits provided under such + minimum essential coverage do not vary based on whether + any individual covered under such coverage is the + employee or another beneficiary. + ``(2) Qualified retiree.--The term `qualified retiree' means + any individual who-- + ``(A) is receiving coverage by reason of being a + retiree, + ``(B) has attained age 55, and + ``(C) is not entitled to benefits or eligible for + enrollment under the Medicare program under title XVIII + of the Social Security Act. + ``(3) Employees engaged in high-risk profession.--The term + `employees engaged in a high-risk profession' means law + enforcement officers (as such term is defined in section 1204 of + the Omnibus Crime Control and Safe Streets Act of 1968), + employees in fire protection activities (as such term is defined + in section 3(y) of the Fair Labor Standards Act of 1938), + individuals who provide out-of-hospital emergency medical care + (including emergency medical technicians, paramedics, and first- + responders), and individuals engaged in the construction, + +[[Page 124 STAT. 853]] + + mining, agriculture (not including food processing), forestry, + and fishing industries. Such term includes an employee who is + retired from a high-risk profession described in the preceding + sentence, if such employee satisfied the requirements of such + sentence for a period of not less than 20 years during the + employee's employment. + ``(4) Group health plan.--The term `group health plan' has + the meaning given such term by section 5000(b)(1). + ``(5) Health insurance coverage; health insurance issuer.-- + ``(A) Health insurance coverage.--The term `health + insurance coverage' has the meaning given such term by + section 9832(b)(1) (applied without regard to + subparagraph (B) thereof, except as provided by the + Secretary in regulations). + ``(B) Health insurance issuer.--The term `health + insurance issuer' has the meaning given such term by + section 9832(b)(2). + ``(6) Person that administers the plan benefits.--The term + `person that administers the plan benefits' shall include the + plan sponsor if the plan sponsor administers benefits under the + plan. + ``(7) Plan sponsor.--The term `plan sponsor' has the meaning + given such term in section 3(16)(B) of the Employee Retirement + Income Security Act of 1974. + ``(8) Taxable period.--The term `taxable period' means the + calendar year or such shorter period as the Secretary may + prescribe. The Secretary may have different taxable periods for + employers of varying sizes. + ``(9) Aggregation rules.--All employers treated as a single + employer under subsection (b), (c), (m), or (o) of section 414 + shall be treated as a single employer. + ``(10) Denial of deduction.--For denial of a deduction for + the tax imposed by this section, see section 275(a)(6). + + ``(g) Regulations.--The Secretary shall prescribe such regulations +as may be necessary to carry out this section.''. + (b) Clerical Amendment.--The table of sections for chapter 43 of +such Code, as amended by section 1513, is amended by adding at the end +the following new item: + +``Sec. 4980I. Excise tax on high cost employer-sponsored health + coverage.''. + + (c) <<NOTE: 26 USC 4980I note.>> Effective Date.--The amendments +made by this section shall apply to taxable years beginning after +December 31, 2012. + +SEC. 9002. INCLUSION OF COST OF EMPLOYER-SPONSORED HEALTH COVERAGE ON W- + 2. + + (a) In General.--Section 6051(a) of the Internal Revenue Code of +1986 <<NOTE: 26 USC 6051.>> (relating to receipts for employees) is +amended by striking ``and'' at the end of paragraph (12), by striking +the period at the end of paragraph (13) and inserting ``, and'', and by +adding after paragraph (13) the following new paragraph: + ``(14) the aggregate cost (determined under rules similar to + the rules of section 4980B(f)(4)) of applicable employer- + sponsored coverage (as defined in section 4980I(d)(1)), except + that this paragraph shall not apply to-- + ``(A) coverage to which paragraphs (11) and (12) + apply, or + +[[Page 124 STAT. 854]] + + ``(B) the amount of any salary reduction + contributions to a flexible spending arrangement (within + the meaning of section 125).''. + + (b) <<NOTE: 26 USC 6051 note.>> Effective Date.--The amendments +made by this section shall apply to taxable years beginning after +December 31, 2010. + +SEC. 9003. DISTRIBUTIONS FOR MEDICINE QUALIFIED ONLY IF FOR PRESCRIBED + DRUG OR INSULIN. + + (a) HSAs.--Subparagraph (A) of section 223(d)(2) of the Internal +Revenue Code of 1986 <<NOTE: 26 USC 223.>> is amended by adding at the +end the following: ``Such term shall include an amount paid for medicine +or a drug only if such medicine or drug is a prescribed drug (determined +without regard to whether such drug is available without a prescription) +or is insulin.''. + + (b) Archer MSAs.--Subparagraph (A) of section 220(d)(2) of the +Internal Revenue Code of 1986 <<NOTE: 26 USC 220.>> is amended by +adding at the end the following: ``Such term shall include an amount +paid for medicine or a drug only if such medicine or drug is a +prescribed drug (determined without regard to whether such drug is +available without a prescription) or is insulin.''. + + (c) Health Flexible Spending Arrangements and Health Reimbursement +Arrangements.--Section 106 of the Internal Revenue Code of +1986 <<NOTE: 26 USC 106.>> is amended by adding at the end the +following new subsection: + + ``(f) Reimbursements for Medicine Restricted to Prescribed Drugs and +Insulin.--For purposes of this section and section 105, reimbursement +for expenses incurred for a medicine or a drug shall be treated as a +reimbursement for medical expenses only if such medicine or drug is a +prescribed drug (determined without regard to whether such drug is +available without a prescription) or is insulin.''. + (d) Effective Dates.-- + (1) <<NOTE: 26 USC 220 note.>> Distributions from savings + accounts.--The amendments made by subsections (a) and (b) shall + apply to amounts paid with respect to taxable years beginning + after December 31, 2010. + (2) <<NOTE: 26 USC 106 note.>> Reimbursements.--The + amendment made by subsection (c) shall apply to expenses + incurred with respect to taxable years beginning after December + 31, 2010. + +SEC. 9004. INCREASE IN ADDITIONAL TAX ON DISTRIBUTIONS FROM HSAS AND + ARCHER MSAS NOT USED FOR QUALIFIED MEDICAL EXPENSES. + + (a) HSAs.--Section 223(f)(4)(A) of the Internal Revenue Code of 1986 +is amended by striking ``10 percent'' and inserting ``20 percent''. + (b) Archer MSAs.--Section 220(f)(4)(A) of the Internal Revenue Code +of 1986 is amended by striking ``15 percent'' and inserting ``20 +percent''. + (c) <<NOTE: 26 USC 220 note.>> Effective Date.--The amendments made +by this section shall apply to distributions made after December 31, +2010. + +SEC. 9005. LIMITATION ON HEALTH FLEXIBLE SPENDING ARRANGEMENTS UNDER + CAFETERIA PLANS. + + (a) In General.--Section 125 of the Internal Revenue Code of +1986 <<NOTE: 26 USC 125.>> is amended-- + (1) by redesignating subsections (i) and (j) as subsections + (j) and (k), respectively, and + +[[Page 124 STAT. 855]] + + (2) by inserting after subsection (h) the following new + subsection: + + ``(i) Limitation on Health Flexible Spending Arrangements.--For +purposes of this section, if a benefit is provided under a cafeteria +plan through employer contributions to a health flexible spending +arrangement, such benefit shall not be treated as a qualified benefit +unless the cafeteria plan provides that an employee may not elect for +any taxable year to have salary reduction contributions in excess of +$2,500 made to such arrangement.''. + (b) <<NOTE: 26 USC 125 note.>> Effective Date.--The amendments made +by this section shall apply to taxable years beginning after December +31, 2010. + +SEC. 9006. EXPANSION OF INFORMATION REPORTING REQUIREMENTS. + + (a) In General.--Section 6041 of the Internal Revenue Code of +1986 <<NOTE: 26 USC 6041.>> is amended by adding at the end the +following new subsections: + + ``(h) Application to Corporations.--Notwithstanding any regulation +prescribed by the Secretary before the date of the enactment of this +subsection, for purposes of this section the term `person' includes any +corporation that is not an organization exempt from tax under section +501(a). + ``(i) Regulations.--The Secretary may prescribe such regulations and +other guidance as may be appropriate or necessary to carry out the +purposes of this section, including rules to prevent duplicative +reporting of transactions.''. + (b) Payments for Property and Other Gross Proceeds.--Subsection (a) +of section 6041 of the Internal Revenue Code of 1986 is amended-- + (1) by inserting ``amounts in consideration for property,'' + after ``wages,'', + (2) by inserting ``gross proceeds,'' after ``emoluments, or + other'', and + (3) by inserting ``gross proceeds,'' after ``setting forth + the amount of such''. + + (c) Effective Date.--The amendments made by this section shall apply +to payments made after December 31, 2011. + +SEC. 9007. ADDITIONAL REQUIREMENTS FOR CHARITABLE HOSPITALS. + + (a) Requirements To Qualify as Section 501(c)(3) Charitable Hospital +Organization.--Section 501 of the Internal Revenue Code of +1986 <<NOTE: 26 USC 501.>> (relating to exemption from tax on +corporations, certain trusts, etc.) is amended by redesignating +subsection (r) as subsection (s) and by inserting after subsection (q) +the following new subsection: + + ``(r) Additional Requirements for Certain Hospitals.-- + ``(1) <<NOTE: Applicability.>> In general.--A hospital + organization to which this subsection applies shall not be + treated as described in subsection (c)(3) unless the + organization-- + ``(A) meets the community health needs assessment + requirements described in paragraph (3), + ``(B) meets the financial assistance policy + requirements described in paragraph (4), + ``(C) meets the requirements on charges described in + paragraph (5), and + ``(D) meets the billing and collection requirement + described in paragraph (6). + ``(2) Hospital organizations to which subsection applies.-- + +[[Page 124 STAT. 856]] + + ``(A) In general.--This subsection shall apply to-- + ``(i) an organization which operates a + facility which is required by a State to be + licensed, registered, or similarly recognized as a + hospital, and + ``(ii) any other organization which the + Secretary determines has the provision of hospital + care as its principal function or purpose + constituting the basis for its exemption under + subsection (c)(3) (determined without regard to + this subsection). + ``(B) Organizations with more than 1 hospital + facility.--If a hospital organization operates more than + 1 hospital facility-- + ``(i) the organization shall meet the + requirements of this subsection separately with + respect to each such facility, and + ``(ii) the organization shall not be treated + as described in subsection (c)(3) with respect to + any such facility for which such requirements are + not separately met. + ``(3) Community health needs assessments.-- + ``(A) In general.--An organization meets the + requirements of this paragraph with respect to any + taxable year only if the organization-- + ``(i) has conducted a community health needs + assessment which meets the requirements of + subparagraph (B) in such taxable year or in either + of the 2 taxable years immediately preceding such + taxable year, and + ``(ii) has adopted an implementation strategy + to meet the community health needs identified + through such assessment. + ``(B) Community health needs assessment.--A + community health needs assessment meets the requirements + of this paragraph if such community health needs + assessment-- + ``(i) takes into account input from persons + who represent the broad interests of the community + served by the hospital facility, including those + with special knowledge of or expertise in public + health, and + ``(ii) <<NOTE: Public information.>> is made + widely available to the public. + ``(4) Financial assistance policy.--An organization meets + the requirements of this paragraph if the organization + establishes the following policies: + ``(A) Financial assistance policy.--A written + financial assistance policy which includes-- + ``(i) eligibility criteria for financial + assistance, and whether such assistance includes + free or discounted care, + ``(ii) the basis for calculating amounts + charged to patients, + ``(iii) the method for applying for financial + assistance, + ``(iv) in the case of an organization which + does not have a separate billing and collections + policy, the actions the organization may take in + the event of non-payment, including collections + action and reporting to credit agencies, and + +[[Page 124 STAT. 857]] + + ``(v) measures to widely publicize the policy + within the community to be served by the + organization. + ``(B) Policy relating to emergency medical care.--A + written policy requiring the organization to provide, + without discrimination, care for emergency medical + conditions (within the meaning of section 1867 of the + Social Security Act (42 U.S.C. 1395dd)) to individuals + regardless of their eligibility under the financial + assistance policy described in subparagraph (A). + ``(5) Limitation on charges.--An organization meets the + requirements of this paragraph if the organization-- + ``(A) limits amounts charged for emergency or other + medically necessary care provided to individuals + eligible for assistance under the financial assistance + policy described in paragraph (4)(A) to not more than + the lowest amounts charged to individuals who have + insurance covering such care, and + ``(B) prohibits the use of gross charges. + ``(6) Billing and collection requirements.--An organization + meets the requirement of this paragraph only if the organization + does not engage in extraordinary collection actions before the + organization has made reasonable efforts to determine whether + the individual is eligible for assistance under the financial + assistance policy described in paragraph (4)(A). + ``(7) <<NOTE: Regulations. Guidelines.>> Regulatory + authority.--The Secretary shall issue such regulations and + guidance as may be necessary to carry out the provisions of this + subsection, including guidance relating to what constitutes + reasonable efforts to determine the eligibility of a patient + under a financial assistance policy for purposes of paragraph + (6).''. + + (b) Excise Tax for Failures To Meet Hospital Exemption +Requirements.-- + (1) In general.--Subchapter D of chapter 42 of the Internal + Revenue Code of 1986 (relating to failure by certain charitable + organizations to meet certain qualification requirements) is + amended by adding at the end the following new section: + +``SEC. 4959. <<NOTE: 26 USC 4959.>> TAXES ON FAILURES BY HOSPITAL + ORGANIZATIONS. + + ``If a hospital organization to which section 501(r) applies fails +to meet the requirement of section 501(r)(3) for any taxable year, there +is imposed on the organization a tax equal to $50,000.''. + (2) Conforming amendment.--The table of sections for + subchapter D of chapter 42 of such Code is amended by adding at + the end the following new item: + +``Sec. 4959. Taxes on failures by hospital organizations.''. + + (c) <<NOTE: 26 USC 501 note.>> Mandatory Review of Tax Exemption +for Hospitals.--The Secretary <<NOTE: Deadline.>> of the Treasury or +the Secretary's delegate shall review at least once every 3 years the +community benefit activities of each hospital organization to which +section 501(r) of the Internal Revenue Code of 1986 (as added by this +section) applies. + + (d) Additional Reporting Requirements.-- + (1) Community health needs assessments and audited financial + statements.--Section 6033(b) of the Internal Revenue Code of + 1986 <<NOTE: 26 USC 6033.>> (relating to certain organizations + described in section 501(c)(3)) is amended by striking ``and'' + at the end + +[[Page 124 STAT. 858]] + + of paragraph (14), by redesignating paragraph (15) as paragraph + (16), and by inserting after paragraph (14) the following new + paragraph: + ``(15) in the case of an organization to which the + requirements of section 501(r) apply for the taxable year-- + ``(A) a description of how the organization is + addressing the needs identified in each community health + needs assessment conducted under section 501(r)(3) and a + description of any such needs that are not being + addressed together with the reasons why such needs are + not being addressed, and + ``(B) the audited financial statements of such + organization (or, in the case of an organization the + financial statements of which are included in a + consolidated financial statement with other + organizations, such consolidated financial + statement).''. + (2) Taxes.--Section 6033(b)(10) of such Code is amended by + striking ``and'' at the end of subparagraph (B), by inserting + ``and'' at the end of subparagraph (C), and by adding at the end + the following new subparagraph: + ``(D) section 4959 (relating to taxes on failures by + hospital organizations),''. + + (e) <<NOTE: 26 USC 501 note.>> Reports.-- + (1) Report on levels of charity care.--The Secretary of the + Treasury, in consultation with the Secretary of Health and Human + Services, shall submit to the Committees on Ways and Means, + Education and Labor, and Energy and Commerce of the House of + Representatives and to the Committees on Finance and Health, + Education, Labor, and Pensions of the Senate an annual report on + the following: + (A) Information with respect to private tax-exempt, + taxable, and government-owned hospitals regarding-- + (i) levels of charity care provided, + (ii) bad debt expenses, + (iii) unreimbursed costs for services provided + with respect to means-tested government programs, + and + (iv) unreimbursed costs for services provided + with respect to non-means tested government + programs. + (B) Information with respect to private tax-exempt + hospitals regarding costs incurred for community benefit + activities. + (2) Report on trends.-- + (A) Study.--The Secretary of the Treasury, in + consultation with the Secretary of Health and Human + Services, shall conduct a study on trends in the + information required to be reported under paragraph (1). + (B) Report.--Not later than 5 years after the date + of the enactment of this Act, the Secretary of the + Treasury, in consultation with the Secretary of Health + and Human Services, shall submit a report on the study + conducted under subparagraph (A) to the Committees on + Ways and Means, Education and Labor, and Energy and + Commerce of the House of Representatives and to the + Committees on Finance and Health, Education, Labor, and + Pensions of the Senate. + + (f) <<NOTE: Applicability. 26 USC 501 note.>> Effective Dates.-- + +[[Page 124 STAT. 859]] + + (1) In general.--Except as provided in paragraphs (2) and + (3), the amendments made by this section shall apply to taxable + years beginning after the date of the enactment of this Act. + (2) Community health needs assessment.--The requirements of + section 501(r)(3) of the Internal Revenue Code of 1986, as added + by subsection (a), shall apply to taxable years beginning after + the date which is 2 years after the date of the enactment of + this Act. + (3) Excise tax.--The amendments made by subsection (b) shall + apply to failures occurring after the date of the enactment of + this Act. + +SEC. 9008. <<NOTE: 26 USC 4001 note prec.>> IMPOSITION OF ANNUAL FEE ON + BRANDED PRESCRIPTION PHARMACEUTICAL MANUFACTURERS AND + IMPORTERS. + + (a) <<NOTE: Deadlines.>> Imposition of Fee.-- + (1) In general.--Each covered entity engaged in the business + of manufacturing or importing branded prescription drugs shall + pay to the Secretary of the Treasury not later than the annual + payment date of each calendar year beginning after 2009 a fee in + an amount determined under subsection (b). + (2) <<NOTE: Definition.>> Annual payment date.--For + purposes of this section, the term ``annual payment date'' means + with respect to any calendar year the date determined by the + Secretary, but in no event later than September 30 of such + calendar year. + + (b) Determination of Fee Amount.-- + (1) In general.--With respect to each covered entity, the + fee under this section for any calendar year shall be equal to + an amount that bears the same ratio to $2,300,000,000 as-- + (A) the covered entity's branded prescription drug + sales taken into account during the preceding calendar + year, bear to + (B) the aggregate branded prescription drug sales of + all covered entities taken into account during such + preceding calendar year. + (2) Sales taken into account.--For purposes of paragraph + (1), the branded prescription drug sales taken into account + during any calendar year with respect to any covered entity + shall be determined in accordance with the following table: + + + With respect to a covered entity's + aggregate branded prescription drug The percentage of such sales + sales during the calendar year that taken into account is: + are: + + Not more than $5,000,000............. 0 percent + More than $5,000,000 but not more 10 percent + than $125,000,000. + More than $125,000,000 but not more 40 percent + than $225,000,000. + More than $225,000,000 but not more 75 percent + than $400,000,000. + More than $400,000,000............... 100 percent. + + + +[[Page 124 STAT. 860]] + + (3) Secretarial determination.--The Secretary of the + Treasury shall calculate the amount of each covered entity's fee + for any calendar year under paragraph (1). In calculating such + amount, the Secretary of the Treasury shall determine such + covered entity's branded prescription drug sales on the basis of + reports submitted under subsection (g) and through the use of + any other source of information available to the Secretary of + the Treasury. + + (c) Transfer of Fees to Medicare Part B Trust Fund.--There is hereby +appropriated to the Federal Supplementary Medical Insurance Trust Fund +established under section 1841 of the Social Security Act an amount +equal to the fees received by the Secretary of the Treasury under +subsection (a). + (d) Covered Entity.-- + (1) In general.--For purposes <<NOTE: Definition.>> of this + section, the term ``covered entity'' means any manufacturer or + importer with gross receipts from branded prescription drug + sales. + (2) Controlled groups.-- + (A) In general.--For purposes of this subsection, + all persons treated as a single employer under + subsection (a) or (b) of section 52 of the Internal + Revenue Code of 1986 or subsection (m) or (o) of section + 414 of such Code shall be treated as a single covered + entity. + (B) <<NOTE: Applicability.>> Inclusion of foreign + corporations.--For purposes of subparagraph (A), in + applying subsections (a) and (b) of section 52 of such + Code to this section, section 1563 of such Code shall be + applied without regard to subsection (b)(2)(C) thereof. + + (e) <<NOTE: Definitions.>> Branded Prescription Drug Sales.--For +purposes of this section-- + (1) In general.--The term ``branded prescription drug + sales'' means sales of branded prescription drugs to any + specified government program or pursuant to coverage under any + such program. + (2) Branded prescription drugs.-- + (A) In general.--The term ``branded prescription + drug'' means-- + (i) any prescription drug the application for + which was submitted under section 505(b) of the + Federal Food, Drug, and Cosmetic Act (21 U.S.C. + 355(b)), or + (ii) any biological product the license for + which was submitted under section 351(a) of the + Public Health Service Act (42 U.S.C. 262(a)). + (B) Prescription drug.--For purposes of subparagraph + (A)(i), the term ``prescription drug'' means any drug + which is subject to section 503(b) of the Federal Food, + Drug, and Cosmetic Act (21 U.S.C. 353(b)). + (3) Exclusion of orphan drug sales.--The term ``branded + prescription drug sales'' shall not include sales of any drug or + biological product with respect to which a credit was allowed + for any taxable year under section 45C of the Internal Revenue + Code of 1986. The preceding sentence shall not apply with + respect to any such drug or biological product after the date on + which such drug or biological product is approved by the Food + and Drug Administration for marketing for any indication other + than the treatment of the rare disease or condition with respect + to which such credit was allowed. + +[[Page 124 STAT. 861]] + + (4) Specified government program.--The term ``specified + government program'' means-- + (A) the Medicare Part D program under part D of + title XVIII of the Social Security Act, + (B) the Medicare Part B program under part B of + title XVIII of the Social Security Act, + (C) the Medicaid program under title XIX of the + Social Security Act, + (D) any program under which branded prescription + drugs are procured by the Department of Veterans + Affairs, + (E) any program under which branded prescription + drugs are procured by the Department of Defense, or + (F) the TRICARE retail pharmacy program under + section 1074g of title 10, United States Code. + + (f) Tax Treatment of Fees.--The fees imposed by this section-- + (1) <<NOTE: Applicability.>> for purposes of subtitle F of + the Internal Revenue Code of 1986, shall be treated as excise + taxes with respect to which only civil actions for refund under + procedures of such subtitle shall apply, and + (2) for purposes of section 275 of such Code, shall be + considered to be a tax described in section 275(a)(6). + + (g) Reporting Requirement.--Not later than the date determined by +the Secretary of the Treasury following the end of any calendar year, +the Secretary of Health and Human Services, the Secretary of Veterans +Affairs, and the Secretary of Defense shall report to the Secretary of +the Treasury, in such manner as the Secretary of the Treasury +prescribes, the total branded prescription drug sales for each covered +entity with respect to each specified government program under such +Secretary's jurisdiction using the following methodology: + (1) Medicare part d program.--The Secretary of Health and + Human Services shall report, for each covered entity and for + each branded prescription drug of the covered entity covered by + the Medicare Part D program, the product of-- + (A) the per-unit ingredient cost, as reported to the + Secretary of Health and Human Services by prescription + drug plans and Medicare Advantage prescription drug + plans, minus any per-unit rebate, discount, or other + price concession provided by the covered entity, as + reported to the Secretary of Health and Human Services + by the prescription drug plans and Medicare Advantage + prescription drug plans, and + (B) the number of units of the branded prescription + drug paid for under the Medicare Part D program. + (2) Medicare part b program.--The Secretary of Health and + Human Services shall report, for each covered entity and for + each branded prescription drug of the covered entity covered by + the Medicare Part B program under section 1862(a) of the Social + Security Act, the product of-- + (A) the per-unit average sales price (as defined in + section 1847A(c) of the Social Security Act) or the per- + unit Part B payment rate for a separately paid branded + prescription drug without a reported average sales + price, and + (B) the number of units of the branded prescription + drug paid for under the Medicare Part B program. + +[[Page 124 STAT. 862]] + + The Centers <<NOTE: Process.>> for Medicare and Medicaid + Services shall establish a process for determining the units and + the allocated price for purposes of this section for those + branded prescription drugs that are not separately payable or + for which National Drug Codes are not reported. + (3) Medicaid program.--The Secretary of Health and Human + Services shall report, for each covered entity and for each + branded prescription drug of the covered entity covered under + the Medicaid program, the product of-- + (A) the per-unit ingredient cost paid to pharmacies + by States for the branded prescription drug dispensed to + Medicaid beneficiaries, minus any per-unit rebate paid + by the covered entity under section 1927 of the Social + Security Act and any State supplemental rebate, and + (B) the number of units of the branded prescription + drug paid for under the Medicaid program. + (4) Department of veterans affairs programs.--The Secretary + of Veterans Affairs shall report, for each covered entity and + for each branded prescription drug of the covered entity the + total amount paid for each such branded prescription drug + procured by the Department of Veterans Affairs for its + beneficiaries. + (5) Department of defense programs and tricare.--The + Secretary of Defense shall report, for each covered entity and + for each branded prescription drug of the covered entity, the + sum of-- + (A) the total amount paid for each such branded + prescription drug procured by the Department of Defense + for its beneficiaries, and + (B) for each such branded prescription drug + dispensed under the TRICARE retail pharmacy program, the + product of-- + (i) the per-unit ingredient cost, minus any + per-unit rebate paid by the covered entity, and + (ii) the number of units of the branded + prescription drug dispensed under such program. + + (h) Secretary.--For purposes of this section, the term ``Secretary'' +includes the Secretary's delegate. + (i) <<NOTE: Publication.>> Guidance.--The Secretary of the Treasury +shall publish guidance necessary to carry out the purposes of this +section. + + (j) Application of Section.--This section shall apply to any branded +prescription drug sales after December 31, 2008. + (k) Conforming Amendment.--Section 1841(a) of the Social Security +Act <<NOTE: 42 USC 1395t.>> is amended by inserting ``or section +9008(c) of the Patient Protection and Affordable Care Act of 2009'' +after ``this part''. + +SEC. 9009. <<NOTE: 26 USC 4001 note prec. Definitions.>> IMPOSITION OF + ANNUAL FEE ON MEDICAL DEVICE MANUFACTURERS AND IMPORTERS. + + (a) <<NOTE: Deadlines.>> Imposition of Fee.-- + (1) In general.--Each covered entity engaged in the business + of manufacturing or importing medical devices shall pay to the + Secretary not later than the annual payment date of each + calendar year beginning after 2009 a fee in an amount determined + under subsection (b). + (2) Annual payment date.--For purposes of this section, the + term ``annual payment date'' means with respect to any + +[[Page 124 STAT. 863]] + + calendar year the date determined by the Secretary, but in no + event later than September 30 of such calendar year. + + (b) Determination of Fee Amount.-- + (1) In general.--With respect to each covered entity, the + fee under this section for any calendar year shall be equal to + an amount that bears the same ratio to $2,000,000,000 as-- + (A) the covered entity's gross receipts from medical + device sales taken into account during the preceding + calendar year, bear to + (B) the aggregate gross receipts of all covered + entities from medical device sales taken into account + during such preceding calendar year. + (2) Gross receipts from sales taken into account.--For + purposes of paragraph (1), the gross receipts from medical + device sales taken into account during any calendar year with + respect to any covered entity shall be determined in accordance + with the following table: + + + With respect to a covered entity's + aggregate gross receipts from medical The percentage of gross + device sales during the calendar year receipts taken into account is: + that are: + + Not more than $5,000,000............. 0 percent + More than $5,000,000 but not more 50 percent + than $25,000,000. + More than $25,000,000................ 100 percent. + + + (3) Secretarial determination.--The Secretary shall + calculate the amount of each covered entity's fee for any + calendar year under paragraph (1). In calculating such amount, + the Secretary shall determine such covered entity's gross + receipts from medical device sales on the basis of reports + submitted by the covered entity under subsection (f) and through + the use of any other source of information available to the + Secretary. + + (c) Covered Entity.-- + (1) In general.--For purposes of this section, the term + ``covered entity'' means any manufacturer or importer with gross + receipts from medical device sales. + (2) Controlled groups.-- + (A) In general.--For purposes of this subsection, + all persons treated as a single employer under + subsection (a) or (b) of section 52 of the Internal + Revenue Code of 1986 or subsection (m) or (o) of section + 414 of such Code shall be treated as a single covered + entity. + (B) <<NOTE: Applicability.>> Inclusion of foreign + corporations.--For purposes of subparagraph (A), in + applying subsections (a) and (b) of section 52 of such + Code to this section, section 1563 of such Code shall be + applied without regard to subsection (b)(2)(C) thereof. + + (d) Medical Device Sales.--For purposes of this section-- + (1) In general.--The term ``medical device sales'' means + sales for use in the United States of any medical device, other + than the sales of a medical device that-- + (A) has been classified in class II under section + 513 of the Federal Food, Drug, and Cosmetic Act (21 + U.S.C. + +[[Page 124 STAT. 864]] + + 360c) and is primarily sold to consumers at retail for + not more than $100 per unit, or + (B) has been classified in class I under such + section. + (2) United states.--For purposes of paragraph (1), the term + ``United States'' means the several States, the District of + Columbia, the Commonwealth of Puerto Rico, and the possessions + of the United States. + (3) Medical device.--For purposes of paragraph (1), the term + ``medical device'' means any device (as defined in section + 201(h) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. + 321(h))) intended for humans. + + (e) Tax Treatment of Fees.--The fees imposed by this section-- + (1) for purposes of subtitle F of the Internal Revenue Code + of 1986, shall be treated as excise taxes with respect to which + only civil actions for refund under procedures of such subtitle + shall apply, and + (2) for purposes of section 275 of such Code, shall be + considered to be a tax described in section 275(a)(6). + + (f) Reporting Requirement.-- + (1) In general.--Not later than the date determined by the + Secretary following the end of any calendar year, each covered + entity shall report to the Secretary, in such manner as the + Secretary prescribes, the gross receipts from medical device + sales of such covered entity during such calendar year. + (2) Penalty for failure to report.-- + (A) In general.--In the case of any failure to make + a report containing the information required by + paragraph (1) on the date prescribed therefor + (determined with regard to any extension of time for + filing), unless it is shown that such failure is due to + reasonable cause, there shall be paid by the covered + entity failing to file such report, an amount equal to-- + (i) $10,000, plus + (ii) the lesser of-- + (I) an amount equal to $1,000, + multiplied by the number of days during + which such failure continues, or + (II) the amount of the fee imposed + by this section for which such report + was required. + (B) Treatment of penalty.--The penalty imposed under + subparagraph (A)-- + (i) shall be treated as a penalty for purposes + of subtitle F of the Internal Revenue Code of + 1986, + (ii) <<NOTE: Notice.>> shall be paid on + notice and demand by the Secretary and in the same + manner as tax under such Code, and + (iii) <<NOTE: Applicability.>> with respect + to which only civil actions for refund under + procedures of such subtitle F shall apply. + + (g) Secretary.--For purposes of this section, the term ``Secretary'' +means the Secretary of the Treasury or the Secretary's delegate. + (h) <<NOTE: Publication.>> Guidance.--The Secretary shall publish +guidance necessary to carry out the purposes of this section, including +identification of medical devices described in subsection (d)(1)(A) and +with respect to the treatment of gross receipts from sales of medical +devices + +[[Page 124 STAT. 865]] + +to another covered entity or to another entity by reason of the +application of subsection (c)(2). + + (i) Application of Section.--This section shall apply to any medical +device sales after December 31, 2008. + +SEC. 9010. <<NOTE: 26 USC 4001 note prec.>> IMPOSITION OF ANNUAL FEE ON + HEALTH INSURANCE PROVIDERS. + + (a) <<NOTE: Deadline.>> Imposition of Fee.-- + (1) In general.--Each covered entity engaged in the business + of providing health insurance shall pay to the Secretary not + later than the annual payment date of each calendar year + beginning after 2009 a fee in an amount determined under + subsection (b). + (2) <<NOTE: Definition.>> Annual payment date.--For + purposes of this section, the term ``annual payment date'' means + with respect to any calendar year the date determined by the + Secretary, but in no event later than September 30 of such + calendar year. + + (b) Determination of Fee Amount.-- + (1) In general.--With respect to each covered entity, the + fee under this section for any calendar year shall be equal to + an amount that bears the same ratio to $6,700,000,000 as-- + (A) the sum of-- + (i) the covered entity's net premiums written + with respect to health insurance for any United + States health risk that are taken into account + during the preceding calendar year, plus + (ii) 200 percent of the covered entity's third + party administration agreement fees that are taken + into account during the preceding calendar year, + bears to + (B) the sum of-- + (i) the aggregate net premiums written with + respect to such health insurance of all covered + entities that are taken into account during such + preceding calendar year, plus + (ii) 200 percent of the aggregate third party + administration agreement fees of all covered + entities that are taken into account during such + preceding calendar year. + (2) Amounts taken into account.--For purposes of paragraph + (1)-- + (A) Net premiums written.--The net premiums written + with respect to health insurance for any United States + health risk that are taken into account during any + calendar year with respect to any covered entity shall + be determined in accordance with the following table: + + + With respect to a covered entity's net The percentage of net premiums + premiums written during the calendar written that are taken into + year that are: account is: + + Not more than $25,000,000............ 0 percent + More than $25,000,000 but not more 50 percent + than $50,000,000. + More than $50,000,000................ 100 percent. + + + +[[Page 124 STAT. 866]] + + (B) Third party administration agreement fees.--The + third party administration agreement fees that are taken + into account during any calendar year with respect to + any covered entity shall be determined in accordance + with the following table: + + + With respect to a covered entity's The percentage of third party + third party administration agreement administration agreement fees +fees during the calendar year that are: that are taken into account is: + + Not more than $5,000,000............. 0 percent + More than $5,000,000 but not more 50 percent + than $10,000,000. + More than $10,000,000................ 100 percent. + + + (3) Secretarial determination.--The Secretary shall + calculate the amount of each covered entity's fee for any + calendar year under paragraph (1). In calculating such amount, + the Secretary shall determine such covered entity's net premiums + written with respect to any United States health risk and third + party administration agreement fees on the basis of reports + submitted by the covered entity under subsection (g) and through + the use of any other source of information available to the + Secretary. + + (c) Covered Entity.-- + (1) <<NOTE: Definition.>> In general.--For purposes of this + section, the term ``covered entity'' means any entity which + provides health insurance for any United States health risk. + (2) Exclusion.--Such term does not include-- + (A) any employer to the extent that such employer + self-insures its employees' health risks, or + (B) any governmental entity (except to the extent + such an entity provides health insurance coverage + through the community health insurance option under + section 1323). + (3) Controlled groups.-- + (A) In general.--For purposes of this subsection, + all persons treated as a single employer under + subsection (a) or (b) of section 52 of the Internal + Revenue Code of 1986 or subsection (m) or (o) of section + 414 of such Code shall be treated as a single covered + entity (or employer for purposes of paragraph (2)). + (B) <<NOTE: Applicability.>> Inclusion of foreign + corporations.--For purposes of subparagraph (A), in + applying subsections (a) and (b) of section 52 of such + Code to this section, section 1563 of such Code shall be + applied without regard to subsection (b)(2)(C) thereof. + + (d) <<NOTE: Definition.>> United States Health Risk.--For purposes +of this section, the term ``United States health risk'' means the health +risk of any individual who is-- + (1) a United States citizen, + (2) a resident of the United States (within the meaning of + section 7701(b)(1)(A) of the Internal Revenue Code of 1986), or + (3) located in the United States, with respect to the period + such individual is so located. + +[[Page 124 STAT. 867]] + + (e) <<NOTE: Definition.>> Third Party Administration Agreement +Fees.--For purposes of this section, the term ``third party +administration agreement fees'' means, with respect to any covered +entity, amounts received from an employer which are in excess of +payments made by such covered entity for health benefits under an +arrangement under which such employer self-insures the United States +health risk of its employees. + + (f) Tax Treatment of Fees.--The fees imposed by this section-- + (1) <<NOTE: Applicability.>> for purposes of subtitle F of + the Internal Revenue Code of 1986, shall be treated as excise + taxes with respect to which only civil actions for refund under + procedures of such subtitle shall apply, and + (2) for purposes of section 275 of such Code shall be + considered to be a tax described in section 275(a)(6). + + (g) Reporting Requirement.-- + (1) In general.--Not later than the date determined by the + Secretary following the end of any calendar year, each covered + entity shall report to the Secretary, in such manner as the + Secretary prescribes, the covered entity's net premiums written + with respect to health insurance for any United States health + risk and third party administration agreement fees for such + calendar year. + (2) Penalty for failure to report.-- + (A) In general.--In the case of any failure to make + a report containing the information required by + paragraph (1) on the date prescribed therefor + (determined with regard to any extension of time for + filing), unless it is shown that such failure is due to + reasonable cause, there shall be paid by the covered + entity failing to file such report, an amount equal to-- + (i) $10,000, plus + (ii) the lesser of-- + (I) an amount equal to $1,000, + multiplied by the number of days during + which such failure continues, or + (II) the amount of the fee imposed + by this section for which such report + was required. + (B) Treatment of penalty.--The penalty imposed under + subparagraph (A)-- + (i) shall be treated as a penalty for purposes + of subtitle F of the Internal Revenue Code of + 1986, + (ii) <<NOTE: Notice.>> shall be paid on + notice and demand by the Secretary and in the same + manner as tax under such Code, and + (iii) with respect to which only civil actions + for refund under procedures of such subtitle F + shall apply. + + (h) Additional Definitions.--For purposes of this section-- + (1) Secretary.--The term ``Secretary'' means the Secretary + of the Treasury or the Secretary's delegate. + (2) United states.--The term ``United States'' means the + several States, the District of Columbia, the Commonwealth of + Puerto Rico, and the possessions of the United States. + (3) Health insurance.--The term ``health insurance'' shall + not include insurance for long-term care or disability. + + (i) <<NOTE: Publication.>> Guidance.--The Secretary shall publish +guidance necessary to carry out the purposes of this section. + +[[Page 124 STAT. 868]] + + (j) Application of Section.--This section shall apply to any net +premiums written after December 31, 2008, with respect to health +insurance for any United States health risk, and any third party +administration agreement fees received after such date. + +SEC. 9011. STUDY AND REPORT OF EFFECT ON VETERANS HEALTH CARE. + + (a) In General.--The Secretary of Veterans Affairs shall conduct a +study on the effect (if any) of the provisions of sections 9008, 9009, +and 9010 on-- + (1) the cost of medical care provided to veterans, and + (2) veterans' access to medical devices and branded + prescription drugs. + + (b) Report.--The Secretary of Veterans Affairs shall report the +results of the study under subsection (a) to the Committee on Ways and +Means of the House of Representatives and to the Committee on Finance of +the Senate not later than December 31, 2012. + +SEC. 9012. ELIMINATION OF DEDUCTION FOR EXPENSES ALLOCABLE TO MEDICARE + PART D SUBSIDY. + + (a) In General.--Section 139A of the Internal Revenue Code of +1986 <<NOTE: 26 USC 139A.>> is amended by striking the second sentence. + + (b) <<NOTE: 26 USC 139A note.>> Effective Date.--The amendment made +by this section shall apply to taxable years beginning after December +31, 2010. + +SEC. 9013. MODIFICATION OF ITEMIZED DEDUCTION FOR MEDICAL EXPENSES. + + (a) In General.--Subsection (a) of section 213 of the Internal +Revenue Code of 1986 <<NOTE: 26 USC 213.>> is amended by striking ``7.5 +percent'' and inserting ``10 percent''. + + (b) Temporary Waiver of Increase for Certain Seniors.--Section 213 +of the Internal Revenue Code of 1986 is amended by adding at the end the +following new subsection: + ``(f) <<NOTE: Time period. Applicability.>> Special Rule for 2013, +2014, 2015, and 2016.--In the case of any taxable year beginning after +December 31, 2012, and ending before January 1, 2017, subsection (a) +shall be applied with respect to a taxpayer by substituting `7.5 +percent' for `10 percent' if such taxpayer or such taxpayer's spouse has +attained age 65 before the close of such taxable year.''. + + (c) Conforming Amendment.--Section 56(b)(1)(B) of the Internal +Revenue Code of 1986 <<NOTE: 26 USC 56.>> is amended by striking ``by +substituting `10 percent' for `7.5 percent' '' and inserting ``without +regard to subsection (f) of such section''. + + (d) <<NOTE: 26 USC 56 note.>> Effective Date.--The amendments made +by this section shall apply to taxable years beginning after December +31, 2012. + +SEC. 9014. LIMITATION ON EXCESSIVE REMUNERATION PAID BY CERTAIN HEALTH + INSURANCE PROVIDERS. + + (a) In General.--Section 162(m) of the Internal Revenue Code of +1986 <<NOTE: 26 USC 162.>> is amended by adding at the end the +following new subparagraph: + ``(6) <<NOTE: Definitions.>> Special rule for application + to certain health insurance providers.-- + ``(A) In general.--No deduction shall be allowed + under this chapter-- + +[[Page 124 STAT. 869]] + + ``(i) in the case of applicable individual + remuneration which is for any disqualified taxable + year beginning after December 31, 2012, and which + is attributable to services performed by an + applicable individual during such taxable year, to + the extent that the amount of such remuneration + exceeds $500,000, or + ``(ii) in the case of deferred deduction + remuneration for any taxable year beginning after + December 31, 2012, which is attributable to + services performed by an applicable individual + during any disqualified taxable year beginning + after December 31, 2009, to the extent that the + amount of such remuneration exceeds $500,000 + reduced (but not below zero) by the sum of-- + ``(I) the applicable individual + remuneration for such disqualified + taxable year, plus + ``(II) the portion of the deferred + deduction remuneration for such services + which was taken into account under this + clause in a preceding taxable year (or + which would have been taken into account + under this clause in a preceding taxable + year if this clause were applied by + substituting `December 31, 2009' for + `December 31, 2012' in the matter + preceding subclause (I)). + ``(B) Disqualified taxable year.--For purposes of + this paragraph, the term `disqualified taxable year' + means, with respect to any employer, any taxable year + for which such employer is a covered health insurance + provider. + ``(C) Covered health insurance provider.--For + purposes of this paragraph-- + ``(i) In general.--The term `covered health + insurance provider' means-- + ``(I) with respect to taxable years + beginning after December 31, 2009, and + before January 1, 2013, any employer + which is a health insurance issuer (as + defined in section 9832(b)(2)) and which + receives premiums from providing health + insurance coverage (as defined in + section 9832(b)(1)), and + ``(II) with respect to taxable years + beginning after December 31, 2012, any + employer which is a health insurance + issuer (as defined in section + 9832(b)(2)) and with respect to which + not less than 25 percent of the gross + premiums received from providing health + insurance coverage (as defined in + section 9832(b)(1)) is from minimum + essential coverage (as defined in + section 5000A(f)). + ``(ii) Aggregation rules.--Two or more persons + who are treated as a single employer under + subsection (b), (c), (m), or (o) of section 414 + shall be treated as a single employer, except that + in applying section 1563(a) for purposes of any + such subsection, paragraphs (2) and (3) thereof + shall be disregarded. + ``(D) Applicable individual remuneration.--For + purposes of this paragraph, the term `applicable + individual + +[[Page 124 STAT. 870]] + + remuneration' means, with respect to any applicable + individual for any disqualified taxable year, the + aggregate amount allowable as a deduction under this + chapter for such taxable year (determined without regard + to this subsection) for remuneration (as defined in + paragraph (4) without regard to subparagraphs (B), (C), + and (D) thereof) for services performed by such + individual (whether or not during the taxable year). + Such term shall not include any deferred deduction + remuneration with respect to services performed during + the disqualified taxable year. + ``(E) Deferred deduction remuneration.--For purposes + of this paragraph, the term `deferred deduction + remuneration' means remuneration which would be + applicable individual remuneration for services + performed in a disqualified taxable year but for the + fact that the deduction under this chapter (determined + without regard to this paragraph) for such remuneration + is allowable in a subsequent taxable year. + ``(F) Applicable individual.--For purposes of this + paragraph, the term `applicable individual' means, with + respect to any covered health insurance provider for any + disqualified taxable year, any individual-- + ``(i) who is an officer, director, or employee + in such taxable year, or + ``(ii) who provides services for or on behalf + of such covered health insurance provider during + such taxable year. + ``(G) Coordination.--Rules similar to the rules of + subparagraphs (F) and (G) of paragraph (4) shall apply + for purposes of this paragraph. + ``(H) Regulatory authority.--The Secretary may + prescribe such guidance, rules, or regulations as are + necessary to carry out the purposes of this + paragraph.''. + + (b) <<NOTE: 26 USC 162 note.>> Effective Date.--The amendment made +by this section shall apply to taxable years beginning after December +31, 2009, with respect to services performed after such date. + +SEC. 9015. ADDITIONAL HOSPITAL INSURANCE TAX ON HIGH-INCOME TAXPAYERS. + + (a) FICA.-- + (1) <<NOTE: 26 USC 3101.>> In general.--Section 3101(b) of + the Internal Revenue Code of 1986 is amended-- + (A) by striking ``In addition'' and inserting the + following: + ``(1) In general.--In addition'', + (B) by striking ``the following percentages of the'' + and inserting ``1.45 percent of the'', + (C) by striking ``(as defined in section 3121(b))-- + '' and all that follows and inserting ``(as defined in + section 3121(b)).'', and + (D) by adding at the end the following new + paragraph: + ``(2) Additional tax.--In addition to the tax imposed by + paragraph (1) and the preceding subsection, there is hereby + imposed on every taxpayer (other than a corporation, estate, or + trust) a tax equal to 0.5 percent of wages which are received + with respect to employment (as defined in section 3121(b)) + +[[Page 124 STAT. 871]] + + during any taxable year beginning after December 31, 2012, and + which are in excess of-- + ``(A) in the case of a joint return, $250,000, and + ``(B) in any other case, $200,000.''. + (2) Collection of tax.--Section 3102 of the Internal Revenue + Code of 1986 <<NOTE: 26 USC 3102.>> is amended by adding at the + end the following new subsection: + + ``(f) Special Rules for Additional Tax.-- + ``(1) In general.--In the case of any tax imposed by section + 3101(b)(2), subsection (a) shall only apply to the extent to + which the taxpayer receives wages from the employer in excess of + $200,000, and the employer may disregard the amount of wages + received by such taxpayer's spouse. + ``(2) Collection of amounts not withheld.--To the extent + that the amount of any tax imposed by section 3101(b)(2) is not + collected by the employer, such tax shall be paid by the + employee. + ``(3) Tax paid by recipient.--If an employer, in violation + of this chapter, fails to deduct and withhold the tax imposed by + section 3101(b)(2) and thereafter the tax is paid by the + employee, the tax so required to be deducted and withheld shall + not be collected from the employer, but this paragraph shall in + no case relieve the employer from liability for any penalties or + additions to tax otherwise applicable in respect of such failure + to deduct and withhold.''. + + (b) SECA.-- + (1) In general.--Section 1401(b) of the Internal Revenue + Code of 1986 <<NOTE: 26 USC 1401.>> is amended-- + (A) by striking ``In addition'' and inserting the + following: + ``(1) In general.--In addition'', and + (B) by adding at the end the following new + paragraph: + ``(2) Additional tax.-- + ``(A) In general.--In addition to the tax imposed by + paragraph (1) and the preceding subsection, there is + hereby imposed on every taxpayer (other than a + corporation, estate, or trust) for each taxable year + beginning after December 31, 2012, a tax equal to 0.5 + percent of the self-employment income for such taxable + year which is in excess of-- + ``(i) in the case of a joint return, $250,000, + and + ``(ii) in any other case, $200,000. + ``(B) Coordination with fica.--The amounts under + clauses (i) and (ii) of subparagraph (A) shall be + reduced (but not below zero) by the amount of wages + taken into account in determining the tax imposed under + section 3121(b)(2) with respect to the taxpayer.''. + (2) No deduction for additional tax.-- + (A) In general.--Section 164(f) of such Code is + amended by inserting ``(other than the taxes imposed by + section 1401(b)(2))'' after ``section 1401)''. + (B) Deduction for net earnings from self- + employment.--Subparagraph (B) of section + 1402(a)(12) <<NOTE: 26 USC 1402.>> is amended by + inserting ``(determined without regard to the rate + imposed under paragraph (2) of section 1401(b))'' after + ``for such year''. + +[[Page 124 STAT. 872]] + + (c) <<NOTE: 26 USC 164 note.>> Effective Date.--The amendments made +by this section shall apply with respect to remuneration received, and +taxable years beginning, after December 31, 2012. + +SEC. 9016. MODIFICATION OF SECTION 833 TREATMENT OF CERTAIN HEALTH + ORGANIZATIONS. + + (a) In General.--Subsection (c) of section 833 of the Internal +Revenue Code of 1986 <<NOTE: 26 USC 833.>> is amended by adding at the +end the following new paragraph: + ``(5) Nonapplication of section in case of low medical loss + ratio.--Notwithstanding the preceding paragraphs, this section + shall not apply to any organization unless such organization's + percentage of total premium revenue expended on reimbursement + for clinical services provided to enrollees under its policies + during such taxable year (as reported under section 2718 of the + Public Health Service Act) is not less than 85 percent.''. + + (b) <<NOTE: 26 USC 853 note.>> Effective Date.--The amendment made +by this section shall apply to taxable years beginning after December +31, 2009. + +SEC. 9017. EXCISE TAX ON ELECTIVE COSMETIC MEDICAL PROCEDURES. + + (a) In General.--Subtitle D of the Internal Revenue Code of 1986, as +amended by this Act, is amended by adding at the end the following new +chapter: + + ``CHAPTER 49--ELECTIVE COSMETIC MEDICAL PROCEDURES + +``Sec. 5000B. Imposition of tax on elective cosmetic medical procedures. + +``SEC. 5000B. <<NOTE: 26 USC 5000B.>> IMPOSITION OF TAX ON ELECTIVE + COSMETIC MEDICAL PROCEDURES. + + ``(a) In General.--There is hereby imposed on any cosmetic surgery +and medical procedure a tax equal to 5 percent of the amount paid for +such procedure (determined without regard to this section), whether paid +by insurance or otherwise. + ``(b) Cosmetic Surgery and Medical Procedure.--For purposes of this +section, the term `cosmetic surgery and medical procedure' means any +cosmetic surgery (as defined in section 213(d)(9)(B)) or other similar +procedure which-- + ``(1) is performed by a licensed medical professional, and + ``(2) is not necessary to ameliorate a deformity arising + from, or directly related to, a congenital abnormality, a + personal injury resulting from an accident or trauma, or + disfiguring disease. + + ``(c) Payment of Tax.-- + ``(1) In general.--The tax imposed by this section shall be + paid by the individual on whom the procedure is performed. + ``(2) Collection.--Every person receiving a payment for + procedures on which a tax is imposed under subsection (a) shall + collect the amount of the tax from the individual on whom the + procedure is performed and remit such tax quarterly to the + Secretary at such time and in such manner as provided by the + Secretary. + ``(3) Secondary liability.--Where any tax imposed by + subsection (a) is not paid at the time payments for cosmetic + surgery and medical procedures are made, then to the extent that + +[[Page 124 STAT. 873]] + + such tax is not collected, such tax shall be paid by the person + who performs the procedure.''. + + (b) Clerical Amendment.--The table of chapters for subtitle D of the +Internal Revenue Code of 1986, as amended by this Act, is amended by +inserting after the item relating to chapter 48 the following new item: + + ``Chapter 49--Elective Cosmetic Medical Procedures''. + + (c) <<NOTE: 26 USC 5000B note.>> Effective Date.--The amendments +made by this section shall apply to procedures performed on or after +January 1, 2010. + + Subtitle B--Other Provisions + +SEC. 9021. EXCLUSION OF HEALTH BENEFITS PROVIDED BY INDIAN TRIBAL + GOVERNMENTS. + + (a) In General.--Part III of subchapter B of chapter 1 of the +Internal Revenue Code of 1986 is amended by inserting after section 139C +the following new section: + +``SEC. 139D. <<NOTE: 26 USC 139D.>> INDIAN HEALTH CARE BENEFITS. + + ``(a) General Rule.--Except as otherwise provided in this section, +gross income does not include the value of any qualified Indian health +care benefit. + ``(b) <<NOTE: Definition.>> Qualified Indian Health Care Benefit.-- +For purposes of this section, the term `qualified Indian health care +benefit' means-- + ``(1) any health service or benefit provided or purchased, + directly or indirectly, by the Indian Health Service through a + grant to or a contract or compact with an Indian tribe or tribal + organization, or through a third-party program funded by the + Indian Health Service, + ``(2) medical care provided or purchased by, or amounts to + reimburse for such medical care provided by, an Indian tribe or + tribal organization for, or to, a member of an Indian tribe, + including a spouse or dependent of such a member, + ``(3) coverage under accident or health insurance (or an + arrangement having the effect of accident or health insurance), + or an accident or health plan, provided by an Indian tribe or + tribal organization for medical care to a member of an Indian + tribe, include a spouse or dependent of such a member, and + ``(4) any other medical care provided by an Indian tribe or + tribal organization that supplements, replaces, or substitutes + for a program or service relating to medical care provided by + the Federal government to Indian tribes or members of such a + tribe. + + ``(c) Definitions.--For purposes of this section-- + ``(1) Indian tribe.--The term `Indian tribe' has the meaning + given such term by section 45A(c)(6). + ``(2) Tribal organization.--The term `tribal organization' + has the meaning given such term by section 4(l) of the Indian + Self-Determination and Education Assistance Act. + ``(3) Medical care.--The term `medical care' has the same + meaning as when used in section 213. + ``(4) Accident or health insurance; accident or health + plan.--The terms `accident or health insurance' and `accident + +[[Page 124 STAT. 874]] + + or health plan' have the same meaning as when used in section + 105. + ``(5) Dependent.--The term `dependent' has the meaning given + such term by section 152, determined without regard to + subsections (b)(1), (b)(2), and (d)(1)(B) thereof. + + ``(d) Denial of Double Benefit.--Subsection (a) shall not apply to +the amount of any qualified Indian health care benefit which is not +includible in gross income of the beneficiary of such benefit under any +other provision of this chapter, or to the amount of any such benefit +for which a deduction is allowed to such beneficiary under any other +provision of this chapter.''. + (b) Clerical Amendment.--The table of sections for part III of +subchapter B of chapter 1 of the Internal Revenue Code of 1986 is +amended by inserting after the item relating to section 139C the +following new item: + +``Sec. 139D. Indian health care benefits.''. + + (c) <<NOTE: 26 USC 139D note.>> Effective Date.--The amendments +made by this section shall apply to benefits and coverage provided after +the date of the enactment of this Act. + + (d) <<NOTE: 26 USC 139D note.>> No Inference.--Nothing in the +amendments made by this section shall be construed to create an +inference with respect to the exclusion from gross income of-- + (1) benefits provided by an Indian tribe or tribal + organization that are not within the scope of this section, and + (2) benefits provided prior to the date of the enactment of + this Act. + +SEC. 9022. ESTABLISHMENT OF SIMPLE CAFETERIA PLANS FOR SMALL BUSINESSES. + + (a) In General.--Section 125 of the Internal Revenue Code of +1986 <<NOTE: 26 USC 125.>> (relating to cafeteria plans), as amended by +this Act, is amended by redesignating subsections (j) and (k) as +subsections (k) and (l), respectively, and by inserting after subsection +(i) the following new subsection: + + ``(j) Simple Cafeteria Plans for Small Businesses.-- + ``(1) In general.--An eligible employer maintaining a simple + cafeteria plan with respect to which the requirements of this + subsection are met for any year shall be treated as meeting any + applicable nondiscrimination requirement during such year. + ``(2) Simple cafeteria plan.--For purposes of this + subsection, the term `simple cafeteria plan' means a cafeteria + plan-- + ``(A) which is established and maintained by an + eligible employer, and + ``(B) with respect to which the contribution + requirements of paragraph (3), and the eligibility and + participation requirements of paragraph (4), are met. + ``(3) Contribution requirements.-- + ``(A) In general.--The requirements of this + paragraph are met if, under the plan the employer is + required, without regard to whether a qualified employee + makes any salary reduction contribution, to make a + contribution to provide qualified benefits under the + plan on behalf of each qualified employee in an amount + equal to-- + ``(i) a uniform percentage (not less than 2 + percent) of the employee's compensation for the + plan year, or + +[[Page 124 STAT. 875]] + + ``(ii) an amount which is not less than the + lesser of-- + ``(I) 6 percent of the employee's + compensation for the plan year, or + ``(II) twice the amount of the + salary reduction contributions of each + qualified employee. + ``(B) Matching contributions on behalf of highly + compensated and key employees.--The requirements of + subparagraph (A)(ii) shall not be treated as met if, + under the plan, the rate of contributions with respect + to any salary reduction contribution of a highly + compensated or key employee at any rate of contribution + is greater than that with respect to an employee who is + not a highly compensated or key employee. + ``(C) Additional contributions.--Subject to + subparagraph (B), nothing in this paragraph shall be + treated as prohibiting an employer from making + contributions to provide qualified benefits under the + plan in addition to contributions required under + subparagraph (A). + ``(D) Definitions.--For purposes of this paragraph-- + ``(i) Salary reduction contribution.--The term + `salary reduction contribution' means, with + respect to a cafeteria plan, any amount which is + contributed to the plan at the election of the + employee and which is not includible in gross + income by reason of this section. + ``(ii) Qualified employee.--The term + `qualified employee' means, with respect to a + cafeteria plan, any employee who is not a highly + compensated or key employee and who is eligible to + participate in the plan. + ``(iii) Highly compensated employee.--The term + `highly compensated employee' has the meaning + given such term by section 414(q). + ``(iv) Key employee.--The term `key employee' + has the meaning given such term by section 416(i). + ``(4) Minimum eligibility and participation requirements.-- + ``(A) In general.--The requirements of this + paragraph shall be treated as met with respect to any + year if, under the plan-- + ``(i) all employees who had at least 1,000 + hours of service for the preceding plan year are + eligible to participate, and + ``(ii) each employee eligible to participate + in the plan may, subject to terms and conditions + applicable to all participants, elect any benefit + available under the plan. + ``(B) Certain employees may be excluded.--For + purposes of subparagraph (A)(i), an employer may elect + to exclude under the plan employees-- + ``(i) who have not attained the age of 21 + before the close of a plan year, + ``(ii) who have less than 1 year of service + with the employer as of any day during the plan + year, + ``(iii) who are covered under an agreement + which the Secretary of Labor finds to be a + collective bargaining agreement if there is + evidence that the benefits + +[[Page 124 STAT. 876]] + + covered under the cafeteria plan were the subject + of good faith bargaining between employee + representatives and the employer, or + ``(iv) who are described in section + 410(b)(3)(C) (relating to nonresident aliens + working outside the United States). + A plan may provide a shorter period of service or + younger age for purposes of clause (i) or (ii). + ``(5) Eligible employer.--For purposes of this subsection-- + ``(A) In general.--The term `eligible employer' + means, with respect to any year, any employer if such + employer employed an average of 100 or fewer employees + on business days during either of the 2 preceding years. + For purposes of this subparagraph, a year may only be + taken into account if the employer was in existence + throughout the year. + ``(B) Employers not in existence during preceding + year.--If an employer was not in existence throughout + the preceding year, the determination under subparagraph + (A) shall be based on the average number of employees + that it is reasonably expected such employer will employ + on business days in the current year. + ``(C) Growing employers retain treatment as small + employer.-- + ``(i) In general.--If-- + ``(I) an employer was an eligible + employer for any year (a `qualified + year'), and + ``(II) such employer establishes a + simple cafeteria plan for its employees + for such year, + then, notwithstanding the fact the employer fails + to meet the requirements of subparagraph (A) for + any subsequent year, such employer shall be + treated as an eligible employer for such + subsequent year with respect to employees (whether + or not employees during a qualified year) of any + trade or business which was covered by the plan + during any qualified year. + ``(ii) Exception.--This subparagraph shall + cease to apply if the employer employs an average + of 200 or more employees on business days during + any year preceding any such subsequent year. + ``(D) Special rules.-- + ``(i) Predecessors.--Any reference in this + paragraph to an employer shall include a reference + to any predecessor of such employer. + ``(ii) Aggregation rules.--All persons treated + as a single employer under subsection (a) or (b) + of section 52, or subsection (n) or (o) of section + 414, shall be treated as one person. + ``(6) Applicable nondiscrimination requirement.--For + purposes of this subsection, the term `applicable + nondiscrimination requirement' means any requirement under + subsection (b) of this section, section 79(d), section 105(h), + or paragraph (2), (3), (4), or (8) of section 129(d). + ``(7) Compensation.--The term `compensation' has the meaning + given such term by section 414(s).''. + + (b) <<NOTE: 26 USC 125 note.>> Effective Date.--The amendments made +by this section shall apply to years beginning after December 31, 2010. + +[[Page 124 STAT. 877]] + +SEC. 9023. QUALIFYING THERAPEUTIC DISCOVERY PROJECT CREDIT. + + (a) In General.--Subpart E of part IV of subchapter A of chapter 1 +of the Internal Revenue Code of 1986 is amended by inserting after +section 48C the following new section: + +``SEC. 48D. <<NOTE: 26 USC 48D.>> QUALIFYING THERAPEUTIC DISCOVERY + PROJECT CREDIT. + + ``(a) In General.--For purposes of section 46, the qualifying +therapeutic discovery project credit for any taxable year is an amount +equal to 50 percent of the qualified investment for such taxable year +with respect to any qualifying therapeutic discovery project of an +eligible taxpayer. + ``(b) Qualified Investment.-- + ``(1) In general.--For purposes of subsection (a), the + qualified investment for any taxable year is the aggregate + amount of the costs paid or incurred in such taxable year for + expenses necessary for and directly related to the conduct of a + qualifying therapeutic discovery project. + ``(2) Limitation.--The amount which is treated as qualified + investment for all taxable years with respect to any qualifying + therapeutic discovery project shall not exceed the amount + certified by the Secretary as eligible for the credit under this + section. + ``(3) Exclusions.--The qualified investment for any taxable + year with respect to any qualifying therapeutic discovery + project shall not take into account any cost-- + ``(A) for remuneration for an employee described in + section 162(m)(3), + ``(B) for interest expenses, + ``(C) for facility maintenance expenses, + ``(D) which is identified as a service cost under + section 1.263A-1(e)(4) of title 26, Code of Federal + Regulations, or + ``(E) for any other expense as determined by the + Secretary as appropriate to carry out the purposes of + this section. + ``(4) Certain progress expenditure rules made applicable.-- + In the case of costs described in paragraph (1) that are paid + for property of a character subject to an allowance for + depreciation, rules similar to the rules of subsections (c)(4) + and (d) of section 46 (as in effect on the day before the date + of the enactment of the Revenue Reconciliation Act of 1990) + shall apply for purposes of this section. + ``(5) Application of subsection.--An investment shall be + considered a qualified investment under this subsection only if + such investment is made in a taxable year beginning in 2009 or + 2010. + + ``(c) Definitions.-- + ``(1) Qualifying therapeutic discovery project.--The term + `qualifying therapeutic discovery project' means a project which + is designed-- + ``(A) to treat or prevent diseases or conditions by + conducting pre-clinical activities, clinical trials, and + clinical studies, or carrying out research protocols, + for the purpose of securing approval of a product under + section 505(b) of the Federal Food, Drug, and Cosmetic + Act or section 351(a) of the Public Health Service Act, + +[[Page 124 STAT. 878]] + + ``(B) to diagnose diseases or conditions or to + determine molecular factors related to diseases or + conditions by developing molecular diagnostics to guide + therapeutic decisions, or + ``(C) to develop a product, process, or technology + to further the delivery or administration of + therapeutics. + ``(2) Eligible taxpayer.-- + ``(A) In general.--The term `eligible taxpayer' + means a taxpayer which employs not more than 250 + employees in all businesses of the taxpayer at the time + of the submission of the application under subsection + (d)(2). + ``(B) Aggregation rules.--All persons treated as a + single employer under subsection (a) or (b) of section + 52, or subsection (m) or (o) of section 414, shall be so + treated for purposes of this paragraph. + ``(3) Facility maintenance expenses.--The term `facility + maintenance expenses' means costs paid or incurred to maintain a + facility, including-- + ``(A) mortgage or rent payments, + ``(B) insurance payments, + ``(C) utility and maintenance costs, and + ``(D) costs of employment of maintenance personnel. + + ``(d) Qualifying Therapeutic Discovery Project Program.-- + ``(1) Establishment.-- + ``(A) <<NOTE: Deadline.>> In general.--Not later + than 60 days after the date of the enactment of this + section, the Secretary, in consultation with the + Secretary of Health and Human Services, shall establish + a qualifying therapeutic discovery project program to + consider and award certifications for qualified + investments eligible for credits under this section to + qualifying therapeutic discovery project sponsors. + ``(B) Limitation.--The total amount of credits that + may be allocated under the program shall not exceed + $1,000,000,000 for the 2-year period beginning with + 2009. + ``(2) Certification.-- + ``(A) Application period.--Each applicant for + certification under this paragraph shall submit an + application containing such information as the Secretary + may require during the period beginning on the date the + Secretary establishes the program under paragraph (1). + ``(B) Time for review of applications.--The + Secretary shall take action to approve or deny any + application under subparagraph (A) within 30 days of the + submission of such application. + ``(C) Multi-year applications.--An application for + certification under subparagraph (A) may include a + request for an allocation of credits for more than 1 of + the years described in paragraph (1)(B). + ``(3) Selection criteria.--In determining the qualifying + therapeutic discovery projects with respect to which qualified + investments may be certified under this section, the Secretary-- + ``(A) shall take into consideration only those + projects that show reasonable potential-- + ``(i) to result in new therapies-- + ``(I) to treat areas of unmet + medical need, or + ``(II) to prevent, detect, or treat + chronic or acute diseases and + conditions, + +[[Page 124 STAT. 879]] + + ``(ii) to reduce long-term health care costs + in the United States, or + ``(iii) to significantly advance the goal of + curing cancer within the 30-year period beginning + on the date the Secretary establishes the program + under paragraph (1), and + ``(B) shall take into consideration which projects + have the greatest potential-- + ``(i) to create and sustain (directly or + indirectly) high quality, high-paying jobs in the + United States, and + ``(ii) to advance United States + competitiveness in the fields of life, biological, + and medical sciences. + ``(4) <<NOTE: Certification. Public information.>> + Disclosure of allocations.--The Secretary shall, upon making a + certification under this subsection, publicly disclose the + identity of the applicant and the amount of the credit with + respect to such applicant. + + ``(e) Special Rules.-- + ``(1) Basis adjustment.--For purposes of this subtitle, if a + credit is allowed under this section for an expenditure related + to property of a character subject to an allowance for + depreciation, the basis of such property shall be reduced by the + amount of such credit. + ``(2) Denial of double benefit.-- + ``(A) Bonus depreciation.--A credit shall not be + allowed under this section for any investment for which + bonus depreciation is allowed under section 168(k), + 1400L(b)(1), or 1400N(d)(1). + ``(B) Deductions.--No deduction under this subtitle + shall be allowed for the portion of the expenses + otherwise allowable as a deduction taken into account in + determining the credit under this section for the + taxable year which is equal to the amount of the credit + determined for such taxable year under subsection (a) + attributable to such portion. This subparagraph shall + not apply to expenses related to property of a character + subject to an allowance for depreciation the basis of + which is reduced under paragraph (1), or which are + described in section 280C(g). + ``(C) Credit for research activities.-- + ``(i) In general.--Except as provided in + clause (ii), any expenses taken into account under + this section for a taxable year shall not be taken + into account for purposes of determining the + credit allowable under section 41 or 45C for such + taxable year. + ``(ii) Expenses included in determining base + period research expenses.--Any expenses for any + taxable year which are qualified research expenses + (within the meaning of section 41(b)) shall be + taken into account in determining base period + research expenses for purposes of applying section + 41 to subsequent taxable years. + + ``(f) Coordination With Department of Treasury Grants.--In the case +of any investment with respect to which the Secretary makes a grant +under section 9023(e) of the Patient Protection and Affordable Care Act +of 2009-- + ``(1) Denial of credit.--No credit shall be determined under + this section with respect to such investment for the + +[[Page 124 STAT. 880]] + + taxable year in which such grant is made or any subsequent + taxable year. + ``(2) Recapture of credits for progress expenditures made + before grant.--If a credit was determined under this section + with respect to such investment for any taxable year ending + before such grant is made-- + ``(A) the tax imposed under subtitle A on the + taxpayer for the taxable year in which such grant is + made shall be increased by so much of such credit as was + allowed under section 38, + ``(B) the general business carryforwards under + section 39 shall be adjusted so as to recapture the + portion of such credit which was not so allowed, and + ``(C) the amount of such grant shall be determined + without regard to any reduction in the basis of any + property of a character subject to an allowance for + depreciation by reason of such credit. + ``(3) Treatment of grants.--Any such grant shall not be + includible in the gross income of the taxpayer.''. + + (b) Inclusion as Part of Investment Credit.--Section 46 of the +Internal Revenue Code of 1986 <<NOTE: 26 USC 46.>> is amended-- + (1) by adding a comma at the end of paragraph (2), + (2) by striking the period at the end of paragraph (5) and + inserting ``, and'', and + (3) by adding at the end the following new paragraph: + ``(6) the qualifying therapeutic discovery project + credit.''. + + (c) Conforming Amendments.-- + (1) Section 49(a)(1)(C) of the Internal Revenue Code of 1986 + is <<NOTE: 26 USC 49.>> amended-- + (A) by striking ``and'' at the end of clause (iv), + (B) by striking the period at the end of clause (v) + and inserting ``, and'', and + (C) by adding at the end the following new clause: + ``(vi) the basis of any property to which + paragraph (1) of section 48D(e) applies which is + part of a qualifying therapeutic discovery project + under such section 48D.''. + (2) <<NOTE: 26 USC 280C.>> Section 280C of such Code is + amended by adding at the end the following new subsection: + + ``(g) Qualifying Therapeutic Discovery Project Credit.-- + ``(1) In general.--No deduction shall be allowed for that + portion of the qualified investment (as defined in section + 48D(b)) otherwise allowable as a deduction for the taxable year + which-- + ``(A) would be qualified research expenses (as + defined in section 41(b)), basic research expenses (as + defined in section 41(e)(2)), or qualified clinical + testing expenses (as defined in section 45C(b)) if the + credit under section 41 or section 45C were allowed with + respect to such expenses for such taxable year, and + ``(B) is equal to the amount of the credit + determined for such taxable year under section 48D(a), + reduced by-- + ``(i) the amount disallowed as a deduction by + reason of section 48D(e)(2)(B), and + ``(ii) the amount of any basis reduction under + section 48D(e)(1). + ``(2) Similar rule where taxpayer capitalizes rather than + deducts expenses.--In the case of expenses described + +[[Page 124 STAT. 881]] + + in paragraph (1)(A) taken into account in determining the credit + under section 48D for the taxable year, if-- + ``(A) the amount of the portion of the credit + determined under such section with respect to such + expenses, exceeds + ``(B) the amount allowable as a deduction for such + taxable year for such expenses (determined without + regard to paragraph (1)), + the amount chargeable to capital account for the taxable year + for such expenses shall be reduced by the amount of such excess. + ``(3) <<NOTE: Applicability.>> Controlled groups.-- + Paragraph (3) of subsection (b) shall apply for purposes of this + subsection.''. + + (d) Clerical Amendment.--The table of sections for subpart E of part +IV of subchapter A of chapter 1 of the Internal Revenue Code of 1986 is +amended by inserting after the item relating to section 48C the +following new item: + +``Sec. 48D. Qualifying therapeutic discovery project credit.''. + + (e) <<NOTE: 26 USC 48D note.>> Grants for Qualified Investments in +Therapeutic Discovery Projects in Lieu of Tax Credits.-- + (1) In general.--Upon application, the Secretary of the + Treasury shall, subject to the requirements of this subsection, + provide a grant to each person who makes a qualified investment + in a qualifying therapeutic discovery project in the amount of + 50 percent of such investment. No grant shall be made under this + subsection with respect to any investment unless such investment + is made during a taxable year beginning in 2009 or 2010. + (2) Application.-- + (A) In general.--At the stated election of the + applicant, an application for certification under + section 48D(d)(2) of the Internal Revenue Code of 1986 + for a credit under such section for the taxable year of + the applicant which begins in 2009 shall be considered + to be an application for a grant under paragraph (1) for + such taxable year. + (B) Taxable years beginning in 2010.--An application + for a grant under paragraph (1) for a taxable year + beginning in 2010 shall be submitted-- + (i) not earlier than the day after the last + day of such taxable year, and + (ii) not later than the due date (including + extensions) for filing the return of tax for such + taxable year. + (C) Information to be submitted.--An application for + a grant under paragraph (1) shall include such + information and be in such form as the Secretary may + require to state the amount of the credit allowable (but + for the receipt of a grant under this subsection) under + section 48D for the taxable year for the qualified + investment with respect to which such application is + made. + (3) Time for payment of grant.-- + (A) In general.--The Secretary of the Treasury shall + make payment of the amount of any grant under paragraph + (1) during the 30-day period beginning on the later of-- + (i) the date of the application for such + grant, or + (ii) the date the qualified investment for + which the grant is being made is made. + +[[Page 124 STAT. 882]] + + (B) Regulations.--In the case of investments of an + ongoing nature, the Secretary shall issue regulations to + determine the date on which a qualified investment shall + be deemed to have been made for purposes of this + paragraph. + (4) <<NOTE: Definition.>> Qualified investment.--For + purposes of this subsection, the term ``qualified investment'' + means a qualified investment that is certified under section + 48D(d) of the Internal Revenue Code of 1986 for purposes of the + credit under such section 48D. + (5) Application of certain rules.-- + (A) In general.--In making grants under this + subsection, the Secretary of the Treasury shall apply + rules similar to the rules of section 50 of the Internal + Revenue Code of 1986. In applying such rules, any + increase in tax under chapter 1 of such Code by reason + of an investment ceasing to be a qualified investment + shall be imposed on the person to whom the grant was + made. + (B) Special rules.-- + (i) Recapture of excessive grant amounts.--If + the amount of a grant made under this subsection + exceeds the amount allowable as a grant under this + subsection, such excess shall be recaptured under + subparagraph (A) as if the investment to which + such excess portion of the grant relates had + ceased to be a qualified investment immediately + after such grant was made. + (ii) Grant information not treated as return + information.--In no event shall the amount of a + grant made under paragraph (1), the identity of + the person to whom such grant was made, or a + description of the investment with respect to + which such grant was made be treated as return + information for purposes of section 6103 of the + Internal Revenue Code of 1986. + (6) Exception for certain non-taxpayers.--The Secretary of + the Treasury shall not make any grant under this subsection to-- + (A) any Federal, State, or local government (or any + political subdivision, agency, or instrumentality + thereof), + (B) any organization described in section 501(c) of + the Internal Revenue Code of 1986 and exempt from tax + under section 501(a) of such Code, + (C) any entity referred to in paragraph (4) of + section 54(j) of such Code, or + (D) any partnership or other pass-thru entity any + partner (or other holder of an equity or profits + interest) of which is described in subparagraph (A), (B) + or (C). + In the case of a partnership or other pass-thru entity described + in subparagraph (D), partners and other holders of any equity or + profits interest shall provide to such partnership or entity + such information as the Secretary of the Treasury may require to + carry out the purposes of this paragraph. + (7) Secretary.--Any reference in this subsection to the + Secretary of the Treasury shall be treated as including the + Secretary's delegate. + (8) Other terms.--Any term used in this subsection which is + also used in section 48D of the Internal Revenue Code + +[[Page 124 STAT. 883]] + + of 1986 shall have the same meaning for purposes of this + subsection as when used in such section. + (9) Denial of double benefit.--No credit shall be allowed + under section 46(6) of the Internal Revenue Code of 1986 by + reason of section 48D of such Code for any investment for which + a grant is awarded under this subsection. + (10) Appropriations.--There is hereby appropriated to the + Secretary of the Treasury such sums as may be necessary to carry + out this subsection. + (11) Termination.--The Secretary of the Treasury shall not + make any grant to any person under this subsection unless the + application of such person for such grant is received before + January 1, 2013. + (12) Protecting middle class families from tax increases.-- + It is the sense of the Senate that the Senate should reject any + procedural maneuver that would raise taxes on middle class + families, such as a motion to commit the pending legislation to + the Committee on Finance, which is designed to kill legislation + that provides tax cuts for American workers and families, + including the affordability tax credit and the small business + tax credit. + + (f) <<NOTE: 26 USC 46 note.>> Effective Date.--The amendments made +by subsections (a) through (d) of this section shall apply to amounts +paid or incurred after December 31, 2008, in taxable years beginning +after such date. + +TITLE X--STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS + + Subtitle A--Provisions Relating to Title I + +SEC. 10101. AMENDMENTS TO SUBTITLE A. + + (a) Section 2711 of the Public Health Service Act, as added by +section 1001(5) of this Act, is amended to read as follows: + +``SEC. 2711. <<NOTE: 42 USC 300gg-11.>> NO LIFETIME OR ANNUAL LIMITS. + + ``(a) Prohibition.-- + ``(1) In general.--A group health plan and a health + insurance issuer offering group or individual health insurance + coverage may not establish-- + ``(A) lifetime limits on the dollar value of + benefits for any participant or beneficiary; or + ``(B) except as provided in paragraph (2), annual + limits on the dollar value of benefits for any + participant or beneficiary. + ``(2) Annual limits prior to 2014.--With respect to plan + years beginning prior to January 1, 2014, a group health plan + and a health insurance issuer offering group or individual + health insurance coverage may only establish a restricted annual + limit on the dollar value of benefits for any participant or + beneficiary with respect to the scope of benefits that are + essential health benefits under section 1302(b) of the Patient + +[[Page 124 STAT. 884]] + + Protection and Affordable Care Act, as determined by the + Secretary. In defining the term `restricted annual limit' for + purposes of the preceding sentence, the Secretary shall ensure + that access to needed services is made available with a minimal + impact on premiums. + + ``(b) Per Beneficiary Limits.--Subsection (a) shall not be construed +to prevent a group health plan or health insurance coverage from placing +annual or lifetime per beneficiary limits on specific covered benefits +that are not essential health benefits under section 1302(b) of the +Patient Protection and Affordable Care Act, to the extent that such +limits are otherwise permitted under Federal or State law.''. + (b) Section 2715(a) of the Public Health Service Act, as added by +section 1001(5) of this Act, <<NOTE: 42 USC 300gg-15.>> is amended by +striking ``and providing to enrollees'' and inserting ``and providing to +applicants, enrollees, and policyholders or certificate holders''. + + (c) Subpart II of part A of title XXVII of the Public Health Service +Act, as added by section 1001(5), is amended by inserting after section +2715, the following: + +``SEC. 2715A. <<NOTE: Public information. 42 USC 300gg-15a.>> PROVISION + OF ADDITIONAL INFORMATION. + + ``A group health plan and a health insurance issuer offering group +or individual health insurance coverage shall comply with the provisions +of section 1311(e)(3) of the Patient Protection and Affordable Care Act, +except that a plan or coverage that is not offered through an Exchange +shall only be required to submit the information required to the +Secretary and the State insurance commissioner, and make such +information available to the public.''. + (d) Section 2716 of the Public Health Service Act, as added by +section 1001(5) of this Act, is amended to read as follows: + +``SEC. 2716. <<NOTE: 42 USC 300gg-16.>> PROHIBITION ON DISCRIMINATION + IN FAVOR OF HIGHLY COMPENSATED INDIVIDUALS. + + ``(a) In General.--A group health plan (other than a self-insured +plan) shall satisfy the requirements of section 105(h)(2) of the +Internal Revenue Code of 1986 (relating to prohibition on discrimination +in favor of highly compensated individuals). + ``(b) Rules and Definitions.--For purposes of this section-- + ``(1) Certain rules to apply.--Rules similar to the rules + contained in paragraphs (3), (4), and (8) of section 105(h) of + such Code shall apply. + ``(2) Highly compensated individual.--The term `highly + compensated individual' has the meaning given such term by + section 105(h)(5) of such Code.''. + + (e) Section 2717 of the Public Health Service Act, as added by +section 1001(5) of this Act, <<NOTE: 42 USC 300gg-17.>> is amended-- + (1) by redesignating subsections (c) and (d) as subsections + (d) and (e), respectively; and + (2) by inserting after subsection (b), the following: + + ``(c) Protection of Second Amendment Gun Rights.-- + ``(1) Wellness and prevention programs.--A wellness and + health promotion activity implemented under subsection (a)(1)(D) + may not require the disclosure or collection of any information + relating to-- + ``(A) the presence or storage of a lawfully- + possessed firearm or ammunition in the residence or on + the property of an individual; or + +[[Page 124 STAT. 885]] + + ``(B) the lawful use, possession, or storage of a + firearm or ammunition by an individual. + ``(2) Limitation on data collection.--None of the + authorities provided to the Secretary under the Patient + Protection and Affordable Care Act or an amendment made by that + Act shall be construed to authorize or may be used for the + collection of any information relating to-- + ``(A) the lawful ownership or possession of a + firearm or ammunition; + ``(B) the lawful use of a firearm or ammunition; or + ``(C) the lawful storage of a firearm or ammunition. + ``(3) Limitation on databases or data banks.--None of the + authorities provided to the Secretary under the Patient + Protection and Affordable Care Act or an amendment made by that + Act shall be construed to authorize or may be used to maintain + records of individual ownership or possession of a firearm or + ammunition. + ``(4) Limitation on determination of premium rates or + eligibility for health insurance.--A premium rate may not be + increased, health insurance coverage may not be denied, and a + discount, rebate, or reward offered for participation in a + wellness program may not be reduced or withheld under any health + benefit plan issued pursuant to or in accordance with the + Patient Protection and Affordable Care Act or an amendment made + by that Act on the basis of, or on reliance upon-- + ``(A) the lawful ownership or possession of a + firearm or ammunition; or + ``(B) the lawful use or storage of a firearm or + ammunition. + ``(5) Limitation on data collection requirements for + individuals.--No individual shall be required to disclose any + information under any data collection activity authorized under + the Patient Protection and Affordable Care Act or an amendment + made by that Act relating to-- + ``(A) the lawful ownership or possession of a + firearm or ammunition; or + ``(B) the lawful use, possession, or storage of a + firearm or ammunition.''. + + (f) Section 2718 of the Public Health Service Act, as added by +section 1001(5), is amended to read as follows: + +``SEC. 2718. <<NOTE: 42 USC 300gg-18. Reports.>> BRINGING DOWN THE COST + OF HEALTH CARE COVERAGE. + + ``(a) Clear Accounting for Costs.--A health insurance issuer +offering group or individual health insurance coverage (including a +grandfathered health plan) shall, with respect to each plan year, submit +to the Secretary a report concerning the ratio of the incurred loss (or +incurred claims) plus the loss adjustment expense (or change in contract +reserves) to earned premiums. Such report shall include the percentage +of total premium revenue, after accounting for collections or receipts +for risk adjustment and risk corridors and payments of reinsurance, that +such coverage expends-- + ``(1) on reimbursement for clinical services provided to + enrollees under such coverage; + ``(2) for activities that improve health care quality; and + +[[Page 124 STAT. 886]] + + ``(3) on all other non-claims costs, including an + explanation of the nature of such costs, and excluding Federal + and State taxes and licensing or regulatory fees. + +The Secretary <<NOTE: Public information. Web posting.>> shall make +reports received under this section available to the public on the +Internet website of the Department of Health and Human Services. + + ``(b) Ensuring That Consumers Receive Value for Their Premium +Payments.-- + ``(1) Requirement to provide value for premium payments.-- + ``(A) <<NOTE: Deadline.>> Requirement.--Beginning + not later than January 1, 2011, a health insurance + issuer offering group or individual health insurance + coverage (including a grandfathered health plan) shall, + with respect to each plan year, provide an annual rebate + to each enrollee under such coverage, on a pro rata + basis, if the ratio of the amount of premium revenue + expended by the issuer on costs described in paragraphs + (1) and (2) of subsection (a) to the total amount of + premium revenue (excluding Federal and State taxes and + licensing or regulatory fees and after accounting for + payments or receipts for risk adjustment, risk + corridors, and reinsurance under sections 1341, 1342, + and 1343 of the Patient Protection and Affordable Care + Act) for the plan year (except as provided in + subparagraph (B)(ii)), is less than-- + ``(i) with respect to a health insurance + issuer offering coverage in the large group + market, 85 percent, or such higher percentage as a + State may by regulation determine; or + ``(ii) with respect to a health insurance + issuer offering coverage in the small group market + or in the individual market, 80 percent, or such + higher percentage as a State may by regulation + determine, except that the Secretary may adjust + such percentage with respect to a State if the + Secretary determines that the application of such + 80 percent may destabilize the individual market + in such State. + ``(B) Rebate amount.-- + ``(i) Calculation of amount.--The total amount + of an annual rebate required under this paragraph + shall be in an amount equal to the product of-- + ``(I) the amount by which the + percentage described in clause (i) or + (ii) of subparagraph (A) exceeds the + ratio described in such subparagraph; + and + ``(II) the total amount of premium + revenue (excluding Federal and State + taxes and licensing or regulatory fees + and after accounting for payments or + receipts for risk adjustment, risk + corridors, and reinsurance under + sections 1341, 1342, and 1343 of the + Patient Protection and Affordable Care + Act) for such plan year. + ``(ii) Calculation based on average ratio.-- + Beginning on January 1, 2014, <<NOTE: Effective + date.>> the determination made under subparagraph + (A) for the year involved shall be based on the + averages of the premiums expended on the costs + described in such subparagraph and total + +[[Page 124 STAT. 887]] + + premium revenue for each of the previous 3 years + for the plan. + ``(2) Consideration in setting percentages.--In determining + the percentages under paragraph (1), a State shall seek to + ensure adequate participation by health insurance issuers, + competition in the health insurance market in the State, and + value for consumers so that premiums are used for clinical + services and quality improvements. + ``(3) <<NOTE: Regulations.>> Enforcement.--The Secretary + shall promulgate regulations for enforcing the provisions of + this section and may provide for appropriate penalties. + + ``(c) <<NOTE: Deadline. Certification.>> Definitions.--Not later +than December 31, 2010, and subject to the certification of the +Secretary, the National Association of Insurance Commissioners shall +establish uniform definitions of the activities reported under +subsection (a) and standardized methodologies for calculating measures +of such activities, including definitions of which activities, and in +what regard such activities, constitute activities described in +subsection (a)(2). Such methodologies shall be designed to take into +account the special circumstances of smaller plans, different types of +plans, and newer plans. + + ``(d) Adjustments.--The Secretary may adjust the rates described in +subsection (b) if the Secretary determines appropriate on account of the +volatility of the individual market due to the establishment of State +Exchanges. + ``(e) Standard Hospital Charges.--Each hospital operating within the +United States shall for each year establish (and update) and make public +(in accordance with guidelines developed by the Secretary) a list of the +hospital's standard charges for items and services provided by the +hospital, including for diagnosis-related groups established under +section 1886(d)(4) of the Social Security Act.''. + (g) Section 2719 of the Public Health Service Act, as added by +section 1001(4) of this Act, is amended to read as follows: + +``SEC. 2719. <<NOTE: 42 USC 300gg-19.>> APPEALS PROCESS. + + ``(a) Internal Claims Appeals.-- + ``(1) In general.--A group health plan and a health + insurance issuer offering group or individual health insurance + coverage shall implement an effective appeals process for + appeals of coverage determinations and claims, under which the + plan or issuer shall, at a minimum-- + ``(A) have in effect an internal claims appeal + process; + ``(B) provide notice to enrollees, in a culturally + and linguistically appropriate manner, of available + internal and external appeals processes, and the + availability of any applicable office of health + insurance consumer assistance or ombudsman established + under section 2793 to assist such enrollees with the + appeals processes; and + ``(C) allow an enrollee to review their file, to + present evidence and testimony as part of the appeals + process, and to receive continued coverage pending the + outcome of the appeals process. + ``(2) Established processes.--To comply with paragraph (1)-- + ``(A) a group health plan and a health insurance + issuer offering group health coverage shall provide an + internal claims and appeals process that initially + incorporates the + +[[Page 124 STAT. 888]] + + claims and appeals procedures (including urgent claims) + set forth at section 2560.503-1 of title 29, Code of + Federal Regulations, as published on November 21, 2000 + (65 Fed. Reg. 70256), and shall update such process in + accordance with any standards established by the + Secretary of Labor for such plans and issuers; and + ``(B) a health insurance issuer offering individual + health coverage, and any other issuer not subject to + subparagraph (A), shall provide an internal claims and + appeals process that initially incorporates the claims + and appeals procedures set forth under applicable law + (as in existence on the date of enactment of this + section), and shall update such process in accordance + with any standards established by the Secretary of + Health and Human Services for such issuers. + + ``(b) External Review.--A group health plan and a health insurance +issuer offering group or individual health insurance coverage-- + ``(1) shall comply with the applicable State external review + process for such plans and issuers that, at a minimum, includes + the consumer protections set forth in the Uniform External + Review Model Act promulgated by the National Association of + Insurance Commissioners and is binding on such plans; or + ``(2) shall implement an effective external review process + that meets minimum standards established by the Secretary + through guidance and that is similar to the process described + under paragraph (1)-- + ``(A) if the applicable State has not established an + external review process that meets the requirements of + paragraph (1); or + ``(B) if the plan is a self-insured plan that is not + subject to State insurance regulation (including a State + law that establishes an external review process + described in paragraph (1)). + + ``(c) Secretary Authority.--The Secretary may deem the external +review process of a group health plan or health insurance issuer, in +operation as of the date of enactment of this section, to be in +compliance with the applicable process established under subsection (b), +as determined appropriate by the Secretary.''. + (h) Subpart II of part A of title XVIII of the Public Health Service +Act, as added by section 1001(5) of this Act, is amended by inserting +after section 2719 the following: + +``SEC. 2719A. <<NOTE: 42 USC 300gg-19a.>> PATIENT PROTECTIONS. + + ``(a) Choice of Health Care Professional.--If a group health plan, +or a health insurance issuer offering group or individual health +insurance coverage, requires or provides for designation by a +participant, beneficiary, or enrollee of a participating primary care +provider, then the plan or issuer shall permit each participant, +beneficiary, and enrollee to designate any participating primary care +provider who is available to accept such individual. + ``(b) Coverage of Emergency Services.-- + ``(1) In general.--If a group health plan, or a health + insurance issuer offering group or individual health insurance + issuer, provides or covers any benefits with respect to services + in an emergency department of a hospital, the plan or issuer + +[[Page 124 STAT. 889]] + + shall cover emergency services (as defined in paragraph + (2)(B))-- + ``(A) without the need for any prior authorization + determination; + ``(B) whether the health care provider furnishing + such services is a participating provider with respect + to such services; + ``(C) in a manner so that, if such services are + provided to a participant, beneficiary, or enrollee-- + ``(i) by a nonparticipating health care + provider with or without prior authorization; or + ``(ii)(I) such services will be provided + without imposing any requirement under the plan + for prior authorization of services or any + limitation on coverage where the provider of + services does not have a contractual relationship + with the plan for the providing of services that + is more restrictive than the requirements or + limitations that apply to emergency department + services received from providers who do have such + a contractual relationship with the plan; and + ``(II) if such services are provided out-of- + network, the cost-sharing requirement (expressed + as a copayment amount or coinsurance rate) is the + same requirement that would apply if such services + were provided in-network; + ``(D) without regard to any other term or condition + of such coverage (other than exclusion or coordination + of benefits, or an affiliation or waiting period, + permitted under section 2701 of this Act, section 701 of + the Employee Retirement Income Security Act of 1974, or + section 9801 of the Internal Revenue Code of 1986, and + other than applicable cost-sharing). + ``(2) Definitions.--In this subsection: + ``(A) Emergency medical condition.--The term + `emergency medical condition' means a medical condition + manifesting itself by acute symptoms of sufficient + severity (including severe pain) such that a prudent + layperson, who possesses an average knowledge of health + and medicine, could reasonably expect the absence of + immediate medical attention to result in a condition + described in clause (i), (ii), or (iii) of section + 1867(e)(1)(A) of the Social Security Act. + ``(B) Emergency services.--The term `emergency + services' means, with respect to an emergency medical + condition-- + ``(i) a medical screening examination (as + required under section 1867 of the Social Security + Act) that is within the capability of the + emergency department of a hospital, including + ancillary services routinely available to the + emergency department to evaluate such emergency + medical condition, and + ``(ii) within the capabilities of the staff + and facilities available at the hospital, such + further medical examination and treatment as are + required under section 1867 of such Act to + stabilize the patient. + +[[Page 124 STAT. 890]] + + ``(C) Stabilize.--The term `to stabilize', with + respect to an emergency medical condition (as defined in + subparagraph (A)), has the meaning give in section + 1867(e)(3) of the Social Security Act (42 U.S.C. + 1395dd(e)(3)). + + ``(c) Access to Pediatric Care.-- + ``(1) Pediatric care.--In the case of a person who has a + child who is a participant, beneficiary, or enrollee under a + group health plan, or health insurance coverage offered by a + health insurance issuer in the group or individual market, if + the plan or issuer requires or provides for the designation of a + participating primary care provider for the child, the plan or + issuer shall permit such person to designate a physician + (allopathic or osteopathic) who specializes in pediatrics as the + child's primary care provider if such provider participates in + the network of the plan or issuer. + ``(2) Construction.--Nothing in paragraph (1) shall be + construed to waive any exclusions of coverage under the terms + and conditions of the plan or health insurance coverage with + respect to coverage of pediatric care. + + ``(d) Patient Access to Obstetrical and Gynecological Care.-- + ``(1) General rights.-- + ``(A) Direct access.--A group health plan, or health + insurance issuer offering group or individual health + insurance coverage, described in paragraph (2) may not + require authorization or referral by the plan, issuer, + or any person (including a primary care provider + described in paragraph (2)(B)) in the case of a female + participant, beneficiary, or enrollee who seeks coverage + for obstetrical or gynecological care provided by a + participating health care professional who specializes + in obstetrics or gynecology. Such professional shall + agree to otherwise adhere to such plan's or issuer's + policies and procedures, including procedures regarding + referrals and obtaining prior authorization and + providing services pursuant to a treatment plan (if any) + approved by the plan or issuer. + ``(B) Obstetrical and gynecological care.--A group + health plan or health insurance issuer described in + paragraph (2) shall treat the provision of obstetrical + and gynecological care, and the ordering of related + obstetrical and gynecological items and services, + pursuant to the direct access described under + subparagraph (A), by a participating health care + professional who specializes in obstetrics or gynecology + as the authorization of the primary care provider. + ``(2) Application of paragraph.--A group health plan, or + health insurance issuer offering group or individual health + insurance coverage, described in this paragraph is a group + health plan or coverage that-- + ``(A) provides coverage for obstetric or gynecologic + care; and + ``(B) requires the designation by a participant, + beneficiary, or enrollee of a participating primary care + provider. + ``(3) Construction.--Nothing in paragraph (1) shall be + construed to-- + ``(A) waive any exclusions of coverage under the + terms and conditions of the plan or health insurance + coverage + +[[Page 124 STAT. 891]] + + with respect to coverage of obstetrical or gynecological + care; or + ``(B) preclude the group health plan or health + insurance issuer involved from requiring that the + obstetrical or gynecological provider notify the primary + care health care professional or the plan or issuer of + treatment decisions.''. + + (i) Section 2794 of the Public Health Service Act, as added by +section 1003 of this Act, <<NOTE: 42 USC 300gg-94.>> is amended-- + (1) in subsection (c)(1)-- + (A) in subparagraph (A), by striking ``and'' at the + end; + (B) in subparagraph (B), by striking the period and + inserting ``; and''; and + (C) by adding at the end the following: + ``(C) in establishing centers (consistent with + subsection (d)) at academic or other nonprofit + institutions to collect medical reimbursement + information from health insurance issuers, to analyze + and organize such information, and to make such + information available to such issuers, health care + providers, health researchers, health care policy + makers, and the general public.''; and + (2) by adding at the end the following: + + ``(d) Medical Reimbursement Data Centers.-- + ``(1) Functions.--A center established under subsection + (c)(1)(C) shall-- + ``(A) develop fee schedules and other database tools + that fairly and accurately reflect market rates for + medical services and the geographic differences in those + rates; + ``(B) use the best available statistical methods and + data processing technology to develop such fee schedules + and other database tools; + ``(C) regularly update such fee schedules and other + database tools to reflect changes in charges for medical + services; + ``(D) <<NOTE: Public information. Web posting.>> + make health care cost information readily available to + the public through an Internet website that allows + consumers to understand the amounts that health care + providers in their area charge for particular medical + services; and + ``(E) <<NOTE: Publication.>> regularly publish + information concerning the statistical methodologies + used by the center to analyze health charge data and + make such data available to researchers and policy + makers. + ``(2) <<NOTE: By-laws.>> Conflicts of interest.--A center + established under subsection (c)(1)(C) shall adopt by-laws that + ensures that the center (and all members of the governing board + of the center) is independent and free from all conflicts of + interest. Such by-laws shall ensure that the center is not + controlled or influenced by, and does not have any corporate + relation to, any individual or entity that may make or receive + payments for health care services based on the center's analysis + of health care costs. + ``(3) Rule of construction.--Nothing in this subsection + shall be construed to permit a center established under + subsection (c)(1)(C) to compel health insurance issuers to + provide data to the center.''. + +[[Page 124 STAT. 892]] + +SEC. 10102. AMENDMENTS TO SUBTITLE B. + + (a) <<NOTE: 42 USC 18002.>> Section 1102(a)(2)(B) of this Act is +amended-- + (1) in the matter preceding clause (i), by striking ``group + health benefits plan'' and inserting ``group benefits plan + providing health benefits''; and + (2) in clause (i)(I), by inserting ``or any agency or + instrumentality of any of the foregoing'' before the closed + parenthetical. + + (b) <<NOTE: 42 USC 18003.>> Section 1103(a) of this Act is +amended-- + (1) in paragraph (1), by inserting ``, or small business + in,'' after ``residents of any''; and + (2) by striking paragraph (2) and inserting the following: + ``(2) Connecting to affordable coverage.--An Internet + website established under paragraph (1) shall, to the extent + practicable, provide ways for residents of, and small businesses + in, any State to receive information on at least the following + coverage options: + ``(A) Health insurance coverage offered by health + insurance issuers, other than coverage that provides + reimbursement only for the treatment or mitigation of-- + ``(i) a single disease or condition; or + ``(ii) an unreasonably limited set of diseases + or conditions (as determined by the Secretary). + ``(B) Medicaid coverage under title XIX of the + Social Security Act. + ``(C) Coverage under title XXI of the Social + Security Act. + ``(D) A State health benefits high risk pool, to the + extent that such high risk pool is offered in such + State; and + ``(E) Coverage under a high risk pool under section + 1101. + ``(F) Coverage within the small group market for + small businesses and their employees, including + reinsurance for early retirees under section 1102, tax + credits available under section 45R of the Internal + Revenue Code of 1986 (as added by section 1421), and + other information specifically for small businesses + regarding affordable health care options.''. + +SEC. 10103. AMENDMENTS TO SUBTITLE C. + + (a) Section 2701(a)(5) of the Public Health Service Act, as added by +section 1201(4) of this Act, <<NOTE: 42 USC 300gg.>> is amended by +inserting ``(other than self-insured group health plans offered in such +market)'' after ``such market''. + + (b) Section 2708 of the Public Health Service Act, as added by +section 1201(4) of this Act, <<NOTE: 42 USC 300gg-7.>> is amended by +striking ``or individual''. + + (c) Subpart I of part A of title XXVII of the Public Health Service +Act, as added by section 1201(4) of this Act, is amended by inserting +after section 2708, the following: + +``SEC. 2709. <<NOTE: 42 USC 300gg-8.>> COVERAGE FOR INDIVIDUALS + PARTICIPATING IN APPROVED CLINICAL TRIALS. + + ``(a) Coverage.-- + ``(1) In general.--If a group health plan or a health + insurance issuer offering group or individual health insurance + coverage provides coverage to a qualified individual, then such + plan or issuer-- + +[[Page 124 STAT. 893]] + + ``(A) may not deny the individual participation in + the clinical trial referred to in subsection (b)(2); + ``(B) subject to subsection (c), may not deny (or + limit or impose additional conditions on) the coverage + of routine patient costs for items and services + furnished in connection with participation in the trial; + and + ``(C) may not discriminate against the individual on + the basis of the individual's participation in such + trial. + ``(2) Routine patient costs.-- + ``(A) Inclusion.--For purposes of paragraph (1)(B), + subject to subparagraph (B), routine patient costs + include all items and services consistent with the + coverage provided in the plan (or coverage) that is + typically covered for a qualified individual who is not + enrolled in a clinical trial. + ``(B) Exclusion.--For purposes of paragraph (1)(B), + routine patient costs does not include-- + ``(i) the investigational item, device, or + service, itself; + ``(ii) items and services that are provided + solely to satisfy data collection and analysis + needs and that are not used in the direct clinical + management of the patient; or + ``(iii) a service that is clearly inconsistent + with widely accepted and established standards of + care for a particular diagnosis. + ``(3) Use of in-network providers.--If one or more + participating providers is participating in a clinical trial, + nothing in paragraph (1) shall be construed as preventing a plan + or issuer from requiring that a qualified individual participate + in the trial through such a participating provider if the + provider will accept the individual as a participant in the + trial. + ``(4) <<NOTE: Applicability.>> Use of out-of-network.-- + Notwithstanding paragraph (3), paragraph (1) shall apply to a + qualified individual participating in an approved clinical trial + that is conducted outside the State in which the qualified + individual resides. + + ``(b) Qualified Individual Defined.--For purposes of subsection (a), +the term `qualified individual' means an individual who is a participant +or beneficiary in a health plan or with coverage described in subsection +(a)(1) and who meets the following conditions: + ``(1) The individual is eligible to participate in an + approved clinical trial according to the trial protocol with + respect to treatment of cancer or other life-threatening disease + or condition. + ``(2) Either-- + ``(A) the referring health care professional is a + participating health care provider and has concluded + that the individual's participation in such trial would + be appropriate based upon the individual meeting the + conditions described in paragraph (1); or + ``(B) the participant or beneficiary provides + medical and scientific information establishing that the + individual's participation in such trial would be + appropriate based upon the individual meeting the + conditions described in paragraph (1). + + ``(c) Limitations on Coverage.--This section shall not be construed +to require a group health plan, or a health insurance issuer + +[[Page 124 STAT. 894]] + +offering group or individual health insurance coverage, to provide +benefits for routine patient care services provided outside of the +plan's (or coverage's) health care provider network unless out-of- +network benefits are otherwise provided under the plan (or coverage). + ``(d) Approved Clinical Trial Defined.-- + ``(1) In general.--In this section, the term `approved + clinical trial' means a phase I, phase II, phase III, or phase + IV clinical trial that is conducted in relation to the + prevention, detection, or treatment of cancer or other life- + threatening disease or condition and is described in any of the + following subparagraphs: + ``(A) Federally funded trials.--The study or + investigation is approved or funded (which may include + funding through in-kind contributions) by one or more of + the following: + ``(i) The National Institutes of Health. + ``(ii) The Centers for Disease Control and + Prevention. + ``(iii) The Agency for Health Care Research + and Quality. + ``(iv) The Centers for Medicare & Medicaid + Services. + ``(v) cooperative group or center of any of + the entities described in clauses (i) through (iv) + or the Department of Defense or the Department of + Veterans Affairs. + ``(vi) A qualified non-governmental research + entity identified in the guidelines issued by the + National Institutes of Health for center support + grants. + ``(vii) Any of the following if the conditions + described in paragraph (2) are met: + ``(I) The Department of Veterans + Affairs. + ``(II) The Department of Defense. + ``(III) The Department of Energy. + ``(B) The study or investigation is conducted under + an investigational new drug application reviewed by the + Food and Drug Administration. + ``(C) The study or investigation is a drug trial + that is exempt from having such an investigational new + drug application. + ``(2) <<NOTE: Determination.>> Conditions for + departments.--The conditions described in this paragraph, for a + study or investigation conducted by a Department, are that the + study or investigation has been reviewed and approved through a + system of peer review that the Secretary determines-- + ``(A) to be comparable to the system of peer review + of studies and investigations used by the National + Institutes of Health, and + ``(B) assures unbiased review of the highest + scientific standards by qualified individuals who have + no interest in the outcome of the review. + + ``(e) Life-threatening Condition Defined.--In this section, the term +`life-threatening condition' means any disease or condition from which +the likelihood of death is probable unless the course of the disease or +condition is interrupted. + ``(f) Construction.--Nothing in this section shall be construed to +limit a plan's or issuer's coverage with respect to clinical trials. + +[[Page 124 STAT. 895]] + + ``(g) Application to FEHBP.--Notwithstanding any provision of +chapter 89 of title 5, United States Code, this section shall apply to +health plans offered under the program under such chapter. + ``(h) Preemption.--Notwithstanding any other provision of this Act, +nothing in this section shall preempt State laws that require a clinical +trials policy for State regulated health insurance plans that is in +addition to the policy required under this section.''. + (d) <<NOTE: 42 USC 18011.>> Section 1251(a) of this Act is +amended-- + (1) in paragraph (2), by striking ``With'' and inserting + ``Except as provided in paragraph (3), with''; and + (2) by adding at the end the following: + ``(3) Application of certain provisions.--The provisions of + sections 2715 and 2718 of the Public Health Service Act (as + added by subtitle A) shall apply to grandfathered health plans + for plan years beginning on or after the date of enactment of + this Act.''. + + (e) <<NOTE: Effective date. 42 USC 300gg note.>> Section 1253 of +this Act is amended insert before the period the following: ``, except +that-- + ``(1) section 1251 shall take effect on the date of + enactment of this Act; and + ``(2) the provisions of section 2704 of the Public Health + Service Act (as amended by section 1201), as they apply to + enrollees who are under 19 years of age, shall become effective + for plan years beginning on or after the date that is 6 months + after the date of enactment of this Act.''. + + (f) Subtitle C of title I of this Act is amended-- + (1) by redesignating section 1253 as section 1255; and + (2) by inserting after section 1252, the following: + +``SEC. 1253. <<NOTE: 42 USC 18013.>> ANNUAL REPORT ON SELF-INSURED + PLANS. + + ``Not later than 1 year after the date of enactment of this Act, and +annually thereafter, the Secretary of Labor shall prepare an aggregate +annual report, using data collected from the Annual Return/Report of +Employee Benefit Plan (Department of Labor Form 5500), that shall +include general information on self-insured group health plans +(including plan type, number of participants, benefits offered, funding +arrangements, and benefit arrangements) as well as data from the +financial filings of self-insured employers (including information on +assets, liabilities, contributions, investments, and expenses). The +Secretary shall submit such reports to the appropriate committees of +Congress. + +``SEC. 1254. STUDY OF LARGE GROUP MARKET. + + ``(a) In General.--The Secretary of Health and Human Services shall +conduct a study of the fully-insured and self-insured group health plan +markets to-- + ``(1) compare the characteristics of employers (including + industry, size, and other characteristics as determined + appropriate by the Secretary), health plan benefits, financial + solvency, capital reserve levels, and the risks of becoming + insolvent; and + ``(2) determine the extent to which new insurance market + reforms are likely to cause adverse selection in the large group + market or to encourage small and midsize employers to self- + insure. + + ``(b) Collection of Information.--In conducting the study under +subsection (a), the Secretary, in coordination with the Secretary of +Labor, shall collect information and analyze-- + +[[Page 124 STAT. 896]] + + ``(1) the extent to which self-insured group health plans + can offer less costly coverage and, if so, whether lower costs + are due to more efficient plan administration and lower overhead + or to the denial of claims and the offering very limited benefit + packages; + ``(2) claim denial rates, plan benefit fluctuations (to + evaluate the extent that plans scale back health benefits during + economic downturns), and the impact of the limited recourse + options on consumers; and + ``(3) any potential conflict of interest as it relates to + the health care needs of self-insured enrollees and self-insured + employer's financial contribution or profit margin, and the + impact of such conflict on administration of the health plan. + + ``(c) Report.--Not later than 1 year after the date of enactment of +this Act, the Secretary shall submit to the appropriate committees of +Congress a report concerning the results of the study conducted under +subsection (a).''. + +SEC. 10104. AMENDMENTS TO SUBTITLE D. + + (a) <<NOTE: 42 USC 18021.>> Section 1301(a) of this Act is amended +by striking paragraph (2) and inserting the following: + ``(2) Inclusion of co-op plans and multi-state qualified + health plans.--Any reference in this title to a qualified health + plan shall be deemed to include a qualified health plan offered + through the CO-OP program under section 1322, and a multi-State + plan under section 1334, unless specifically provided for + otherwise. + ``(3) Treatment of qualified direct primary care medical + home plans.--The Secretary <<NOTE: Criteria.>> of Health and + Human Services shall permit a qualified health plan to provide + coverage through a qualified direct primary care medical home + plan that meets criteria established by the Secretary, so long + as the qualified health plan meets all requirements that are + otherwise applicable and the services covered by the medical + home plan are coordinated with the entity offering the qualified + health plan. + ``(4) Variation based on rating area.--A qualified health + plan, including a multi-State qualified health plan, may as + appropriate vary premiums by rating area (as defined in section + 2701(a)(2) of the Public Health Service Act).''. + + (b) <<NOTE: 42 USC 18022.>> Section 1302 of this Act is amended-- + (1) in subsection (d)(2)(B), by striking ``may issue'' and + inserting ``shall issue''; and + (2) by adding at the end the following: + + ``(g) Payments to Federally-qualified Health Centers.--If any item +or service covered by a qualified health plan is provided by a +Federally-qualified health center (as defined in section 1905(l)(2)(B) +of the Social Security Act (42 U.S.C. 1396d(l)(2)(B)) to an enrollee of +the plan, the offeror of the plan shall pay to the center for the item +or service an amount that is not less than the amount of payment that +would have been paid to the center under section 1902(bb) of such Act +(42 U.S.C. 1396a(bb)) for such item or service.''. + (c) Section 1303 of this Act is amended to read as follows: + +``SEC. 1303. <<NOTE: 42 USC 18023.>> SPECIAL RULES. + + ``(a) State Opt-out of Abortion Coverage.-- + +[[Page 124 STAT. 897]] + + ``(1) In general.--A State may elect to prohibit abortion + coverage in qualified health plans offered through an Exchange + in such State if such State enacts a law to provide for such + prohibition. + ``(2) Termination of opt out.--A State may repeal a law + described in paragraph (1) and provide for the offering of such + services through the Exchange. + + ``(b) Special Rules Relating to Coverage of Abortion Services.-- + ``(1) Voluntary choice of coverage of abortion services.-- + ``(A) In general.--Notwithstanding any other + provision of this title (or any amendment made by this + title)-- + ``(i) nothing in this title (or any amendment + made by this title), shall be construed to require + a qualified health plan to provide coverage of + services described in subparagraph (B)(i) or + (B)(ii) as part of its essential health benefits + for any plan year; and + ``(ii) subject to subsection (a), the issuer + of a qualified health plan shall determine whether + or not the plan provides coverage of services + described in subparagraph (B)(i) or (B)(ii) as + part of such benefits for the plan year. + ``(B) Abortion services.-- + ``(i) Abortions for which public funding is + prohibited.--The services described in this clause + are abortions for which the expenditure of Federal + funds appropriated for the Department of Health + and Human Services is not permitted, based on the + law as in effect as of the date that is 6 months + before the beginning of the plan year involved. + ``(ii) Abortions for which public funding is + allowed.--The services described in this clause + are abortions for which the expenditure of Federal + funds appropriated for the Department of Health + and Human Services is permitted, based on the law + as in effect as of the date that is 6 months + before the beginning of the plan year involved. + ``(2) Prohibition on the use of federal funds.-- + ``(A) In general.--If a qualified health plan + provides coverage of services described in paragraph + (1)(B)(i), the issuer of the plan shall not use any + amount attributable to any of the following for purposes + of paying for such services: + ``(i) The credit under section 36B of the + Internal Revenue Code of 1986 (and the amount (if + any) of the advance payment of the credit under + section 1412 of the Patient Protection and + Affordable Care Act). + ``(ii) Any cost-sharing reduction under + section 1402 of the Patient Protection and + Affordable Care Act (and the amount (if any) of + the advance payment of the reduction under section + 1412 of the Patient Protection and Affordable Care + Act). + ``(B) Establishment of allocation accounts.--In the + case of a plan to which subparagraph (A) applies, the + issuer of the plan shall-- + +[[Page 124 STAT. 898]] + + ``(i) collect from each enrollee in the plan + (without regard to the enrollee's age, sex, or + family status) a separate payment for each of the + following: + ``(I) an amount equal to the portion + of the premium to be paid directly by + the enrollee for coverage under the plan + of services other than services + described in paragraph (1)(B)(i) (after + reduction for credits and cost-sharing + reductions described in subparagraph + (A)); and + ``(II) an amount equal to the + actuarial value of the coverage of + services described in paragraph + (1)(B)(i), and + ``(ii) shall deposit all such separate + payments into separate allocation accounts as + provided in subparagraph (C). + In the case of an enrollee whose premium for coverage + under the plan is paid through employee payroll deposit, + the separate payments required under this subparagraph + shall each be paid by a separate deposit. + ``(C) Segregation of funds.-- + ``(i) In general.--The issuer of a plan to + which subparagraph (A) applies shall establish + allocation accounts described in clause (ii) for + enrollees receiving amounts described in + subparagraph (A). + ``(ii) Allocation accounts.--The issuer of a + plan to which subparagraph (A) applies shall + deposit-- + ``(I) all payments described in + subparagraph (B)(i)(I) into a separate + account that consists solely of such + payments and that is used exclusively to + pay for services other than services + described in paragraph (1)(B)(i); and + ``(II) all payments described in + subparagraph (B)(i)(II) into a separate + account that consists solely of such + payments and that is used exclusively to + pay for services described in paragraph + (1)(B)(i). + ``(D) Actuarial value.-- + ``(i) In general.--The issuer of a qualified + health plan shall estimate the basic per enrollee, + per month cost, determined on an average actuarial + basis, for including coverage under the qualified + health plan of the services described in paragraph + (1)(B)(i). + ``(ii) Considerations.--In making such + estimate, the issuer-- + ``(I) may take into account the + impact on overall costs of the inclusion + of such coverage, but may not take into + account any cost reduction estimated to + result from such services, including + prenatal care, delivery, or postnatal + care; + ``(II) shall estimate such costs as + if such coverage were included for the + entire population covered; and + ``(III) may not estimate such a cost + at less than $1 per enrollee, per month. + ``(E) Ensuring compliance with segregation + requirements.-- + +[[Page 124 STAT. 899]] + + ``(i) In general.--Subject to clause (ii), + State health insurance commissioners shall ensure + that health plans comply with the segregation + requirements in this subsection through the + segregation of plan funds in accordance with + applicable provisions of generally accepted + accounting requirements, circulars on funds + management of the Office of Management and Budget, + and guidance on accounting of the Government + Accountability Office. + ``(ii) Clarification.--Nothing in clause (i) + shall prohibit the right of an individual or + health plan to appeal such action in courts of + competent jurisdiction. + ``(3) Rules relating to notice.-- + ``(A) Notice.--A qualified health plan that provides + for coverage of the services described in paragraph + (1)(B)(i) shall provide a notice to enrollees, only as + part of the summary of benefits and coverage + explanation, at the time of enrollment, of such + coverage. + ``(B) Rules relating to payments.--The notice + described in subparagraph (A), any advertising used by + the issuer with respect to the plan, any information + provided by the Exchange, and any other information + specified by the Secretary shall provide information + only with respect to the total amount of the combined + payments for services described in paragraph (1)(B)(i) + and other services covered by the plan. + ``(4) No discrimination on basis of provision of abortion.-- + No qualified health plan offered through an Exchange may + discriminate against any individual health care provider or + health care facility because of its unwillingness to provide, + pay for, provide coverage of, or refer for abortions + + ``(c) Application of State and Federal Laws Regarding Abortion.-- + ``(1) No preemption of state laws regarding abortion.-- + Nothing in this Act shall be construed to preempt or otherwise + have any effect on State laws regarding the prohibition of (or + requirement of) coverage, funding, or procedural requirements on + abortions, including parental notification or consent for the + performance of an abortion on a minor. + ``(2) No effect on federal laws regarding abortion.-- + ``(A) In general.--Nothing in this Act shall be + construed to have any effect on Federal laws regarding-- + ``(i) conscience protection; + ``(ii) willingness or refusal to provide + abortion; and + ``(iii) discrimination on the basis of the + willingness or refusal to provide, pay for, cover, + or refer for abortion or to provide or participate + in training to provide abortion. + ``(3) No effect on federal civil rights law.--Nothing in + this subsection shall alter the rights and obligations of + employees and employers under title VII of the Civil Rights Act + of 1964. + + ``(d) Application of Emergency Services Laws.--Nothing in this Act +shall be construed to relieve any health care provider from providing +emergency services as required by State or Federal law, including +section 1867 of the Social Security Act (popularly known as +`EMTALA').''. + +[[Page 124 STAT. 900]] + + (d) <<NOTE: 42 USC 18024.>> Section 1304 of this Act is amended by +adding at the end the following: + + ``(e) <<NOTE: Definition.>> Educated Health Care Consumers.--The +term `educated health care consumer' means an individual who is +knowledgeable about the health care system, and has background or +experience in making informed decisions regarding health, medical, and +scientific matters.''. + + (e) <<NOTE: 42 USC 18031.>> Section 1311(d) of this Act is +amended-- + (1) in paragraph (3)(B), by striking clause (ii) and + inserting the following: + ``(ii) State must assume cost.--A State shall + make payments-- + ``(I) to an individual enrolled in a + qualified health plan offered in such + State; or + ``(II) on behalf of an individual + described in subclause (I) directly to + the qualified health plan in which such + individual is enrolled; + to defray the cost of any additional benefits + described in clause (i).''; and + (2) in paragraph (6)(A), by inserting ``educated'' before + ``health care''. + + (f) Section 1311(e) of this Act is amended-- + (1) in paragraph (2), by striking ``may'' in the second + sentence and inserting ``shall''; and + (2) by adding at the end the following: + ``(3) Transparency in coverage.-- + ``(A) <<NOTE: Public information.>> In general.-- + The Exchange shall require health plans seeking + certification as qualified health plans to submit to the + Exchange, the Secretary, the State insurance + commissioner, and make available to the public, accurate + and timely disclosure of the following information: + ``(i) Claims payment policies and practices. + ``(ii) Periodic financial disclosures. + ``(iii) Data on enrollment. + ``(iv) Data on disenrollment. + ``(v) Data on the number of claims that are + denied. + ``(vi) Data on rating practices. + ``(vii) Information on cost-sharing and + payments with respect to any out-of-network + coverage. + ``(viii) Information on enrollee and + participant rights under this title. + ``(ix) Other information as determined + appropriate by the Secretary. + ``(B) Use of plain language.--The information + required to be submitted under subparagraph (A) shall be + provided in plain language. <<NOTE: Definition.>> The + term `plain language' means language that the intended + audience, including individuals with limited English + proficiency, can readily understand and use because that + language is concise, well-organized, and follows other + best practices of plain language + writing. <<NOTE: Guidance.>> The Secretary and the + Secretary of Labor shall jointly develop and issue + guidance on best practices of plain language writing. + ``(C) Cost sharing transparency.--The Exchange shall + require health plans seeking certification as qualified + health plans to permit individuals to learn the amount + of cost-sharing (including deductibles, copayments, and + +[[Page 124 STAT. 901]] + + coinsurance) under the individual's plan or coverage + that the individual would be responsible for paying with + respect to the furnishing of a specific item or service + by a participating provider in a timely manner upon the + request of the individual. <<NOTE: Web posting.>> At a + minimum, such information shall be made available to + such individual through an Internet website and such + other means for individuals without access to the + Internet. + ``(D) Group health plans.--The Secretary of Labor + shall update and harmonize the Secretary's rules + concerning the accurate and timely disclosure to + participants by group health plans of plan disclosure, + plan terms and conditions, and periodic financial + disclosure with the standards established by the + Secretary under subparagraph (A).''. + + (g) <<NOTE: 42 USC 18031.>> Section 1311(g)(1) of this Act is +amended-- + (1) in subparagraph (C), by striking ``; and'' and inserting + a semicolon; + (2) in subparagraph (D), by striking the period and + inserting ``; and''; and + (3) by adding at the end the following: + ``(E) the implementation of activities to reduce + health and health care disparities, including through + the use of language services, community outreach, and + cultural competency trainings.''. + + (h) Section 1311(i)(2)((B) of this Act is amended by striking +``small business development centers'' and inserting ``resource partners +of the Small Business Administration''. + (i) <<NOTE: 42 USC 18032.>> Section 1312 of this Act is amended-- + (1) in subsection (a)(1), by inserting ``and for which such + individual is eligible'' before the period; + (2) in subsection (e)-- + (A) in paragraph (1), by inserting ``and employers'' + after ``enroll individuals''; and + (B) by striking the flush sentence at the end; and + (3) in subsection (f)(1)(A)(ii), by striking the + parenthetical. + + (j)(1) Subparagraph (B) of section 1313(a)(6) <<NOTE: 42 USC 18033 +note.>> of this Act is hereby deemed null, void, and of no effect. + + (2) Section 3730(e) of title 31, United States Code, is amended by +striking paragraph (4) and inserting the following: + ``(4)(A) <<NOTE: Courts.>> The court shall dismiss an + action or claim under this section, unless opposed by the + Government, if substantially the same allegations or + transactions as alleged in the action or claim were publicly + disclosed-- + ``(i) in a Federal criminal, civil, or + administrative hearing in which the Government or its + agent is a party; + ``(ii) in a congressional, Government Accountability + Office, or other Federal report, hearing, audit, or + investigation; or + ``(iii) from the news media, + unless the action is brought by the Attorney General or the + person bringing the action is an original source of the + information. + ``(B) <<NOTE: Definition.>> For purposes of this paragraph, + ``original source'' means an individual who either (i) prior to + a public disclosure under subsection (e)(4)(a), has voluntarily + disclosed to the + +[[Page 124 STAT. 902]] + + Government the information on which allegations or transactions + in a claim are based, or (2) who has knowledge that is + independent of and materially adds to the publicly disclosed + allegations or transactions, and who has voluntarily provided + the information to the Government before filing an action under + this section.''. + + (k) <<NOTE: 42 USC 18033.>> Section 1313(b) of this Act is +amended-- + (1) in paragraph (3), by striking ``and'' at the end; + (2) by redesignating paragraph (4) as paragraph (5); and + (3) by inserting after paragraph (3) the following: + ``(4) a survey of the cost and affordability of health care + insurance provided under the Exchanges for owners and employees + of small business concerns (as defined under section 3 of the + Small Business Act (15 U.S.C. 632)), including data on enrollees + in Exchanges and individuals purchasing health insurance + coverage outside of Exchanges; and''. + + (l) <<NOTE: 42 USC 18042.>> Section 1322(b) of this Act is +amended-- + (1) by redesignating paragraph (3) as paragraph (4); and + (2) by inserting after paragraph (2), the following: + ``(3) <<NOTE: Deadlines. Regulations.>> Repayment of loans + and grants.--Not later than July 1, 2013, and prior to awarding + loans and grants under the CO-OP program, the Secretary shall + promulgate regulations with respect to the repayment of such + loans and grants in a manner that is consistent with State + solvency regulations and other similar State laws that may + apply. In promulgating such regulations, the Secretary shall + provide that such loans shall be repaid within 5 years and such + grants shall be repaid within 15 years, taking into + consideration any appropriate State reserve requirements, + solvency regulations, and requisite surplus note arrangements + that must be constructed in a State to provide for such + repayment prior to awarding such loans and grants.''. + + (m) <<NOTE: 42 USC 18043.>> Part III of subtitle D of title I of +this Act is amended by striking section 1323. + + (n) <<NOTE: 42 USC 18044.>> Section 1324(a) of this Act is amended +by striking ``, a community health'' and all that follows through +``1333(b)'' and inserting ``, or a multi-State qualified health plan +under section 1334''. + + (o) <<NOTE: 42 USC 18051.>> Section 1331 of this Act is amended-- + (1) in subsection (d)(3)(A)(i), by striking ``85'' and + inserting ``95''; and + (2) in subsection (e)(1)(B), by inserting before the + semicolon the following: ``, or, in the case of an alien + lawfully present in the United States, whose income is not + greater than 133 percent of the poverty line for the size of the + family involved but who is not eligible for the Medicaid program + under title XIX of the Social Security Act by reason of such + alien status''. + + (p) <<NOTE: 42 USC 18053.>> Section 1333 of this Act is amended by +striking subsection (b). + + (q) Part IV of subtitle D of title I of this Act is amended by +adding at the end the following: + +``SEC. 1334. <<NOTE: Contracts. 42 USC 18054.>> MULTI-STATE PLANS. + + ``(a) Oversight by the Office of Personnel Management.-- + ``(1) In general.--The Director of the Office of Personnel + Management (referred to in this section as the `Director') shall + enter into contracts with health insurance issuers (which may + +[[Page 124 STAT. 903]] + + include a group of health insurance issuers affiliated either by + common ownership and control or by the common use of a + nationally licensed service mark), without regard to section 5 + of title 41, United States Code, or other statutes requiring + competitive bidding, to offer at least 2 multi-State qualified + health plans through each Exchange in each State. Such plans + shall provide individual, or in the case of small employers, + group coverage. + ``(2) Terms.--Each contract entered into under paragraph (1) + shall be for a uniform term of at least 1 year, but may be made + automatically renewable from term to term in the absence of + notice of termination by either party. In entering into such + contracts, the Director shall ensure that health benefits + coverage is provided in accordance with the types of coverage + provided for under section 2701(a)(1)(A)(i) of the Public Health + Service Act. + ``(3) Non-profit entities.--In entering into contracts under + paragraph (1), the Director shall ensure that at least one + contract is entered into with a non-profit entity. + ``(4) Administration.--The Director shall implement this + subsection in a manner similar to the manner in which the + Director implements the contracting provisions with respect to + carriers under the Federal employees health benefit program + under chapter 89 of title 5, United States Code, including + (through negotiating with each multi-state plan)-- + ``(A) a medical loss ratio; + ``(B) a profit margin; + ``(C) the premiums to be charged; and + ``(D) such other terms and conditions of coverage as + are in the interests of enrollees in such plans. + ``(5) Authority to protect consumers.--The Director may + prohibit the offering of any multi-State health plan that does + not meet the terms and conditions defined by the Director with + respect to the elements described in subparagraphs (A) through + (D) of paragraph (4). + ``(6) Assured availability of varied coverage.--In entering + into contracts under this subsection, the Director shall ensure + that with respect to multi-State qualified health plans offered + in an Exchange, there is at least one such plan that does not + provide coverage of services described in section + 1303(b)(1)(B)(i). + ``(7) Withdrawal.--Approval of a contract under this + subsection may be withdrawn by the Director only after notice + and opportunity for hearing to the issuer concerned without + regard to subchapter II of chapter 5 and chapter 7 of title 5, + United States Code. + + ``(b) Eligibility.--A health insurance issuer shall be eligible to +enter into a contract under subsection (a)(1) if such issuer-- + ``(1) agrees to offer a multi-State qualified health plan + that meets the requirements of subsection (c) in each Exchange + in each State; + ``(2) is licensed in each State and is subject to all + requirements of State law not inconsistent with this section, + including the standards and requirements that a State imposes + that do not prevent the application of a requirement of part A + of title XXVII of the Public Health Service Act or a requirement + of this title; + +[[Page 124 STAT. 904]] + + ``(3) otherwise complies with the minimum standards + prescribed for carriers offering health benefits plans under + section 8902(e) of title 5, United States Code, to the extent + that such standards do not conflict with a provision of this + title; and + ``(4) meets such other requirements as determined + appropriate by the Director, in consultation with the Secretary. + + ``(c) Requirements for Multi-State Qualified Health Plan.-- + ``(1) In general.--A multi-State qualified health plan meets + the requirements of this subsection if, in the determination of + the Director-- + ``(A) the plan offers a benefits package that is + uniform in each State and consists of the essential + benefits described in section 1302; + ``(B) the plan meets all requirements of this title + with respect to a qualified health plan, including + requirements relating to the offering of the bronze, + silver, and gold levels of coverage and catastrophic + coverage in each State Exchange; + ``(C) except as provided in paragraph (5), the + issuer provides for determinations of premiums for + coverage under the plan on the basis of the rating + requirements of part A of title XXVII of the Public + Health Service Act; and + ``(D) the issuer offers the plan in all geographic + regions, and in all States that have adopted adjusted + community rating before the date of enactment of this + Act. + ``(2) States may offer additional benefits.--Nothing in + paragraph (1)(A) shall preclude a State from requiring that + benefits in addition to the essential health benefits required + under such paragraph be provided to enrollees of a multi-State + qualified health plan offered in such State. + ``(3) Credits.-- + ``(A) In general.--An individual enrolled in a + multi-State qualified health plan under this section + shall be eligible for credits under section 36B of the + Internal Revenue Code of 1986 and cost sharing + assistance under section 1402 in the same manner as an + individual who is enrolled in a qualified health plan. + ``(B) No additional federal cost.--A requirement by + a State under paragraph (2) that benefits in addition to + the essential health benefits required under paragraph + (1)(A) be provided to enrollees of a multi-State + qualified health plan shall not affect the amount of a + premium tax credit provided under section 36B of the + Internal Revenue Code of 1986 with respect to such plan. + ``(4) State must assume cost.--A State shall make payments-- + ``(A) to an individual enrolled in a multi-State + qualified health plan offered in such State; or + ``(B) on behalf of an individual described in + subparagraph (A) directly to the multi-State qualified + health plan in which such individual is enrolled; + to defray the cost of any additional benefits described in + paragraph (2). + ``(5) Application of certain state rating requirements.-- + With respect to a multi-State qualified health plan that is + offered in a State with age rating requirements that + +[[Page 124 STAT. 905]] + + are lower than 3:1, the State may require that Exchanges + operating in such State only permit the offering of such multi- + State qualified health plans if such plans comply with the + State's more protective age rating requirements. + + ``(d) Plans Deemed To Be Certified.--A multi-State qualified health +plan that is offered under a contract under subsection (a) shall be +deemed to be certified by an Exchange for purposes of section +1311(d)(4)(A). + ``(e) <<NOTE: Contracts.>> Phase-in.--Notwithstanding paragraphs +(1) and (2) of subsection (b), the Director shall enter into a contract +with a health insurance issuer for the offering of a multi-State +qualified health plan under subsection (a) if-- + ``(1) with respect to the first year for which the issuer + offers such plan, such issuer offers the plan in at least 60 + percent of the States; + ``(2) with respect to the second such year, such issuer + offers the plan in at least 70 percent of the States; + ``(3) with respect to the third such year, such issuer + offers the plan in at least 85 percent of the States; and + ``(4) with respect to each subsequent year, such issuer + offers the plan in all States. + + ``(f) Applicability.--The requirements under chapter 89 of title 5, +United States Code, applicable to health benefits plans under such +chapter shall apply to multi-State qualified health plans provided for +under this section to the extent that such requirements do not conflict +with a provision of this title. + ``(g) Continued Support for FEHBP.-- + ``(1) Maintenance of effort.--Nothing in this section shall + be construed to permit the Director to allocate fewer financial + or personnel resources to the functions of the Office of + Personnel Management related to the administration of the + Federal Employees Health Benefit Program under chapter 89 of + title 5, United States Code. + ``(2) Separate risk pool.--Enrollees in multi-State + qualified health plans under this section shall be treated as a + separate risk pool apart from enrollees in the Federal Employees + Health Benefit Program under chapter 89 of title 5, United + States Code. + ``(3) Authority to establish separate entities.--The + Director may establish such separate units or offices within the + Office of Personnel Management as the Director determines to be + appropriate to ensure that the administration of multi-State + qualified health plans under this section does not interfere + with the effective administration of the Federal Employees + Health Benefit Program under chapter 89 of title 5, United + States Code. + ``(4) Effective oversight.--The Director may appoint such + additional personnel as may be necessary to enable the Director + to carry out activities under this section. + ``(5) Assurance of separate program.--In carrying out this + section, the Director shall ensure that the program under this + section is separate from the Federal Employees Health Benefit + Program under chapter 89 of title 5, United States Code. + Premiums paid for coverage under a multi-State qualified health + plan under this section shall not be considered to be Federal + funds for any purposes. + +[[Page 124 STAT. 906]] + + ``(6) FEHBP plans not required to participate.--Nothing in + this section shall require that a carrier offering coverage + under the Federal Employees Health Benefit Program under chapter + 89 of title 5, United States Code, also offer a multi-State + qualified health plan under this section. + + ``(h) <<NOTE: Establishment.>> Advisory Board.--The Director shall +establish an advisory board to provide recommendations on the activities +described in this section. A significant percentage of the members of +such board shall be comprised of enrollees in a multi-State qualified +health plan, or representatives of such enrollees. + + ``(i) Authorization of Appropriations.--There is authorized to be +appropriated, such sums as may be necessary to carry out this +section.''. + (r) <<NOTE: 42 USC 18061.>> Section 1341 of this Act is amended-- + (1) in the section heading, by striking ``and small group + markets'' and inserting ``market''; + (2) in subsection (b)(2)(B), by striking ``paragraph + (1)(A)'' and inserting ``paragraph (1)(B)''; and + (3) in subsection (c)(1)(A), by striking ``and small group + markets'' and inserting ``market''. + +SEC. 10105. AMENDMENTS TO SUBTITLE E. + + (a) Section 36B(b)(3)(A)(ii) of the Internal Revenue Code of 1986, +as added by section 1401(a) of this Act, <<NOTE: 26 USC 36B.>> is +amended by striking ``is in excess of'' and inserting ``equals or +exceeds''. + + (b) Section 36B(c)(1)(A) of the Internal Revenue Code of 1986, as +added by section 1401(a) of this Act, is amended by inserting ``equals +or'' before ``exceeds''. + (c) Section 36B(c)(2)(C)(iv) of the Internal Revenue Code of 1986, +as added by section 1401(a) of this Act, is amended by striking +``subsection (b)(3)(A)(ii)'' and inserting ``subsection +(b)(3)(A)(iii)''. + (d) <<NOTE: 26 USC 6211.>> Section 1401(d) of this Act is amended +by adding at the end the following: + ``(3) Section 6211(b)(4)(A) of the Internal Revenue Code of + 1986 is amended by inserting `36B,' after `36A,'.''. + + (e)(1) Subparagraph (B) of section 45R(d)(3) of the Internal Revenue +Code of 1986, as added by section 1421(a) <<NOTE: 26 USC 45R.>> of this +Act, is amended to read as follows: + ``(B) Dollar amount.--For purposes of paragraph + (1)(B) and subsection (c)(2)-- + ``(i) 2010, 2011, 2012, and 2013.--The dollar + amount in effect under this paragraph for taxable + years beginning in 2010, 2011, 2012, or 2013 is + $25,000. + ``(ii) Subsequent years.--In the case of a + taxable year beginning in a calendar year after + 2013, the dollar amount in effect under this + paragraph shall be equal to $25,000, multiplied by + the cost-of-living adjustment under section + 1(f)(3) for the calendar year, determined by + substituting `calendar year 2012' for `calendar + year 1992' in subparagraph (B) thereof.''. + + (2) Subsection (g) of section 45R of the Internal Revenue Code of +1986, as added by section 1421(a) of this Act, is amended by striking +``2011'' both places it appears and inserting ``2010, 2011''. + (3) Section 280C(h) of the Internal Revenue Code of 1986, as added +by section 1421(d)(1) of this Act, <<NOTE: 26 USC 280C.>> is amended by +striking ``2011'' and inserting ``2010, 2011''. + +[[Page 124 STAT. 907]] + + (4) <<NOTE: 26 USC 38 note.>> Section 1421(f) of this Act is +amended by striking ``2010'' both places it appears and inserting +``2009''. + + (5) <<NOTE: 26 USC 45R note.>> The amendments made by this +subsection shall take effect as if included in the enactment of section +1421 of this Act. + + (f) Part I of subtitle E of title I of this Act is amended by adding +at the end of subpart B, the following: + +``SEC. 1416. STUDY OF GEOGRAPHIC VARIATION IN APPLICATION OF FPL. + + ``(a) In General.--The Secretary shall conduct a study to examine +the feasibility and implication of adjusting the application of the +Federal poverty level under this subtitle (and the amendments made by +this subtitle) for different geographic areas so as to reflect the +variations in cost-of-living among different areas within the United +States. <<NOTE: Determination.>> If the Secretary determines that an +adjustment is feasible, the study should include a methodology to make +such an adjustment. <<NOTE: Deadline. Reports. Recommenda- tions.>> Not +later than January 1, 2013, the Secretary shall submit to Congress a +report on such study and shall include such recommendations as the +Secretary determines appropriate. + + ``(b) Inclusion of Territories.-- + ``(1) In general.--The Secretary shall ensure that the study + under subsection (a) covers the territories of the United States + and that special attention is paid to the disparity that exists + among poverty levels and the cost of living in such territories + and to the impact of such disparity on efforts to expand health + coverage and ensure health care. + ``(2) Territories defined.--In this subsection, the term + `territories of the United States' includes the Commonwealth of + Puerto Rico, the United States Virgin Islands, Guam, the + Northern Mariana Islands, and any other territory or possession + of the United States.''. + +SEC. 10106. AMENDMENTS TO SUBTITLE F. + + (a) <<NOTE: 42 USC 18091.>> Section 1501(a)(2) of this Act is +amended to read as follows: + ``(2) Effects on the national economy and interstate + commerce.--The effects described in this paragraph are the + following: + ``(A) The requirement regulates activity that is + commercial and economic in nature: economic and + financial decisions about how and when health care is + paid for, and when health insurance is purchased. In the + absence of the requirement, some individuals would make + an economic and financial decision to forego health + insurance coverage and attempt to self-insure, which + increases financial risks to households and medical + providers. + ``(B) Health insurance and health care services are + a significant part of the national economy. National + health spending is projected to increase from + $2,500,000,000,000, or 17.6 percent of the economy, in + 2009 to $4,700,000,000,000 in 2019. Private health + insurance spending is projected to be $854,000,000,000 + in 2009, and pays for medical supplies, drugs, and + equipment that are shipped in interstate commerce. Since + most health insurance is sold by national or regional + health insurance companies, health insurance is sold in + interstate commerce and claims payments flow through + interstate commerce. + +[[Page 124 STAT. 908]] + + ``(C) The requirement, together with the other + provisions of this Act, will add millions of new + consumers to the health insurance market, increasing the + supply of, and demand for, health care services, and + will increase the number and share of Americans who are + insured. + ``(D) The requirement achieves near-universal + coverage by building upon and strengthening the private + employer-based health insurance system, which covers + 176,000,000 Americans nationwide. In Massachusetts, a + similar requirement has strengthened private employer- + based coverage: despite the economic downturn, the + number of workers offered employer-based coverage has + actually increased. + ``(E) The economy loses up to $207,000,000,000 a + year because of the poorer health and shorter lifespan + of the uninsured. By significantly reducing the number + of the uninsured, the requirement, together with the + other provisions of this Act, will significantly reduce + this economic cost. + ``(F) The cost of providing uncompensated care to + the uninsured was $43,000,000,000 in 2008. To pay for + this cost, health care providers pass on the cost to + private insurers, which pass on the cost to families. + This cost-shifting increases family premiums by on + average over $1,000 a year. By significantly reducing + the number of the uninsured, the requirement, together + with the other provisions of this Act, will lower health + insurance premiums. + ``(G) 62 percent of all personal bankruptcies are + caused in part by medical expenses. By significantly + increasing health insurance coverage, the requirement, + together with the other provisions of this Act, will + improve financial security for families. + ``(H) Under the Employee Retirement Income Security + Act of 1974 (29 U.S.C. 1001 et seq.), the Public Health + Service Act (42 U.S.C. 201 et seq.), and this Act, the + Federal Government has a significant role in regulating + health insurance. The requirement is an essential part + of this larger regulation of economic activity, and the + absence of the requirement would undercut Federal + regulation of the health insurance market. + ``(I) Under sections 2704 and 2705 of the Public + Health Service Act (as added by section 1201 of this + Act), if there were no requirement, many individuals + would wait to purchase health insurance until they + needed care. By significantly increasing health + insurance coverage, the requirement, together with the + other provisions of this Act, will minimize this adverse + selection and broaden the health insurance risk pool to + include healthy individuals, which will lower health + insurance premiums. The requirement is essential to + creating effective health insurance markets in which + improved health insurance products that are guaranteed + issue and do not exclude coverage of pre-existing + conditions can be sold. + ``(J) Administrative costs for private health + insurance, which were $90,000,000,000 in 2006, are 26 to + 30 percent of premiums in the current individual and + small group + +[[Page 124 STAT. 909]] + + markets. By significantly increasing health insurance + coverage and the size of purchasing pools, which will + increase economies of scale, the requirement, together + with the other provisions of this Act, will + significantly reduce administrative costs and lower + health insurance premiums. The requirement is essential + to creating effective health insurance markets that do + not require underwriting and eliminate its associated + administrative costs.''. + + (b)(1) Section 5000A(b)(1) of the Internal Revenue Code of 1986, as +added by section 1501(b) of this Act, <<NOTE: 26 USC 5000A.>> is +amended to read as follows: + ``(1) In general.--If a taxpayer who is an applicable + individual, or an applicable individual for whom the taxpayer is + liable under paragraph (3), fails to meet the requirement of + subsection (a) for 1 or more months, then, except as provided in + subsection (e), there is hereby imposed on the taxpayer a + penalty with respect to such failures in the amount determined + under subsection (c).''. + (2) Paragraphs (1) and (2) of section 5000A(c) of the + Internal Revenue Code of 1986, as so added, are amended to read + as follows: + ``(1) In general.--The amount of the penalty imposed by this + section on any taxpayer for any taxable year with respect to + failures described in subsection (b)(1) shall be equal to the + lesser of-- + ``(A) the sum of the monthly penalty amounts + determined under paragraph (2) for months in the taxable + year during which 1 or more such failures occurred, or + ``(B) an amount equal to the national average + premium for qualified health plans which have a bronze + level of coverage, provide coverage for the applicable + family size involved, and are offered through Exchanges + for plan years beginning in the calendar year with or + within which the taxable year ends. + ``(2) Monthly penalty amounts.--For purposes of paragraph + (1)(A), the monthly penalty amount with respect to any taxpayer + for any month during which any failure described in subsection + (b)(1) occurred is an amount equal to \1/12\ of the greater of + the following amounts: + ``(A) Flat dollar amount.--An amount equal to the + lesser of-- + ``(i) the sum of the applicable dollar amounts + for all individuals with respect to whom such + failure occurred during such month, or + ``(ii) 300 percent of the applicable dollar + amount (determined without regard to paragraph + (3)(C)) for the calendar year with or within which + the taxable year ends. + ``(B) Percentage of income.--An amount equal to the + following percentage of the taxpayer's household income + for the taxable year: + ``(i) 0.5 percent for taxable years beginning + in 2014. + ``(ii) 1.0 percent for taxable years beginning + in 2015. + ``(iii) 2.0 percent for taxable years + beginning after 2015.''. + +[[Page 124 STAT. 910]] + + (3) Section 5000A(c)(3) of the Internal Revenue Code of 1986, as +added by section 1501(b) of this Act, <<NOTE: 26 USC 5000A.>> is +amended by striking ``$350'' and inserting ``$495''. + + (c) Section 5000A(d)(2)(A) of the Internal Revenue Code of 1986, as +added by section 1501(b) of this Act, is amended to read as follows: + ``(A) Religious conscience exemption.--Such term + shall not include any individual for any month if such + individual has in effect an exemption under section + 1311(d)(4)(H) of the Patient Protection and Affordable + Care Act which certifies that such individual is-- + ``(i) a member of a recognized religious sect + or division thereof which is described in section + 1402(g)(1), and + ``(ii) an adherent of established tenets or + teachings of such sect or division as described in + such section.''. + + (d) Section 5000A(e)(1)(C) of the Internal Revenue Code of 1986, as +added by section 1501(b) of this Act, is amended to read as follows: + ``(C) Special rules for individuals related to + employees.--For purposes of subparagraph (B)(i), if an + applicable individual is eligible for minimum essential + coverage through an employer by reason of a relationship + to an employee, the determination under subparagraph (A) + shall be made by reference to required contribution of + the employee.''. + + (e) Section 4980H(b) of the Internal Revenue Code of 1986, as added +by section 1513(a) of this Act, <<NOTE: 26 USC 4980H.>> is amended to +read as follows: + + ``(b) Large Employers With Waiting Periods Exceeding 60 Days.-- + ``(1) In general.--In the case of any applicable large + employer which requires an extended waiting period to enroll in + any minimum essential coverage under an employer-sponsored plan + (as defined in section 5000A(f)(2)), there is hereby imposed on + the employer an assessable payment of $600 for each full-time + employee of the employer to whom the extended waiting period + applies. + ``(2) <<NOTE: Definition.>> Extended waiting period.--The + term `extended waiting period' means any waiting period (as + defined in section 2701(b)(4) of the Public Health Service Act) + which exceeds 60 days.''. + + (f)(1) Subparagraph (A) of section 4980H(d)(4) of the Internal +Revenue Code of 1986, as added by section 1513(a) of this Act, is +amended by inserting ``, with respect to any month,'' after ``means''. + (2) Section 4980H(d)(2) of the Internal Revenue Code of 1986, as +added by section 1513(a) of this Act, is amended by adding at the end +the following: + ``(D) Application to construction industry + employers.--In the case of any employer the substantial + annual gross receipts of which are attributable to the + construction industry-- + ``(i) subparagraph (A) shall be applied by + substituting `who employed an average of at least + 5 full-time employees on business days during the + preceding calendar year and whose annual payroll + expenses + +[[Page 124 STAT. 911]] + + exceed $250,000 for such preceding calendar year' + for `who employed an average of at least 50 full- + time employees on business days during the + preceding calendar year', and + ``(ii) subparagraph (B) shall be applied by + substituting `5' for `50'.''. + + (3) <<NOTE: Applicability. 26 USC 4980H note.>> The amendment made +by paragraph (2) shall apply to months beginning after December 31, +2013. + + (g) Section 6056(b) of the Internal Revenue Code of 1986, as added +by section 1514(a) of the Act, <<NOTE: 26 USC 6056.>> is amended by +adding at the end the following new flush sentence: + +``The Secretary shall have the authority to review the accuracy of the +information provided under this subsection, including the applicable +large employer's share under paragraph (2)(C)(iv).''. + +SEC. 10107. AMENDMENTS TO SUBTITLE G. + + (a) Section 1562 of this Act <<NOTE: 42 USC 300gg-21.>> is amended, +in the amendment made by subsection (a)(2)(B)(iii), by striking +``subpart 1'' and inserting ``subparts I and II''; and + + (b) Subtitle G of title I of this Act is amended-- + (1) <<NOTE: 26 USC 9815; 29 USC 1185d; 42 USC 300gg-1-- + 300gg-3, 300gg-9, 300gg-11, 300gg-12, 300gg-21--300gg-23, 300gg- + 25--300gg-28, 300gg-62, 300gg-91, 18120.>> by redesignating + section 1562 (as amended) as section 1563; and + (2) by inserting after section 1561 the following: + +``SEC. 1562. GAO STUDY REGARDING THE RATE OF DENIAL OF COVERAGE AND + ENROLLMENT BY HEALTH INSURANCE ISSUERS AND GROUP HEALTH + PLANS. + + ``(a) In General.--The Comptroller General of the United States +(referred to in this section as the `Comptroller General') shall conduct +a study of the incidence of denials of coverage for medical services and +denials of applications to enroll in health insurance plans, as +described in subsection (b), by group health plans and health insurance +issuers. + ``(b) Data.-- + ``(1) In general.--In conducting the study described in + subsection (a), the Comptroller General shall consider samples + of data concerning the following: + ``(A)(i) denials of coverage for medical services to + a plan enrollees, by the types of services for which + such coverage was denied; and + ``(ii) the reasons such coverage was denied; and + ``(B)(i) incidents in which group health plans and + health insurance issuers deny the application of an + individual to enroll in a health insurance plan offered + by such group health plan or issuer; and + ``(ii) the reasons such applications are denied. + ``(2) Scope of data.-- + ``(A) Favorably resolved disputes.--The data that + the Comptroller General considers under paragraph (1) + shall include data concerning denials of coverage for + medical services and denials of applications for + enrollment in a plan by a group health plan or health + insurance issuer, where such group health plan or health + insurance issuer later approves such coverage or + application. + ``(B) All health plans.--The study under this + section shall consider data from varied group health + plans and health insurance plans offered by health + insurance issuers, + +[[Page 124 STAT. 912]] + + including qualified health plans and health plans that + are not qualified health plans. + + ``(c) Report.--Not later than one year after the date of enactment +of this Act, the Comptroller General shall submit to the Secretaries of +Health and Human Services and Labor a report describing the results of +the study conducted under this section. + ``(d) <<NOTE: Public information. Web posting.>> Publication of +Report.--The Secretaries of Health and Human Services and Labor shall +make the report described in subsection (c) available to the public on +an Internet website. + +``SEC. 1563. <<NOTE: 42 USC 18119.>> SMALL BUSINESS PROCUREMENT. + + ``Part 19 of the Federal Acquisition Regulation, section 15 of the +Small Business Act (15 U.S.C. 644), and any other applicable laws or +regulations establishing procurement requirements relating to small +business concerns (as defined in section 3 of the Small Business Act (15 +U.S.C. 632)) may not be waived with respect to any contract awarded +under any program or other authority under this Act or an amendment made +by this Act.''. + +SEC. 10108. <<NOTE: 42 USC 18101.>> FREE CHOICE VOUCHERS. + + (a) In General.--An offering employer shall provide free choice +vouchers to each qualified employee of such employer. + (b) Offering Employer.--For purposes of this section, the term +``offering employer'' means any employer who-- + (1) offers minimum essential coverage to its employees + consisting of coverage through an eligible employer-sponsored + plan; and + (2) pays any portion of the costs of such plan. + + (c) Qualified Employee.--For purposes of this section-- + (1) <<NOTE: Definition.>> In general.--The term ``qualified + employee'' means, with respect to any plan year of an offering + employer, any employee-- + (A) whose required contribution (as determined under + section 5000A(e)(1)(B)) for minimum essential coverage + through an eligible employer-sponsored plan-- + (i) exceeds 8 percent of such employee's + household income for the taxable year described in + section 1412(b)(1)(B) which ends with or within in + the plan year; and + (ii) does not exceed 9.8 percent of such + employee's household income for such taxable year; + (B) whose household income for such taxable year is + not greater than 400 percent of the poverty line for a + family of the size involved; and + (C) who does not participate in a health plan + offered by the offering employer. + (2) Indexing.--In the case of any calendar year beginning + after 2014, the Secretary shall adjust the 8 percent under + paragraph (1)(A)(i) and 9.8 percent under paragraph (1)(A)(ii) + for the calendar year to reflect the rate of premium growth + between the preceding calendar year and 2013 over the rate of + income growth for such period. + + (d) Free Choice Voucher.-- + (1) Amount.-- + (A) In general.--The amount of any free choice + voucher provided under subsection (a) shall be equal to + the monthly portion of the cost of the eligible + employer-sponsored plan which would have been paid by + the + +[[Page 124 STAT. 913]] + + employer if the employee were covered under the plan + with respect to which the employer pays the largest + portion of the cost of the plan. Such amount shall be + equal to the amount the employer would pay for an + employee with self-only coverage unless such employee + elects family coverage (in which case such amount shall + be the amount the employer would pay for family + coverage). + (B) <<NOTE: Regulations.>> Determination of cost.-- + The cost of any health plan shall be determined under + the rules similar to the rules of section 2204 of the + Public Health Service Act, except that such amount shall + be adjusted for age and category of enrollment in + accordance with regulations established by the + Secretary. + (2) Use of vouchers.--An Exchange shall credit the amount of + any free choice voucher provided under subsection (a) to the + monthly premium of any qualified health plan in the Exchange in + which the qualified employee is enrolled and the offering + employer shall pay any amounts so credited to the Exchange. + (3) Payment of excess amounts.--If the amount of the free + choice voucher exceeds the amount of the premium of the + qualified health plan in which the qualified employee is + enrolled for such month, such excess shall be paid to the + employee. + + (e) Other Definitions.--Any term used in this section which is also +used in section 5000A of the Internal Revenue Code of 1986 shall have +the meaning given such term under such section 5000A. + (f) Exclusion From Income for Employee.-- + (1) In general.--Part III of subchapter B of chapter 1 of + the Internal Revenue Code of 1986 is amended by inserting after + section 139C the following new section: + +``SEC. 139D. <<NOTE: 26 USC 139D.>> FREE CHOICE VOUCHERS. + + ``Gross income shall not include the amount of any free choice +voucher provided by an employer under section 10108 of the Patient +Protection and Affordable Care Act to the extent that the amount of such +voucher does not exceed the amount paid for a qualified health plan (as +defined in section 1301 of such Act) by the taxpayer.''. + (2) Clerical amendment.--The table of sections for part III + of subchapter B of chapter 1 of such Code is amended by + inserting after the item relating to section 139C the following + new item: + +``Sec. 139D. Free choice vouchers.''. + + (3) <<NOTE: 26 USC 139D note.>> Effective date.--The + amendments made by this subsection shall apply to vouchers + provided after December 31, 2013. + + (g) Deduction Allowed to Employer.-- + (1) In general.--Section 162(a) of the Internal Revenue Code + of 1986 <<NOTE: 26 USC 162.>> is amended by adding at the end + the following new sentence: ``For purposes of paragraph (1), the + amount of a free choice voucher provided under section 10108 of + the Patient Protection and Affordable Care Act shall be treated + as an amount for compensation for personal services actually + rendered.''. + +[[Page 124 STAT. 914]] + + (2) <<NOTE: 26 USC 162 note.>> Effective date.--The + amendments made by this subsection shall apply to vouchers + provided after December 31, 2013. + + (h) Voucher Taken Into Account in Determining Premium Credit.-- + (1) In general.--Subsection (c)(2) of section 36B of the + Internal Revenue Code of 1986, <<NOTE: 26 USC 36B.>> as added + by section 1401, is amended by adding at the end the following + new subparagraph: + ``(D) Exception for individual receiving free choice + vouchers.--The term `coverage month' shall not include + any month in which such individual has a free choice + voucher provided under section 10108 of the Patient + Protection and Affordable Care Act.''. + (2) <<NOTE: 26 USC 36B note.>> Effective date.--The + amendment made by this subsection shall apply to taxable years + beginning after December 31, 2013. + + (i) Coordination With Employer Responsibilities.-- + (1) Shared responsibility penalty.-- + (A) In general.--Subsection (c) of section 4980H of + the Internal Revenue Code of 1986, as added by section + 1513, is amended <<NOTE: 26 USC 4980H.>> by adding at + the end the following new paragraph: + ``(3) Special rules for employers providing free choice + vouchers.--No assessable payment shall be imposed under + paragraph (1) for any month with respect to any employee to whom + the employer provides a free choice voucher under section 10108 + of the Patient Protection and Affordable Care Act for such + month.''. + (B) <<NOTE: 26 USC 4980H note.>> Effective date.-- + The amendment made by this paragraph shall apply to + months beginning after December 31, 2013. + (2) Notification requirement.--Section 18B(a)(3) of the Fair + Labor Standards Act of 1938, <<NOTE: 29 USC 218b.>> as added by + section 1512, is amended-- + (A) by inserting ``and the employer does not offer a + free choice voucher'' after ``Exchange''; and + (B) by striking ``will lose'' and inserting ``may + lose''. + + (j) Employer Reporting.-- + (1) In general.--Subsection (a) of section 6056 of the + Internal Revenue Code of 1986, <<NOTE: 26 USC 6056.>> as added + by section 1514, is amended by inserting ``and every offering + employer'' before ``shall''. + (2) Offering employers.--Subsection (f) of section 6056 of + such Code, as added by section 1514, is amended to read as + follows: + + ``(f) Definitions.--For purposes of this section-- + ``(1) Offering employer.-- + ``(A) In general.--The term `offering employer' + means any offering employer (as defined in section + 10108(b) of the Patient Protection and Affordable Care + Act) if the required contribution (within the meaning of + section 5000A(e)(1)(B)(i)) of any employee exceeds 8 + percent of the wages (as defined in section 3121(a)) + paid to such employee by such employer. + ``(B) Indexing.--In the case of any calendar year + beginning after 2014, the 8 percent under subparagraph + (A) + +[[Page 124 STAT. 915]] + + shall be adjusted for the calendar year to reflect the + rate of premium growth between the preceding calendar + year and 2013 over the rate of income growth for such + period. + ``(2) Other definitions.--Any term used in this section + which is also used in section 4980H shall have the meaning given + such term by section 4980H.''. + (3) Conforming amendments.-- + (A) The heading of section 6056 of such Code, as + added by section 1514, <<NOTE: 26 USC 6056.>> is + amended by striking ``large'' and inserting ``certain''. + (B) Section 6056(b)(2)(C) of such Code is amended-- + (i) by inserting ``in the case of an + applicable large employer,'' before ``the length'' + in clause (i); + (ii) by striking ``and'' at the end of clause + (iii); + (iii) by striking ``applicable large + employer'' in clause (iv) and inserting + ``employer''; + (iv) by inserting ``and'' at the end of clause + (iv); and + (v) by inserting at the end the following new + clause: + ``(v) in the case of an offering employer, the + option for which the employer pays the largest + portion of the cost of the plan and the portion of + the cost paid by the employer in each of the + enrollment categories under such option,''. + (C) Section 6056(d)(2) of such Code is amended by + inserting ``or offering employer'' after ``applicable + large employer''. + (D) Section 6056(e) of such Code is amended by + inserting ``or offering employer'' after ``applicable + large employer''. + (E) Section 6724(d)(1)(B)(xxv) of such Code, as + added by section 1514, is amended by striking ``large'' + and inserting ``certain''. + (F) Section 6724(d)(2)(HH) of such Code, as added by + section 1514, is amended by striking ``large'' and + inserting ``certain''. + (G) The table of sections for subpart D of part III + of subchapter A of chapter 1 of such Code, as amended by + section 1514, is amended by striking ``Large employers'' + in the item relating to section 6056 and inserting + ``Certain employers''. + (4) <<NOTE: 26 USC 6056 note.>> Effective date.--The + amendments made by this subsection shall apply to periods + beginning after December 31, 2013. + +SEC. 10109. DEVELOPMENT OF STANDARDS FOR FINANCIAL AND ADMINISTRATIVE + TRANSACTIONS. + + (a) Additional Transaction Standards and Operating Rules.-- + (1) Development of additional transaction standards and + operating rules.--Section 1173(a) of the Social Security Act (42 + U.S.C. 1320d-2(a)), as amended by section 1104(b)(2), is + amended-- + (A) in paragraph (1)(B), by inserting before the + period the following: ``, and subject to the + requirements under paragraph (5)''; and + +[[Page 124 STAT. 916]] + + (B) by adding at the end the following new + paragraph: + ``(5) Consideration of standardization of activities and + items.-- + ``(A) <<NOTE: Deadlines.>> In general.--For + purposes of carrying out paragraph (1)(B), the Secretary + shall solicit, not later than January 1, 2012, and not + less than every 3 years thereafter, input from entities + described in subparagraph (B) on-- + ``(i) whether there could be greater + uniformity in financial and administrative + activities and items, as determined appropriate by + the Secretary; and + ``(ii) whether such activities should be + considered financial and administrative + transactions (as described in paragraph (1)(B)) + for which the adoption of standards and operating + rules would improve the operation of the health + care system and reduce administrative costs. + ``(B) Solicitation of input.--For purposes of + subparagraph (A), the Secretary shall seek input from-- + ``(i) the National Committee on Vital and + Health Statistics, the Health Information + Technology Policy Committee, and the Health + Information Technology Standards Committee; and + ``(ii) standard setting organizations and + stakeholders, as determined appropriate by the + Secretary.''. + + (b) <<NOTE: Deadline.>> Activities and Items for Initial +Consideration.--For purposes of section 1173(a)(5) of the Social +Security Act, as added by subsection (a), the Secretary of Health and +Human Services (in this section referred to as the ``Secretary'') shall, +not later than January 1, 2012, seek input on activities and items +relating to the following areas: + (1) Whether the application process, including the use of a + uniform application form, for enrollment of health care + providers by health plans could be made electronic and + standardized. + (2) Whether standards and operating rules described in + section 1173 of the Social Security Act should apply to the + health care transactions of automobile insurance, worker's + compensation, and other programs or persons not described in + section 1172(a) of such Act (42 U.S.C. 1320d-1(a)). + (3) Whether standardized forms could apply to financial + audits required by health plans, Federal and State agencies + (including State auditors, the Office of the Inspector General + of the Department of Health and Human Services, and the Centers + for Medicare & Medicaid Services), and other relevant entities + as determined appropriate by the Secretary. + (4) Whether there could be greater transparency and + consistency of methodologies and processes used to establish + claim edits used by health plans (as described in section + 1171(5) of the Social Security Act (42 U.S.C. 1320d(5))). + (5) Whether health plans should be required to publish their + timeliness of payment rules. + + (c) ICD Coding Crosswalks.-- + (1) <<NOTE: Meeting. Deadline.>> ICD-9 to icd-10 + crosswalk.--The Secretary shall task the ICD-9-CM Coordination + and Maintenance Committee to convene a meeting, not later than + January 1, 2011, to receive input from appropriate stakeholders + (including health plans, health care providers, and clinicians) + regarding the crosswalk + +[[Page 124 STAT. 917]] + + between the Ninth and Tenth Revisions of the International + Classification of Diseases (ICD-9 and ICD-10, respectively) that + is posted on the website of the Centers for Medicare & Medicaid + Services, and make recommendations about appropriate revisions + to such crosswalk. + (2) Revision of crosswalk.--For purposes of the crosswalk + described in paragraph (1), the Secretary shall make appropriate + revisions and post any such revised crosswalk on the website of + the Centers for Medicare & Medicaid Services. + (3) Use of revised crosswalk.--For purposes of paragraph + (2), any revised crosswalk shall be treated as a code set for + which a standard has been adopted by the Secretary for purposes + of section 1173(c)(1)(B) of the Social Security Act (42 U.S.C. + 1320d-2(c)(1)(B)). + (4) <<NOTE: Deadline.>> Subsequent crosswalks.--For + subsequent revisions of the International Classification of + Diseases that are adopted by the Secretary as a standard code + set under section 1173(c) of the Social Security Act (42 U.S.C. + 1320d-2(c)), the Secretary shall, after consultation with the + appropriate stakeholders, post on the website of the Centers for + Medicare & Medicaid Services a crosswalk between the previous + and subsequent version of the International Classification of + Diseases not later than the date of implementation of such + subsequent revision. + + Subtitle B--Provisions Relating to Title II + + PART I--MEDICAID AND CHIP + +SEC. 10201. AMENDMENTS TO THE SOCIAL SECURITY ACT AND TITLE II OF THIS + ACT. + + (a)(1) Section 1902(a)(10)(A)(i)(IX) of the Social Security Act (42 +U.S.C. 1396a(a)(10)(A)(i)(IX)), as added by section 2004(a), is amended +to read as follows: + ``(IX) who-- + ``(aa) are under 26 years of + age; + ``(bb) are not described in + or enrolled under any of + subclauses (I) through (VII) of + this clause or are described in + any of such subclauses but have + income that exceeds the level of + income applicable under the + State plan for eligibility to + enroll for medical assistance + under such subclause; + ``(cc) were in foster care + under the responsibility of the + State on the date of attaining + 18 years of age or such higher + age as the State has elected + under section 475(8)(B)(iii); + and + ``(dd) were enrolled in the + State plan under this title or + under a waiver of the plan while + in such foster care;''. + + (2) Section 1902(a)(10) of the Social Security Act (42 U.S.C. +1396a(a)(10), as amended by section 2001(a)(5)(A), is amended in the +matter following subparagraph (G), by striking ``and (XV)'' and +inserting ``(XV)'', and by inserting ``and (XVI) if an individual is +described in subclause (IX) of subparagraph (A)(i) and is also described +in subclause (VIII) of that subparagraph, the medical + +[[Page 124 STAT. 918]] + +assistance shall be made available to the individual through subclause +(IX) instead of through subclause (VIII)'' before the semicolon. + (3) <<NOTE: 42 USC 1396a note.>> Section 2004(d) of this Act is +amended by striking ``2019'' and inserting ``2014''. + + (b) Section 1902(k)(2) of the Social Security Act (42 U.S.C. +1396a(k)(2)), as added by section 2001(a)(4)(A), is amended by striking +``January 1, 2011'' and inserting ``April 1, 2010''. + (c) Section 1905 of the Social Security Act (42 U.S.C. 1396d), as +amended by sections 2001(a)(3), 2001(a)(5)(C), 2006, and 4107(a)(2), is +amended-- + (1) in subsection (a), in the matter preceding paragraph + (1), by inserting in clause (xiv), ``or 1902(a)(10)(A)(i)(IX)'' + before the comma; + (2) in subsection (b), in the first sentence, by inserting + ``, (z),'' before ``and (aa)''; + (3) in subsection (y)-- + (A) in paragraph (1)(B)(ii)(II), in the first + sentence, by inserting ``includes inpatient hospital + services,'' after ``100 percent of the poverty line, + that''; and + (B) in paragraph (2)(A), by striking ``on the date + of enactment of the Patient Protection and Affordable + Care Act'' and inserting ``as of December 1, 2009''; + (4) by inserting after subsection (y) the following: + + ``(z) Equitable Support for Certain States.-- + ``(1)(A) <<NOTE: Time period.>> During the period that + begins on January 1, 2014, and ends on September 30, 2019, + notwithstanding subsection (b), the Federal medical assistance + percentage otherwise determined under subsection (b) with + respect to a fiscal year occurring during that period shall be + increased by 2.2 percentage points for any State described in + subparagraph (B) for amounts expended for medical assistance for + individuals who are not newly eligible (as defined in subsection + (y)(2)) individuals described in subclause (VIII) of section + 1902(a)(10)(A)(i). + ``(B) For purposes of subparagraph (A), a State described in + this subparagraph is a State that-- + ``(i) is an expansion State described in subsection + (y)(1)(B)(ii)(II); + ``(ii) the Secretary determines will not receive any + payments under this title on the basis of an increased + Federal medical assistance percentage under subsection + (y) for expenditures for medical assistance for newly + eligible individuals (as so defined); and + ``(iii) has not been approved by the Secretary to + divert a portion of the DSH allotment for a State to the + costs of providing medical assistance or other health + benefits coverage under a waiver that is in effect on + July 2009. + + ``(2)(A) <<NOTE: Time period.>> During the period that begins on +January 1, 2014, and ends on December 31, 2016, notwithstanding +subsection (b), the Federal medical assistance percentage otherwise +determined under subsection (b) with respect to all or any portion of a +fiscal year occurring during that period shall be increased by .5 +percentage point for a State described in subparagraph (B) for amounts +expended for medical assistance under the State plan under this title or +under a waiver of that plan during that period. + + ``(B) For purposes of subparagraph (A), a State described in this +subparagraph is a State that-- + +[[Page 124 STAT. 919]] + + ``(i) is described in clauses (i) and (ii) of paragraph + (1)(B); and + ``(ii) is the State with the highest percentage of its + population insured during 2008, based on the Current Population + Survey. + + ``(3) <<NOTE: Nebraska. Determination.>> Notwithstanding subsection +(b) and paragraphs (1) and (2) of this subsection, the Federal medical +assistance percentage otherwise determined under subsection (b) with +respect to all or any portion of a fiscal year that begins on or after +January 1, 2017, for the State of Nebraska, with respect to amounts +expended for newly eligible individuals described in subclause (VIII) of +section 1902(a)(10)(A)(i), shall be determined as provided for under +subsection (y)(1)(A) (notwithstanding the period provided for in such +paragraph). + + ``(4) <<NOTE: Applicability.>> The increase in the Federal medical +assistance percentage for a State under paragraphs (1), (2), or (3) +shall apply only for purposes of this title and shall not apply with +respect to-- + ``(A) disproportionate share hospital payments described in + section 1923; + ``(B) payments under title IV; + ``(C) payments under title XXI; and + ``(D) payments under this title that are based on the + enhanced FMAP described in section 2105(b).''; + (5) in subsection (aa), is amended by striking ``without + regard to this subsection and subsection (y)'' and inserting + ``without regard to this subsection, subsection (y), subsection + (z), and section 10202 of the Patient Protection and Affordable + Care Act'' each place it appears; + (6) by adding after subsection (bb), the following: + + ``(cc) Requirement for Certain States.--Notwithstanding subsections +(y), (z), and (aa), in the case of a State that requires political +subdivisions within the State to contribute toward the non-Federal share +of expenditures required under the State plan under section 1902(a)(2), +the State shall not be eligible for an increase in its Federal medical +assistance percentage under such subsections if it requires that +political subdivisions pay a greater percentage of the non-Federal share +of such expenditures, or a greater percentage of the non-Federal share +of payments under section 1923, than the respective percentages that +would have been required by the State under the State plan under this +title, State law, or both, as in effect on December 31, 2009, and +without regard to any such increase. Voluntary contributions by a +political subdivision to the non-Federal share of expenditures under the +State plan under this title or to the non-Federal share of payments +under section 1923, shall not be considered to be required contributions +for purposes of this subsection. The treatment of voluntary +contributions, and the treatment of contributions required by a State +under the State plan under this title, or State law, as provided by this +subsection, shall also apply to the increases in the Federal medical +assistance percentage under section 5001 of the American Recovery and +Reinvestment Act of 2009.''. + (d) Section 1108(g)(4)(B) of the Social Security Act (42 U.S.C. +1308(g)(4)(B)), as added by section 2005(b), is amended by striking +``income eligibility level in effect for that population under title XIX +or under a waiver'' and inserting ``the highest income eligibility level +in effect for parents under the commonwealth's or territory's State plan +under title XIX or under a waiver of the plan''. + +[[Page 124 STAT. 920]] + + (e)(1) Section 1923(f) of the Social Security Act (42 U.S.C. 1396r- +4(f)), as amended by section 2551, is amended-- + (A) in paragraph (6)-- + (i) by striking the paragraph heading and inserting + the following: ``Allotment adjustments''; and + (ii) in subparagraph (B), by adding at the end the + following: + ``(iii) <<NOTE: Hawaii.>> Allotment for 2d, + 3rd, and 4th quarter of fiscal year 2012, fiscal + year 2013, and succeeding fiscal years.-- + Notwithstanding the table set forth in paragraph + (2) or paragraph (7): + ``(I) 2d, 3rd, and 4th quarter of + fiscal year 2012.--The DSH allotment for + Hawaii for the 2d, 3rd, and 4th quarters + of fiscal year 2012 shall be $7,500,000. + ``(II) Treatment as a low-dsh state + for fiscal year 2013 and succeeding + fiscal years.--With respect to fiscal + year 2013, and each fiscal year + thereafter, the DSH allotment for Hawaii + shall be increased in the same manner as + allotments for low DSH States are + increased for such fiscal year under + clause (iii) of paragraph (5)(B). + ``(III) Certain hospital payments.-- + The Secretary may not impose a + limitation on the total amount of + payments made to hospitals under the + QUEST section 1115 Demonstration Project + except to the extent that such + limitation is necessary to ensure that a + hospital does not receive payments in + excess of the amounts described in + subsection (g), or as necessary to + ensure that such payments under the + waiver and such payments pursuant to the + allotment provided in this clause do + not, in the aggregate in any year, + exceed the amount that the Secretary + determines is equal to the Federal + medical assistance percentage component + attributable to disproportionate share + hospital payment adjustments for such + year that is reflected in the budget + neutrality provision of the QUEST + Demonstration Project.''; and + (B) in paragraph (7)-- + (i) in subparagraph (A), in the matter preceding + clause (i), by striking ``subparagraph (E)'' and + inserting ``subparagraphs (E) and (G)''; + (ii) in subparagraph (B)-- + (I) in clause (i), by striking subclauses (I) + and (II), and inserting the following: + ``(I) if the State is a low DSH + State described in paragraph (5)(B) and + has spent not more than 99.90 percent of + the DSH allotments for the State on + average for the period of fiscal years + 2004 through 2008, as of September 30, + 2009, the applicable percentage is equal + to 25 percent; + ``(II) if the State is a low DSH + State described in paragraph (5)(B) and + has spent more than 99.90 percent of the + DSH allotments for the State on average + for the period of fiscal years 2004 + through + +[[Page 124 STAT. 921]] + + 2008, as of September 30, 2009, the + applicable percentage is equal to 17.5 + percent; + ``(III) if the State is not a low + DSH State described in paragraph (5)(B) + and has spent not more than 99.90 + percent of the DSH allotments for the + State on average for the period of + fiscal years 2004 through 2008, as of + September 30, 2009, the applicable + percentage is equal to 50 percent; and + ``(IV) if the State is not a low DSH + State described in paragraph (5)(B) and + has spent more than 99.90 percent of the + DSH allotments for the State on average + for the period of fiscal years 2004 + through 2008, as of September 30, 2009, + the applicable percentage is equal to 35 + percent.''; + (II) in clause (ii), by striking subclauses + (I) and (II), and inserting the following: + ``(I) if the State is a low DSH + State described in paragraph (5)(B) and + has spent not more than 99.90 percent of + the DSH allotments for the State on + average for the period of fiscal years + 2004 through 2008, as of September 30, + 2009, the applicable percentage is equal + to the product of the percentage + reduction in uncovered individuals for + the fiscal year from the preceding + fiscal year and 27.5 percent; + ``(II) if the State is a low DSH + State described in paragraph (5)(B) and + has spent more than 99.90 percent of the + DSH allotments for the State on average + for the period of fiscal years 2004 + through 2008, as of September 30, 2009, + the applicable percentage is equal to + the product of the percentage reduction + in uncovered individuals for the fiscal + year from the preceding fiscal year and + 20 percent; + ``(III) if the State is not a low + DSH State described in paragraph (5)(B) + and has spent not more than 99.90 + percent of the DSH allotments for the + State on average for the period of + fiscal years 2004 through 2008, as of + September 30, 2009, the applicable + percentage is equal to the product of + the percentage reduction in uncovered + individuals for the fiscal year from the + preceding fiscal year and 55 percent; + and + ``(IV) if the State is not a low DSH + State described in paragraph (5)(B) and + has spent more than 99.90 percent of the + DSH allotments for the State on average + for the period of fiscal years 2004 + through 2008, as of September 30, 2009, + the applicable percentage is equal to + the product of the percentage reduction + in uncovered individuals for the fiscal + year from the preceding fiscal year and + 40 percent.''; + (III) in subparagraph (E), by striking ``35 + percent'' and inserting ``50 percent''; and + (IV) by adding at the end the following: + +[[Page 124 STAT. 922]] + + ``(G) Nonapplication.--The preceding provisions of + this paragraph shall not apply to the DSH allotment + determined for the State of Hawaii for a fiscal year + under paragraph (6).''. + + (f) Section 2551 of this Act <<NOTE: 42 USC 1396r-4 note.>> is +amended by striking subsection (b). + + (g) Section 2105(d)(3)(B) of the Social Security Act (42 U.S.C. +1397ee(d)(3)(B)), as added by section 2101(b)(1), is amended by adding +at the end the following: ``For purposes of eligibility for premium +assistance for the purchase of a qualified health plan under section 36B +of the Internal Revenue Code of 1986 and reduced cost-sharing under +section 1402 of the Patient Protection and Affordable Care Act, children +described in the preceding sentence shall be deemed to be ineligible for +coverage under the State child health plan.''. + (h) Clause (i) of subparagraph (C) of section 513(b)(2) of the +Social Security Act, <<NOTE: 42 USC 713.>> as added by section 2953 of +this Act, is amended to read as follows: + ``(i) Healthy relationships, including + marriage and family interactions.''. + + (i) Section 1115 of the Social Security Act (42 U.S.C. 1315) is +amended by inserting after subsection (c) the following: + ``(d)(1) An application or renewal of any experimental, pilot, or +demonstration project undertaken under subsection (a) to promote the +objectives of title XIX or XXI in a State that would result in an impact +on eligibility, enrollment, benefits, cost-sharing, or financing with +respect to a State program under title XIX or XXI (in this subsection +referred to as a `demonstration project') shall be considered by the +Secretary in accordance with the regulations required to be promulgated +under paragraph (2). + ``(2) <<NOTE: Deadline. Regulations.>> Not later than 180 days after +the date of enactment of this subsection, the Secretary shall promulgate +regulations relating to applications for, and renewals of, a +demonstration project that provide for-- + ``(A) a process for public notice and comment at the State + level, including public hearings, sufficient to ensure a + meaningful level of public input; + ``(B) requirements relating to-- + ``(i) the goals of the program to be implemented or + renewed under the demonstration project; + ``(ii) the expected State and Federal costs and + coverage projections of the demonstration project; and + ``(iii) the specific plans of the State to ensure + that the demonstration project will be in compliance + with title XIX or XXI; + ``(C) a process for providing public notice and comment + after the application is received by the Secretary, that is + sufficient to ensure a meaningful level of public input; + ``(D) a process for the submission to the Secretary of + periodic reports by the State concerning the implementation of + the demonstration project; and + ``(E) a process for the periodic evaluation by the Secretary + of the demonstration project. + + ``(3) <<NOTE: Deadline. Reports.>> The Secretary shall annually +report to Congress concerning actions taken by the Secretary with +respect to applications for demonstration projects under this +section.''. + +[[Page 124 STAT. 923]] + + (j) Subtitle F of title III of this Act is amended by adding at the +end the following: + +``SEC. 3512. GAO STUDY AND REPORT ON CAUSES OF ACTION. + + ``(a) Study.-- + ``(1) In general.--The Comptroller General of the United + States shall conduct a study of whether the development, + recognition, or implementation of any guideline or other + standards under a provision described in paragraph (2) would + result in the establishment of a new cause of action or claim. + ``(2) Provisions described.--The provisions described in + this paragraph include the following: + ``(A) Section 2701 (adult health quality measures). + ``(B) Section 2702 (payment adjustments for health + care acquired conditions). + ``(C) Section 3001 (Hospital Value-Based Purchase + Program). + ``(D) Section 3002 (improvements to the Physician + Quality Reporting Initiative). + ``(E) Section 3003 (improvements to the Physician + Feedback Program). + ``(F) Section 3007 (value based payment modifier + under physician fee schedule). + ``(G) Section 3008 (payment adjustment for + conditions acquired in hospitals). + ``(H) Section 3013 (quality measure development). + ``(I) Section 3014 (quality measurement). + ``(J) Section 3021 (Establishment of Center for + Medicare and Medicaid Innovation). + ``(K) Section 3025 (hospital readmission reduction + program). + ``(L) Section 3501 (health care delivery system + research, quality improvement). + ``(M) Section 4003 (Task Force on Clinical and + Preventive Services). + ``(N) Section 4301 (research to optimize deliver of + public health services). + + ``(b) Report.--Not later than 2 years after the date of enactment of +this Act, the Comptroller General of the United States shall submit to +the appropriate committees of Congress, a report containing the findings +made by the Comptroller General under the study under subsection (a).''. + +SEC. 10202. <<NOTE: 42 USC 1396d note.>> INCENTIVES FOR STATES TO OFFER + HOME AND COMMUNITY-BASED SERVICES AS A LONG-TERM CARE + ALTERNATIVE TO NURSING HOMES. + + (a) State Balancing Incentive Payments Program.--Notwithstanding +section 1905(b) of the Social Security Act (42 U.S.C. 1396d(b)), in the +case of a balancing incentive payment State, as defined in subsection +(b), that meets the conditions described in subsection (c), during the +balancing incentive period, the Federal medical assistance percentage +determined for the State under section 1905(b) of such Act and, if +applicable, increased under subsection (z) or (aa) shall be increased by +the applicable percentage points determined under subsection (d) with +respect to eligible medical assistance expenditures described in +subsection (e). + (b) Balancing Incentive Payment State.--A balancing incentive +payment State is a State-- + +[[Page 124 STAT. 924]] + + (1) in which less than 50 percent of the total expenditures + for medical assistance under the State Medicaid program for a + fiscal year for long-term services and supports (as defined by + the Secretary under subsection (f))(1)) are for non- + institutionally-based long-term services and supports described + in subsection (f)(1)(B); + (2) that submits an application and meets the conditions + described in subsection (c); and + (3) that is selected by the Secretary to participate in the + State balancing incentive payment program established under this + section. + + (c) Conditions.--The conditions described in this subsection are the +following: + (1) Application.--The State submits an application to the + Secretary that includes, in addition to such other information + as the Secretary shall require-- + (A) a proposed budget that details the State's plan + to expand and diversify medical assistance for non- + institutionally-based long-term services and supports + described in subsection (f)(1)(B) under the State + Medicaid program during the balancing incentive period + and achieve the target spending percentage applicable to + the State under paragraph (2), including through + structural changes to how the State furnishes such + assistance, such as through the establishment of a ``no + wrong door--single entry point system'', optional + presumptive eligibility, case management services, and + the use of core standardized assessment instruments, and + that includes a description of the new or expanded + offerings of such services that the State will provide + and the projected costs of such services; and + (B) in the case of a State that proposes to expand + the provision of home and community-based services under + its State Medicaid program through a State plan + amendment under section 1915(i) of the Social Security + Act, at the option of the State, an election to increase + the income eligibility for such services from 150 + percent of the poverty line to such higher percentage as + the State may establish for such purpose, not to exceed + 300 percent of the supplemental security income benefit + rate established by section 1611(b)(1) of the Social + Security Act (42 U.S.C. 1382(b)(1)). + (2) <<NOTE: Deadlines.>> Target spending percentages.-- + (A) In the case of a balancing incentive payment + State in which less than 25 percent of the total + expenditures for long-term services and supports under + the State Medicaid program for fiscal year 2009 are for + home and community-based services, the target spending + percentage for the State to achieve by not later than + October 1, 2015, is that 25 percent of the total + expenditures for long-term services and supports under + the State Medicaid program are for home and community- + based services. + (B) In the case of any other balancing incentive + payment State, the target spending percentage for the + State to achieve by not later than October 1, 2015, is + that 50 percent of the total expenditures for long-term + services and supports under the State Medicaid program + are for home and community-based services. + +[[Page 124 STAT. 925]] + + (3) Maintenance of eligibility requirements.--The State does + not apply eligibility standards, methodologies, or procedures + for determining eligibility for medical assistance for non- + institutionally-based long-term services and supports described + in subsection (f)(1)(B) under the State Medicaid program that + are more restrictive than the eligibility standards, + methodologies, or procedures in effect for such purposes on + December 31, 2010. + (4) Use of additional funds.--The State agrees to use the + additional Federal funds paid to the State as a result of this + section only for purposes of providing new or expanded offerings + of non-institutionally-based long-term services and supports + described in subsection (f)(1)(B) under the State Medicaid + program. + (5) Structural changes. <<NOTE: Deadline.>> --The State + agrees to make, not later than the end of the 6-month period + that begins on the date the State submits an application under + this section, the following changes: + (A) <<NOTE: Standards.>> ``No wrong door--single + entry point system''.--Development of a statewide system + to enable consumers to access all long-term services and + supports through an agency, organization, coordinated + network, or portal, in accordance with such standards as + the State shall establish and that shall provide + information regarding the availability of such services, + how to apply for such services, referral services for + services and supports otherwise available in the + community, and determinations of financial and + functional eligibility for such services and supports, + or assistance with assessment processes for financial + and functional eligibility. + (B) Conflict-free case management services.-- + Conflict-free case management services to develop a + service plan, arrange for services and supports, support + the beneficiary (and, if appropriate, the beneficiary's + caregivers) in directing the provision of services and + supports for the beneficiary, and conduct ongoing + monitoring to assure that services and supports are + delivered to meet the beneficiary's needs and achieve + intended outcomes. + (C) Core standardized assessment instruments.-- + Development of core standardized assessment instruments + for determining eligibility for non-institutionally- + based long-term services and supports described in + subsection (f)(1)(B), which shall be used in a uniform + manner throughout the State, to determine a + beneficiary's needs for training, support services, + medical care, transportation, and other services, and + develop an individual service plan to address such + needs. + (6) Data collection.--The State agrees to collect from + providers of services and through such other means as the State + determines appropriate the following data: + (A) <<NOTE: Procedures.>> Services data.--Services + data from providers of non-institutionally-based long- + term services and supports described in subsection + (f)(1)(B) on a per-beneficiary basis and in accordance + with such standardized coding procedures as the State + shall establish in consultation with the Secretary. + +[[Page 124 STAT. 926]] + + (B) Quality data.--Quality data on a selected set of + core quality measures agreed upon by the Secretary and + the State that are linked to population-specific + outcomes measures and accessible to providers. + (C) Outcomes measures.--Outcomes measures data on a + selected set of core population-specific outcomes + measures agreed upon by the Secretary and the State that + are accessible to providers and include-- + (i) measures of beneficiary and family + caregiver experience with providers; + (ii) measures of beneficiary and family + caregiver satisfaction with services; and + (iii) measures for achieving desired outcomes + appropriate to a specific beneficiary, including + employment, participation in community life, + health stability, and prevention of loss in + function. + + (d) Applicable Percentage Points Increase in FMAP.--The applicable +percentage points increase is-- + (1) in the case of a balancing incentive payment State + subject to the target spending percentage described in + subsection (c)(2)(A), 5 percentage points; and + (2) in the case of any other balancing incentive payment + State, 2 percentage points. + + (e) Eligible Medical Assistance Expenditures.-- + (1) In general.--Subject to paragraph (2), medical + assistance described in this subsection is medical assistance + for non-institutionally-based long-term services and supports + described in subsection (f)(1)(B) that is provided by a + balancing incentive payment State under its State Medicaid + program during the balancing incentive payment period. + (2) Limitation on payments.--In no case may the aggregate + amount of payments made by the Secretary to balancing incentive + payment States under this section during the balancing incentive + period exceed $3,000,000,000. + + (f) Definitions.--In this section: + (1) Long-term services and supports defined.--The term + ``long-term services and supports'' has the meaning given that + term by Secretary and may include any of the following (as + defined for purposes of State Medicaid programs): + (A) Institutionally-based long-term services and + supports.--Services provided in an institution, + including the following: + (i) Nursing facility services. + (ii) Services in an intermediate care facility + for the mentally retarded described in subsection + (a)(15) of section 1905 of such Act. + (B) Non-institutionally-based long-term services and + supports.--Services not provided in an institution, + including the following: + (i) Home and community-based services provided + under subsection (c), (d), or (i) of section 1915 + of such Act or under a waiver under section 1115 + of such Act. + (ii) Home health care services. + (iii) Personal care services. + +[[Page 124 STAT. 927]] + + (iv) Services described in subsection (a)(26) + of section 1905 of such Act (relating to PACE + program services). + (v) Self-directed personal assistance services + described in section 1915(j) of such Act. + (2) Balancing incentive period.--The term ``balancing + incentive period'' means the period that begins on October 1, + 2011, and ends on September 30, 2015. + (3) Poverty line.--The term ``poverty line'' has the meaning + given that term in section 2110(c)(5) of the Social Security Act + (42 U.S.C. 1397jj(c)(5)). + (4) State medicaid program.--The term ``State Medicaid + program'' means the State program for medical assistance + provided under a State plan under title XIX of the Social + Security Act and under any waiver approved with respect to such + State plan. + +SEC. 10203. EXTENSION OF FUNDING FOR CHIP THROUGH FISCAL YEAR 2015 AND + OTHER CHIP-RELATED PROVISIONS. + + (a) Section 1311(c)(1) of this Act <<NOTE: 42 USC 18031.>> is +amended by striking ``and'' at the end of subparagraph (G), by striking +the period at the end of subparagraph (H) and inserting ``; and'', and +by adding at the end the following: + ``(I) <<NOTE: Reports. Deadline.>> report to the + Secretary at least annually and in such manner as the + Secretary shall require, pediatric quality reporting + measures consistent with the pediatric quality reporting + measures established under section 1139A of the Social + Security Act.''. + + (b) <<NOTE: Effective date. 42 USC 1396e note.>> Effective as if +included in the enactment of the Children's Health Insurance Program +Reauthorization Act of 2009 (Public Law 111-3): + (1) Section 1906(e)(2) of the Social Security Act (42 U.S.C. + 1396e(e)(2)) is amended by striking ``means'' and all that + follows through the period and inserting ``has the meaning given + that term in section 2105(c)(3)(A).''. + (2)(A) Section 1906A(a) of the Social Security Act (42 + U.S.C. 1396e-1(a)), is amended by inserting before the period + the following: ``and the offering of such a subsidy is cost- + effective, as defined for purposes of section 2105(c)(3)(A)''. + (B) <<NOTE: Applicability. 42 USC 1396e-1 and note.>> This + Act shall be applied without regard to subparagraph (A) of + section 2003(a)(1) of this Act and that subparagraph and the + amendment made by that subparagraph are hereby deemed null, + void, and of no effect. + (3) Section 2105(c)(10) of the Social Security Act (42 + U.S.C. 1397ee(c)(10)) is amended-- + (A) in subparagraph (A), in the first sentence, by + inserting before the period the following: ``if the + offering of such a subsidy is cost-effective, as defined + for purposes of paragraph (3)(A)''; + (B) by striking subparagraph (M); and + (C) by redesignating subparagraph (N) as + subparagraph (M). + (4) Section 2105(c)(3)(A) of the Social Security Act (42 + U.S.C. 1397ee(c)(3)(A)) is amended-- + (A) in the matter preceding clause (i), by striking + ``to'' and inserting ``to--''; and + +[[Page 124 STAT. 928]] + + (B) in clause (ii), by striking the period and + inserting a semicolon. + + (c) Section 2105 of the Social Security Act (42 U.S.C. 1397ee), as +amended by section 2101, is amended-- + (1) in subsection (b), in the second sentence, by striking + ``2013'' and inserting ``2015''; and + (2) in subsection (d)(3)-- + (A) in subparagraph (A)-- + (i) in the first sentence, by inserting ``as a + condition of receiving payments under section + 1903(a),'' after ``2019,''; + (ii) in clause (i), by striking ``or'' at the + end; + (iii) by redesignating clause (ii) as clause + (iii); and + (iv) by inserting after clause (i), the + following: + ``(ii) after September 30, 2015, enrolling + children eligible to be targeted low-income + children under the State child health plan in a + qualified health plan that has been certified by + the Secretary under subparagraph (C); or''; + (B) <<NOTE: Procedures.>> in subparagraph (B), by + striking ``provided coverage'' and inserting ``screened + for eligibility for medical assistance under the State + plan under title XIX or a waiver of that plan and, if + found eligible, enrolled in such plan or a waiver. In + the case of such children who, as a result of such + screening, are determined to not be eligible for medical + assistance under the State plan or a waiver under title + XIX, the State shall establish procedures to ensure that + the children are enrolled in a qualified health plan + that has been certified by the Secretary under + subparagraph (C) and is offered''; and + (C) by adding at the end the following: + ``(C) Certification of comparability of pediatric + coverage offered by qualified health plans.-- + <<NOTE: Deadline. Review. Determination.>> With respect + to each State, the Secretary, not later than April 1, + 2015, shall review the benefits offered for children and + the cost-sharing imposed with respect to such benefits + by qualified health plans offered through an Exchange + established by the State under section 1311 of the + Patient Protection and Affordable Care Act and shall + certify those plans that offer benefits for children and + impose cost-sharing with respect to such benefits that + the Secretary determines are at least comparable to the + benefits offered and cost-sharing protections provided + under the State child health plan.''. + + (d)(1) Section 2104(a) of such Act (42 U.S.C. 1397dd(a)) is +amended-- + (A) in paragraph (15), by striking ``and'' at the end; and + (B) by striking paragraph (16) and inserting the following: + ``(16) for fiscal year 2013, $17,406,000,000; + ``(17) for fiscal year 2014, $19,147,000,000; and + ``(18) for fiscal year 2015, for purposes of making 2 semi- + annual allotments-- + ``(A) $2,850,000,000 for the period beginning on + October 1, 2014, and ending on March 31, 2015, and + ``(B) $2,850,000,000 for the period beginning on + April 1, 2015, and ending on September 30, 2015.''. + +[[Page 124 STAT. 929]] + + (2)(A) Section 2104(m) of such Act (42 U.S.C. 1397dd(m)), as amended +by section 2102(a)(1), is amended-- + (i) in the subsection heading, by striking ``2013'' and + inserting ``2015''; + (ii) in paragraph (2)-- + (I) in the paragraph heading, by striking ``2012'' + and inserting ``2014''; and + (II) by adding at the end the following: + ``(B) <<NOTE: Allotment.>> Fiscal years 2013 and + 2014.--Subject to paragraphs (4) and (6), from the + amount made available under paragraphs (16) and (17) of + subsection (a) for fiscal years 2013 and 2014, + respectively, the Secretary shall compute a State + allotment for each State (including the District of + Columbia and each commonwealth and territory) for each + such fiscal year as follows: + ``(i) Rebasing in fiscal year 2013.--For + fiscal year 2013, the allotment of the State is + equal to the Federal payments to the State that + are attributable to (and countable towards) the + total amount of allotments available under this + section to the State in fiscal year 2012 + (including payments made to the State under + subsection (n) for fiscal year 2012 as well as + amounts redistributed to the State in fiscal year + 2012), multiplied by the allotment increase factor + under paragraph (5) for fiscal year 2013. + ``(ii) Growth factor update for fiscal year + 2014.--For fiscal year 2014, the allotment of the + State is equal to the sum of-- + ``(I) the amount of the State + allotment under clause (i) for fiscal + year 2013; and + ``(II) the amount of any payments + made to the State under subsection (n) + for fiscal year 2013, + multiplied by the allotment increase factor under + paragraph (5) for fiscal year 2014.''; + (iii) in paragraph (3)-- + (I) in the paragraph heading, by striking + ``2013'' and inserting ``2015''; + (II) in subparagraphs (A) and (B), by striking + ``paragraph (16)'' each place it appears and + inserting ``paragraph (18)''; + (III) in subparagraph (C)-- + (aa) by striking ``2012'' each place + it appears and inserting ``2014''; and + (bb) by striking ``2013'' and + inserting ``2015''; and + (IV) in subparagraph (D)-- + (aa) in clause (i)(I), by striking + ``subsection (a)(16)(A)'' and inserting + ``subsection (a)(18)(A)''; and + (bb) in clause (ii)(II), by striking + ``subsection (a)(16)(B)'' and inserting + ``subsection (a)(18)(B)''; + (iv) in paragraph (4), by striking ``2013'' and + inserting ``2015''; + (v) in paragraph (6)-- + (I) in subparagraph (A), by striking ``2013'' + and inserting ``2015''; and + +[[Page 124 STAT. 930]] + + (II) in the flush language after and below + subparagraph (B)(ii), by striking ``or fiscal year + 2012'' and inserting ``, fiscal year 2012, or + fiscal year 2014''; and + (vi) in paragraph (8)-- + (I) in the paragraph heading, by striking + ``2013'' and inserting ``2015''; and + (II) by striking ``2013'' and inserting + ``2015''. + + (B) Section 2104(n) of such Act (42 U.S.C. 1397dd(n)) is amended-- + (i) in paragraph (2)-- + (I) in subparagraph (A)(ii)-- + (aa) by striking ``2012'' and inserting + ``2014''; and + (bb) by striking ``2013'' and inserting + ``2015''; + (II) in subparagraph (B)-- + (aa) by striking ``2012'' and inserting + ``2014''; and + (bb) by striking ``2013'' and inserting + ``2015''; and + (ii) in paragraph (3)(A), by striking ``or a semi-annual + allotment period for fiscal year 2013'' and inserting ``fiscal + year 2013, fiscal year 2014, or a semi-annual allotment period + for fiscal year 2015''. + + (C) Section 2105(g)(4) of such Act (42 U.S.C. 1397ee(g)(4)) is +amended-- + (i) in the paragraph heading, by striking ``2013'' and + inserting ``2015''; and + (ii) in subparagraph (A), by striking ``2013'' and inserting + ``2015''. + + (D) Section 2110(b) of such Act (42 U.S.C. 1397jj(b)) is amended-- + (i) in paragraph (2)(B), by inserting ``except as provided + in paragraph (6),'' before ``a child''; and + (ii) by adding at the end the following new paragraph: + ``(6) Exceptions to exclusion of children of employees of a + public agency in the state.-- + ``(A) In general.--A child shall not be considered + to be described in paragraph (2)(B) if-- + ``(i) the public agency that employs a member + of the child's family to which such paragraph + applies satisfies subparagraph (B); or + ``(ii) <<NOTE: Applicability.>> subparagraph + (C) applies to such child. + ``(B) Maintenance of effort with respect to per + person agency contribution for family coverage.--For + purposes of subparagraph (A)(i), a public agency + satisfies this subparagraph if the amount of annual + agency expenditures made on behalf of each employee + enrolled in health coverage paid for by the agency that + includes dependent coverage for the most recent State + fiscal year is not less than the amount of such + expenditures made by the agency for the 1997 State + fiscal year, increased by the percentage increase in the + medical care expenditure category of the Consumer Price + Index for All-Urban Consumers (all items: U.S. City + Average) for such preceding fiscal year. + ``(C) <<NOTE: Applicability.>> Hardship exception.-- + For purposes of subparagraph (A)(ii), this subparagraph + applies to a child if the State determines, on a case- + by-case basis, that the annual aggregate amount of + premiums and cost-sharing imposed + +[[Page 124 STAT. 931]] + + for coverage of the family of the child would exceed 5 + percent of such family's income for the year + involved.''. + + (E) Section 2113 of such Act (42 U.S.C. 1397mm) is amended-- + (i) in subsection (a)(1), by striking ``2013'' and inserting + ``2015''; and + (ii) in subsection (g), by striking ``$100,000,000 for the + period of fiscal years 2009 through 2013'' and inserting + ``$140,000,000 for the period of fiscal years 2009 through + 2015''. + + (F) Section 108 of Public Law 111-3 <<NOTE: Time period. 123 Stat. +25.>> is amended by striking ``$11,706,000,000'' and all that follows +through the second sentence and inserting ``$15,361,000,000 to accompany +the allotment made for the period beginning on October 1, 2014, and +ending on March 31, 2015, under section 2104(a)(18)(A) of the Social +Security Act (42 U.S.C. 1397dd(a)(18)(A)), to remain available until +expended. Such <<NOTE: Applicability.>> amount shall be used to provide +allotments to States under paragraph (3) of section 2104(m) of the +Social Security Act (42 U.S.C. 1397dd(m)) for the first 6 months of +fiscal year 2015 in the same manner as allotments are provided under +subsection (a)(18)(A) of such section 2104 and subject to the same terms +and conditions as apply to the allotments provided from such subsection +(a)(18)(A).''. + + PART II--SUPPORT FOR PREGNANT AND PARENTING TEENS AND WOMEN + +SEC. <<NOTE: 42 USC 18201.>> 10211. DEFINITIONS. + + In this part: + (1) Accompaniment.--The term ``accompaniment'' means + assisting, representing, and accompanying a woman in seeking + judicial relief for child support, child custody, restraining + orders, and restitution for harm to persons and property, and in + filing criminal charges, and may include the payment of court + costs and reasonable attorney and witness fees associated + therewith. + (2) Eligible institution of higher education.--The term + ``eligible institution of higher education'' means an + institution of higher education (as such term is defined in + section 101 of the Higher Education Act of 1965 (20 U.S.C. + 1001)) that has established and operates, or agrees to establish + and operate upon the receipt of a grant under this part, a + pregnant and parenting student services office. + (3) Community service center.--The term ``community service + center'' means a non-profit organization that provides social + services to residents of a specific geographical area via direct + service or by contract with a local governmental agency. + (4) High school.--The term ``high school'' means any public + or private school that operates grades 10 through 12, inclusive, + grades 9 through 12, inclusive or grades 7 through 12, + inclusive. + (5) Intervention services.--The term ``intervention + services'' means, with respect to domestic violence, sexual + violence, sexual assault, or stalking, 24-hour telephone hotline + services for police protection and referral to shelters. + (6) Secretary.--The term ``Secretary'' means the Secretary + of Health and Human Services. + +[[Page 124 STAT. 932]] + + (7) State.--The term ``State'' includes the District of + Columbia, any commonwealth, possession, or other territory of + the United States, and any Indian tribe or reservation. + (8) Supportive social services.--The term ``supportive + social services'' means transitional and permanent housing, + vocational counseling, and individual and group counseling aimed + at preventing domestic violence, sexual violence, sexual + assault, or stalking. + (9) Violence.--The term ``violence'' means actual violence + and the risk or threat of violence. + +SEC. 10212. <<NOTE: Grants. 42 USC 18202.>> ESTABLISHMENT OF PREGNANCY + ASSISTANCE FUND. + + (a) In General.--The Secretary, in collaboration and coordination +with the Secretary of Education (as appropriate), shall establish a +Pregnancy Assistance Fund to be administered by the Secretary, for the +purpose of awarding competitive grants to States to assist pregnant and +parenting teens and women. + (b) Use of Fund.--A State may apply for a grant under subsection (a) +to carry out any activities provided for in section 10213. + (c) Applications.--To be eligible to receive a grant under +subsection (a), a State shall submit to the Secretary an application at +such time, in such manner, and containing such information as the +Secretary may require, including a description of the purposes for which +the grant is being requested and the designation of a State agency for +receipt and administration of funding received under this part. + +SEC. 10213. <<NOTE: Grants. 42 USC 18203.>> PERMISSIBLE USES OF FUND. + + (a) In General.--A State shall use amounts received under a grant +under section 10212 for the purposes described in this section to assist +pregnant and parenting teens and women. + (b) Institutions of Higher Education.-- + (1) In general.--A State may use amounts received under a + grant under section 10212 to make funding available to eligible + institutions of higher education to enable the eligible + institutions to establish, maintain, or operate pregnant and + parenting student services. Such funding shall be used to + supplement, not supplant, existing funding for such services. + (2) Application.--An eligible institution of higher + education that desires to receive funding under this subsection + shall submit an application to the designated State agency at + such time, in such manner, and containing such information as + the State agency may require. + (3) Matching requirement.--An eligible institution of higher + education that receives funding under this subsection shall + contribute to the conduct of the pregnant and parenting student + services office supported by the funding an amount from non- + Federal funds equal to 25 percent of the amount of the funding + provided. The non-Federal share may be in cash or in-kind, + fairly evaluated, including services, facilities, supplies, or + equipment. + (4) Use of funds for assisting pregnant and parenting + college students.--An eligible institution of higher education + that receives funding under this subsection shall use such funds + to establish, maintain or operate pregnant and parenting student + services and may use such funding for the following programs and + activities: + +[[Page 124 STAT. 933]] + + (A) Conduct a needs assessment on campus and within + the local community-- + (i) to assess pregnancy and parenting + resources, located on the campus or within the + local community, that are available to meet the + needs described in subparagraph (B); and + (ii) to set goals for-- + (I) improving such resources for + pregnant, parenting, and prospective + parenting students; and + (II) improving access to such + resources. + (B) Annually assess the performance of the eligible + institution in meeting the following needs of students + enrolled in the eligible institution who are pregnant or + are parents: + (i) The inclusion of maternity coverage and + the availability of riders for additional family + members in student health care. + (ii) Family housing. + (iii) Child care. + (iv) Flexible or alternative academic + scheduling, such as telecommuting programs, to + enable pregnant or parenting students to continue + their education or stay in school. + (v) Education to improve parenting skills for + mothers and fathers and to strengthen marriages. + (vi) Maternity and baby clothing, baby food + (including formula), baby furniture, and similar + items to assist parents and prospective parents in + meeting the material needs of their children. + (vii) Post-partum counseling. + (C) Identify public and private service providers, + located on the campus of the eligible institution or + within the local community, that are qualified to meet + the needs described in subparagraph (B), and establishes + programs with qualified providers to meet such needs. + (D) Assist pregnant and parenting students, fathers + or spouses in locating and obtaining services that meet + the needs described in subparagraph (B). + (E) If appropriate, provide referrals for prenatal + care and delivery, infant or foster care, or adoption, + to a student who requests such information. An office + shall make such referrals only to service providers that + serve the following types of individuals: + (i) Parents. + (ii) Prospective parents awaiting adoption. + (iii) Women who are pregnant and plan on + parenting or placing the child for adoption. + (iv) Parenting or prospective parenting + couples. + (5) Reporting.-- + (A) Annual report by institutions.-- + (i) In general.--For each fiscal year that an + eligible institution of higher education receives + funds under this subsection, the eligible + institution shall prepare and submit to the State, + by the date determined by the State, a report + that-- + +[[Page 124 STAT. 934]] + + (I) itemizes the pregnant and + parenting student services office's + expenditures for the fiscal year; + (II) contains a review and + evaluation of the performance of the + office in fulfilling the requirements of + this section, using the specific + performance criteria or standards + established under subparagraph (B)(i); + and + (III) describes the achievement of + the office in meeting the needs listed + in paragraph (4)(B) of the students + served by the eligible institution, and + the frequency of use of the office by + such students. + (ii) Performance criteria.-- + <<NOTE: Deadline.>> Not later than 180 days before + the date the annual report described in clause (i) + is submitted, the State-- + (I) shall identify the specific + performance criteria or standards that + shall be used to prepare the report; and + (II) may establish the form or + format of the report. + (B) Report by state.--The State shall annually + prepare and submit a report on the findings under this + subsection, including the number of eligible + institutions of higher education that were awarded funds + and the number of students served by each pregnant and + parenting student services office receiving funds under + this section, to the Secretary. + + (c) Support for Pregnant and Parenting Teens.--A State may use +amounts received under a grant under section 10212 to make funding +available to eligible high schools and community service centers to +establish, maintain or operate pregnant and parenting services in the +same general manner and in accordance with all conditions and +requirements described in subsection (b), except that paragraph (3) of +such subsection shall not apply for purposes of this subsection. + (d) Improving Services for Pregnant Women Who Are Victims of +Domestic Violence, Sexual Violence, Sexual Assault, and Stalking.-- + (1) In general.--A State may use amounts received under a + grant under section 10212 to make funding available tp its State + Attorney General to assist Statewide offices in providing-- + (A) intervention services, accompaniment, and + supportive social services for eligible pregnant women + who are victims of domestic violence, sexual violence, + sexual assault, or stalking. + (B) technical assistance and training (as described + in subsection (c)) relating to violence against eligible + pregnant women to be made available to the following: + (i) Federal, State, tribal, territorial, and + local governments, law enforcement agencies, and + courts. + (ii) Professionals working in legal, social + service, and health care settings. + (iii) Nonprofit organizations. + (iv) Faith-based organizations. + +[[Page 124 STAT. 935]] + + (2) Eligibility.--To be eligible for a grant under paragraph + (1), a State Attorney General shall submit an application to the + designated State agency at such time, in such manner, and + containing such information, as specified by the State. + (3) Technical assistance and training described.--For + purposes of paragraph (1)(B), technical assistance and training + is-- + (A) the identification of eligible pregnant women + experiencing domestic violence, sexual violence, sexual + assault, or stalking; + (B) the assessment of the immediate and short-term + safety of such a pregnant woman, the evaluation of the + impact of the violence or stalking on the pregnant + woman's health, and the assistance of the pregnant woman + in developing a plan aimed at preventing further + domestic violence, sexual violence, sexual assault, or + stalking, as appropriate; + (C) the maintenance of complete medical or forensic + records that include the documentation of any + examination, treatment given, and referrals made, + recording the location and nature of the pregnant + woman's injuries, and the establishment of mechanisms to + ensure the privacy and confidentiality of those medical + records; and + (D) the identification and referral of the pregnant + woman to appropriate public and private nonprofit + entities that provide intervention services, + accompaniment, and supportive social services. + (4) <<NOTE: Definition.>> Eligible pregnant woman.--In this + subsection, the term ``eligible pregnant woman'' means any woman + who is pregnant on the date on which such woman becomes a victim + of domestic violence, sexual violence, sexual assault, or + stalking or who was pregnant during the one-year period before + such date. + + (e) Public Awareness and Education.--A State may use amounts +received under a grant under section 10212 to make funding available to +increase public awareness and education concerning any services +available to pregnant and parenting teens and women under this part, or +any other resources available to pregnant and parenting women in keeping +with the intent and purposes of this part. <<NOTE: Guidelines.>> The +State shall be responsible for setting guidelines or limits as to how +much of funding may be utilized for public awareness and education in +any funding award. + +SEC. 10214. <<NOTE: 42 USC 18204.>> APPROPRIATIONS. + + There is authorized to be appropriated, and there are appropriated, +$25,000,000 for each of fiscal years 2010 through 2019, to carry out +this part. + + PART III--INDIAN HEALTH CARE IMPROVEMENT + +SEC. 10221. INDIAN HEALTH CARE IMPROVEMENT. + + (a) In General. <<NOTE: Incorporation by reference. 25 USC 16013et +seq.>> --Except as provided in subsection (b), S. 1790 entitled ``A bill +to amend the Indian Health Care Improvement Act to revise and extend +that Act, and for other purposes.'', as reported by the Committee on +Indian Affairs of the Senate in December 2009, is enacted into law. + + (b) Amendments.-- + +[[Page 124 STAT. 936]] + + (1) Section 119 of the Indian Health Care Improvement Act + (as amended by section 111 of the bill referred to in subsection + (a)) <<NOTE: 25 USC 1616l.>> is amended-- + (A) in subsection (d)-- + (i) in paragraph (2), by striking ``In + establishing'' and inserting ``Subject to + paragraphs (3) and (4), in establishing''; and + (ii) by adding at the end the following: + ``(3) Election of indian tribe or tribal organization.-- + ``(A) In general.--Subparagraph (B) of paragraph (2) + shall not apply in the case of an election made by an + Indian tribe or tribal organization located in a State + (other than Alaska) in which the use of dental health + aide therapist services or midlevel dental health + provider services is authorized under State law to + supply such services in accordance with State law. + ``(B) Action by secretary.--On an election by an + Indian tribe or tribal organization under subparagraph + (A), the Secretary, acting through the Service, shall + facilitate implementation of the services elected. + ``(4) Vacancies.--The Secretary shall not fill any vacancy + for a certified dentist in a program operated by the Service + with a dental health aide therapist.''; and + (B) by adding at the end the following: + + ``(e) Effect of Section.--Nothing in this section shall restrict the +ability of the Service, an Indian tribe, or a tribal organization to +participate in any program or to provide any service authorized by any +other Federal law.''. + (2) The Indian Health Care Improvement Act (as amended by + section 134(b) of the bill referred to in subsection <<NOTE: 25 + USC 1616r.>> (a)) is amended by striking section 125 (relating + to treatment of scholarships for certain purposes). + (3) Section 806 of the Indian Health Care Improvement Act + (25 U.S.C. 1676) is amended-- + (A) by striking ``Any limitation'' and inserting the + following: + + ``(a) HHS Appropriations.--Any limitation''; and + (B) by adding at the end the following: + + ``(b) Limitations Pursuant to Other Federal Law.-- +<<NOTE: Applicability. Abortions.>> Any limitation pursuant to other +Federal laws on the use of Federal funds appropriated to the Service +shall apply with respect to the performance or coverage of abortions.''. + (4) The bill referred to in subsection (a) <<NOTE: 42 USC + 1395l, 1395qq.>> is amended by striking section 201. + + Subtitle C--Provisions Relating to Title III + +SEC. 10301. PLANS FOR A VALUE-BASED PURCHASING PROGRAM FOR AMBULATORY + SURGICAL CENTERS. + + (a) In General.--Section 3006 is amended by adding at the end the +following new subsection: + ``(f) Ambulatory Surgical Centers.-- + ``(1) In general.--The Secretary shall develop a plan to + implement a value-based purchasing program for payments under + the Medicare program under title XVIII of the Social + +[[Page 124 STAT. 937]] + + Security Act for ambulatory surgical centers (as described in + section 1833(i) of the Social Security Act (42 U.S.C. + 1395l(i))). + ``(2) Details.--In developing the plan under paragraph (1), + the Secretary shall consider the following issues: + ``(A) The ongoing development, selection, and + modification process for measures (including under + section 1890 of the Social Security Act (42 U.S.C. + 1395aaa) and section 1890A of such Act, as added by + section 3014), to the extent feasible and practicable, + of all dimensions of quality and efficiency in + ambulatory surgical centers. + ``(B) The reporting, collection, and validation of + quality data. + ``(C) The structure of value-based payment + adjustments, including the determination of thresholds + or improvements in quality that would substantiate a + payment adjustment, the size of such payments, and the + sources of funding for the value-based bonus payments. + ``(D) Methods for the public disclosure of + information on the performance of ambulatory surgical + centers. + ``(E) Any other issues determined appropriate by the + Secretary. + ``(3) Consultation.--In developing the plan under paragraph + (1), the Secretary shall-- + ``(A) consult with relevant affected parties; and + ``(B) consider experience with such demonstrations + that the Secretary determines are relevant to the value- + based purchasing program described in paragraph (1). + ``(4) Report to congress.--Not later than January 1, 2011, + the Secretary shall submit to Congress a report containing the + plan developed under paragraph (1).''. + + (b) Technical.--Section 3006(a)(2)(A) is amended by striking clauses +(i) and (ii). + +SEC. 10302. REVISION TO NATIONAL STRATEGY FOR QUALITY IMPROVEMENT IN + HEALTH CARE. + + Section 399HH(a)(2)(B)(iii) of the Public Health Service Act, as +added by section 3011, <<NOTE: 42 USC 280j.>> is amended by inserting +``(taking into consideration the limitations set forth in subsections +(c) and (d) of section 1182 of the Social Security Act)'' after +``information''. + +SEC. 10303. DEVELOPMENT OF OUTCOME MEASURES. + + (a) Development.--Section 931 of the Public Health Service Act, as +added by section 3013(a), <<NOTE: 42 USC 299b-31.>> is amended by adding +at the end the following new subsection: + + ``(f) Development of Outcome Measures.-- + ``(1) In general. <<NOTE: Deadline.>> --The Secretary shall + develop, and periodically update (not less than every 3 years), + provider-level outcome measures for hospitals and physicians, as + well as other providers as determined appropriate by the + Secretary. + ``(2) Categories of measures.--The measures developed under + this subsection shall include, to the extent determined + appropriate by the Secretary-- + ``(A) outcome measurement for acute and chronic + diseases, including, to the extent feasible, the 5 most + prevalent and resource-intensive acute and chronic + medical conditions; and + ``(B) outcome measurement for primary and + preventative care, including, to the extent feasible, + measurements + +[[Page 124 STAT. 938]] + + that cover provision of such care for distinct patient + populations (such as healthy children, chronically ill + adults, or infirm elderly individuals). + ``(3) Goals.--In developing such measures, the Secretary + shall seek to-- + ``(A) address issues regarding risk adjustment, + accountability, and sample size; + ``(B) include the full scope of services that + comprise a cycle of care; and + ``(C) include multiple dimensions. + ``(4) Timeframe.-- + ``(A) Acute and chronic diseases.--Not later than 24 + months after the date of enactment of this Act, the + Secretary shall develop not less than 10 measures + described in paragraph (2)(A). + ``(B) Primary and preventive care.--Not later than + 36 months after the date of enactment of this Act, the + Secretary shall develop not less than 10 measures + described in paragraph (2)(B).''. + + (b) Hospital-acquired Conditions.--Section 1890A of the Social +Security Act, as amended by section 3013(b), <<NOTE: 42 USC 1395aaa- +1.>> is amended by adding at the end the following new subsection: + + ``(f) Hospital Acquired Conditions. <<NOTE: Public information.>> -- +The Secretary shall, to the extent practicable, publicly report on +measures for hospital-acquired conditions that are currently utilized by +the Centers for Medicare & Medicaid Services for the adjustment of the +amount of payment to hospitals based on rates of hospital-acquired +infections.''. + + (c) Clinical Practice Guidelines.--Section 304(b) of the Medicare +Improvements for Patients and Providers Act of 2008 (Public Law 110- +275) <<NOTE: 42 USC 299 note.>> is amended by adding at the end the +following new paragraph: + ``(4) Identification.-- + ``(A) In general. <<NOTE: Deadline. Contracts.>> -- + Following receipt of the report submitted under + paragraph (2), and not less than every 3 years + thereafter, the Secretary shall contract with the + Institute to employ the results of the study performed + under paragraph (1) and the best methods identified by + the Institute for the purpose of identifying existing + and new clinical practice guidelines that were developed + using such best methods, including guidelines listed in + the National Guideline Clearinghouse. + ``(B) Consultation.--In carrying out the + identification process under subparagraph (A), the + Secretary shall allow for consultation with professional + societies, voluntary health care organizations, and + expert panels.''. + +SEC. 10304. SELECTION OF EFFICIENCY MEASURES. + + Sections 1890(b)(7) and 1890A of the Social Security Act, as added +by section 3014, <<NOTE: 42 USC 1395aaa, 1395aaa-1.>> are amended by +striking ``quality'' each place it appears and inserting ``quality and +efficiency''. + +SEC. 10305. DATA COLLECTION; PUBLIC REPORTING. + + Section 399II(a) of the Public Health Service Act, as added by +section 3015 <<NOTE: 42 USC 280j-1.>> , is amended to read as follows: + + ``(a) In General.-- + +[[Page 124 STAT. 939]] + + ``(1) Establishment of strategic framework.--The Secretary + shall establish and implement an overall strategic framework to + carry out the public reporting of performance information, as + described in section 399JJ. Such strategic framework may include + methods and related timelines for implementing nationally + consistent data collection, data aggregation, and analysis + methods. + ``(2) Collection and aggregation of data.--The Secretary + shall collect and aggregate consistent data on quality and + resource use measures from information systems used to support + health care delivery, and may award grants or contracts for this + purpose. The Secretary shall align such collection and + aggregation efforts with the requirements and assistance + regarding the expansion of health information technology + systems, the interoperability of such technology systems, and + related standards that are in effect on the date of enactment of + the Patient Protection and Affordable Care Act. + ``(3) Scope.--The Secretary shall ensure that the data + collection, data aggregation, and analysis systems described in + paragraph (1) involve an increasingly broad range of patient + populations, providers, and geographic areas over time.''. + +SEC. 10306. IMPROVEMENTS UNDER THE CENTER FOR MEDICARE AND MEDICAID + INNOVATION. + + Section 1115A of the Social Security Act, as added by section +3021, <<NOTE: 42 USC 1315a.>> is amended-- + (1) in subsection (a), by inserting at the end the following + new paragraph: + ``(5) Testing within certain geographic areas.--For purposes + of testing payment and service delivery models under this + section, the Secretary may elect to limit testing of a model to + certain geographic areas.''; + (2) in subsection (b)(2)-- + (A) in subparagraph (A)-- + (i) in the second sentence, by striking ``the + preceding sentence may include'' and inserting + ``this subparagraph may include, but are not + limited to,''; and + (ii) by inserting after the first sentence the + following new sentence: ``The Secretary shall + focus on models expected to reduce program costs + under the applicable title while preserving or + enhancing the quality of care received by + individuals receiving benefits under such + title.''; + (B) in subparagraph (B), by adding at the end the + following new clauses: + ``(xix) Utilizing, in particular in entities + located in medically underserved areas and + facilities of the Indian Health Service (whether + operated by such Service or by an Indian tribe or + tribal organization (as those terms are defined in + section 4 of the Indian Health Care Improvement + Act)), telehealth services-- + ``(I) in treating behavioral health + issues (such as post-traumatic stress + disorder) and stroke; and + ``(II) to improve the capacity of + non-medical providers and non- + specialized medical providers to + +[[Page 124 STAT. 940]] + + provide health services for patients + with chronic complex conditions. + ``(xx) Utilizing a diverse network of + providers of services and suppliers to improve + care coordination for applicable individuals + described in subsection (a)(4)(A)(i) with 2 or + more chronic conditions and a history of prior- + year hospitalization through interventions + developed under the Medicare Coordinated Care + Demonstration Project under section 4016 of the + Balanced Budget Act of 1997 (42 U.S.C. 1395b-1 + note).''; and + (C) in subparagraph (C), by adding at the end the + following new clause: + ``(viii) Whether the model demonstrates + effective linkage with other public sector or + private sector payers.''; + (3) in subsection (b)(4), by adding at the end the following + new subparagraph: + ``(C) Measure selection.--To the extent feasible, + the Secretary shall select measures under this paragraph + that reflect national priorities for quality improvement + and patient-centered care consistent with the measures + described in 1890(b)(7)(B).''; and + (4) in subsection (c)-- + (A) in paragraph (1)(B), by striking ``care and + reduce spending; and'' and inserting ``patient care + without increasing spending;''; + (B) in paragraph (2), by striking ``reduce program + spending under applicable titles.'' and inserting + ``reduce (or would not result in any increase in) net + program spending under applicable titles; and''; and + (C) by adding at the end the following: + ``(3) <<NOTE: Determination.>> the Secretary determines that + such expansion would not deny or limit the coverage or provision + of benefits under the applicable title for applicable + individuals. + +In determining which models or demonstration projects to expand under +the preceding sentence, the Secretary shall focus on models and +demonstration projects that improve the quality of patient care and +reduce spending.''. + +SEC. 10307. IMPROVEMENTS TO THE MEDICARE SHARED SAVINGS PROGRAM. + + Section 1899 of the Social Security Act, as added by section +3022, <<NOTE: 42 USC 1395jjj.>> is amended by adding at the end the +following new subsections: + + ``(i) Option To Use Other Payment Models.-- + ``(1) In general.-- <<NOTE: Determination.>> If the + Secretary determines appropriate, the Secretary may use any of + the payment models described in paragraph (2) or (3) for making + payments under the program rather than the payment model + described in subsection (d). + ``(2) Partial capitation model.-- + ``(A) In general.--Subject to subparagraph (B), a + model described in this paragraph is a partial + capitation model in which an ACO is at financial risk + for some, but not all, of the items and services covered + under parts A and B, such as at risk for some or all + physicians' services or all items and services under + part B. The Secretary + +[[Page 124 STAT. 941]] + + may limit a partial capitation model to ACOs that are + highly integrated systems of care and to ACOs capable of + bearing risk, as determined to be appropriate by the + Secretary. + ``(B) <<NOTE: Estimate.>> No additional program + expenditures.--Payments to an ACO for items and services + under this title for beneficiaries for a year under the + partial capitation model shall be established in a + manner that does not result in spending more for such + ACO for such beneficiaries than would otherwise be + expended for such ACO for such beneficiaries for such + year if the model were not implemented, as estimated by + the Secretary. + ``(3) Other payment models.-- + ``(A) <<NOTE: Determination.>> In general.--Subject + to subparagraph (B), a model described in this paragraph + is any payment model that the Secretary determines will + improve the quality and efficiency of items and services + furnished under this title. + ``(B) <<NOTE: Applicability.>> No additional program + expenditures.--Subparagraph (B) of paragraph (2) shall + apply to a payment model under subparagraph (A) in a + similar manner as such subparagraph (B) applies to the + payment model under paragraph (2). + + ``(j) Involvement in Private Payer and Other Third Party +Arrangements.--The Secretary may give preference to ACOs who are +participating in similar arrangements with other payers. + ``(k) Treatment of Physician Group Practice Demonstration.-- +<<NOTE: Time period. Contracts.>> During the period beginning on the +date of the enactment of this section and ending on the date the program +is established, the Secretary may enter into an agreement with an ACO +under the demonstration under section 1866A, subject to rebasing and +other modifications deemed appropriate by the Secretary.''. + +SEC. 10308. REVISIONS TO NATIONAL PILOT PROGRAM ON PAYMENT BUNDLING. + + (a) In General.--Section 1866D of the Social Security Act, as added +by section 3023, <<NOTE: 42 USC 1395cc-4.>> is amended-- + (1) in paragraph (a)(2)(B), in the matter preceding clause + (i), by striking ``8 conditions'' and inserting ``10 + conditions''; + (2) by striking subsection (c)(1)(B) and inserting the + following: + ``(B) Expansion.-- <<NOTE: Determinations.>> The + Secretary may, at any point after January 1, 2016, + expand the duration and scope of the pilot program, to + the extent determined appropriate by the Secretary, if-- + ``(i) the Secretary determines that such + expansion is expected to-- + ``(I) reduce spending under title + XVIII of the Social Security Act without + reducing the quality of care; or + ``(II) improve the quality of care + and reduce spending; + ``(ii) <<NOTE: Certification.>> the Chief + Actuary of the Centers for Medicare & Medicaid + Services certifies that such expansion would + reduce program spending under such title XVIII; + and + +[[Page 124 STAT. 942]] + + ``(iii) the Secretary determines that such + expansion would not deny or limit the coverage or + provision of benefits under this title for + individuals.''; and + (3) by striking subsection (g) and inserting the following + new subsection: + + ``(g) Application of Pilot Program to Continuing Care Hospitals.-- + ``(1) In general.--In conducting the pilot program, the + Secretary shall apply the provisions of the program so as to + separately pilot test the continuing care hospital model. + ``(2) Special rules.--In pilot testing the continuing care + hospital model under paragraph (1), the following rules shall + apply: + ``(A) Such model shall be tested without the + limitation to the conditions selected under subsection + (a)(2)(B). + ``(B) <<NOTE: Definition.>> Notwithstanding + subsection (a)(2)(D), an episode of care shall be + defined as the full period that a patient stays in the + continuing care hospital plus the first 30 days + following discharge from such hospital. + ``(3) Continuing care hospital defined.--In this subsection, + the term `continuing care hospital' means an entity that has + demonstrated the ability to meet patient care and patient safety + standards and that provides under common management the medical + and rehabilitation services provided in inpatient rehabilitation + hospitals and units (as defined in section 1886(d)(1)(B)(ii)), + long term care hospitals (as defined in section + 1886(d)(1)(B)(iv)(I)), and skilled nursing facilities (as + defined in section 1819(a)) that are located in a hospital + described in section 1886(d).''. + + (b) Technical Amendments.-- + (1) Section 3023 <<NOTE: 42 USC 1395cc-4.>> is amended by + striking ``1886C'' and inserting ``1866C''. + (2) Title XVIII of the Social Security Act is amended by + redesignating section 1866D, as added by section + 3024, <<NOTE: 42 USC 1395cc-5.>> as section 1866E. + +SEC. 10309. REVISIONS TO HOSPITAL READMISSIONS REDUCTION PROGRAM. + + Section 1886(q)(1) of the Social Security Act, as added by section +3025, <<NOTE: 42 USC 1395ww.>> in the matter preceding subparagraph (A), +is amended by striking ``the Secretary shall reduce the payments'' and +all that follows through ``the product of'' and inserting ``the +Secretary shall make payments (in addition to the payments described in +paragraph (2)(A)(ii)) for such a discharge to such hospital under +subsection (d) (or section 1814(b)(3), as the case may be) in an amount +equal to the product of''. + +SEC. 10310. REPEAL OF PHYSICIAN PAYMENT UPDATE. + + The provisions of, and the amendment made by, <<NOTE: 42 USC 1395w- +4.>> section 3101 are repealed. + +SEC. 10311. REVISIONS TO EXTENSION OF AMBULANCE ADD-ONS. + + (a) Ground Ambulance.--Section 1834(l)(13)(A) of the Social Security +Act (42 U.S.C. 1395m(l)(13)(A)), as amended by section 3105(a), is +further amended-- + (1) in the matter preceding clause (i)-- + (A) by striking ``2007, for'' and inserting ``2007, + and for''; and + +[[Page 124 STAT. 943]] + + (B) by striking ``2010, and for such services + furnished on or after April 1, 2010, and before January + 1, 2011'' and inserting ``2011''; and + (2) in each of clauses (i) and (ii)-- + (A) by striking ``, and on or after April 1, 2010, + and before January 1, 2011'' each place it appears; and + (B) by striking ``January 1, 2010'' and inserting + ``January 1, 2011'' each place it appears. + + (b) Air Ambulance.--Section 146(b)(1) of the Medicare Improvements +for Patients and Providers Act of 2008 (Public Law 110-275), as amended +by section 3105(b), <<NOTE: 42 USC 1395m note.>> is further amended by +striking ``December 31, 2009, and during the period beginning on April +1, 2010, and ending on January 1, 2011'' and inserting ``December 31, +2010''. + + (c) Super Rural Ambulance.--Section 1834(l)(12)(A) of the Social +Security Act (42 U.S.C. 1395m(l)(12)(A)), as amended by section 3105(c), +is further amended by striking ``2010, and on or after April 1, 2010, +and before January 1, 2011'' and inserting ``2011''. + +SEC. 10312. CERTAIN PAYMENT RULES FOR LONG-TERM CARE HOSPITAL SERVICES + AND MORATORIUM ON THE ESTABLISHMENT OF CERTAIN HOSPITALS AND + FACILITIES. + + (a) Certain Payment Rules.--Section 114(c) of the Medicare, +Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395ww note), as +amended by section 4302(a) of the American Recovery and Reinvestment Act +(Public Law 111-5) and section 3106(a) of this Act, is further amended +by striking ``4-year period'' each place it appears and inserting ``5- +year period''. + (b) Moratorium.--Section 114(d) of such Act (42 U.S.C. 1395ww note), +as amended by section 3106(b) of this Act, in the matter preceding +subparagraph (A), is amended by striking ``4-year period'' and inserting +``5-year period''. + +SEC. 10313. REVISIONS TO THE EXTENSION FOR THE RURAL COMMUNITY HOSPITAL + DEMONSTRATION PROGRAM. + + (a) In General.--Subsection (g) of section 410A of the Medicare +Prescription Drug, Improvement, and Modernization Act of 2003 (Public +Law 108-173; 117 Stat. 2272), as added by section 3123(a) of this +Act, <<NOTE: 42 USC 1395ww note.>> is amended to read as follows: + + ``(g) Five-Year Extension of Demonstration Program.-- + ``(1) In general.--Subject to the succeeding provisions of + this subsection, the Secretary shall conduct the demonstration + program under this section for an additional 5-year period (in + this section referred to as the `5-year extension period') that + begins on the date immediately following the last day of the + initial 5-year period under subsection (a)(5). + ``(2) <<NOTE: Determination.>> Expansion of demonstration + states.--Notwithstanding subsection (a)(2), during the 5-year + extension period, the Secretary shall expand the number of + States with low population densities determined by the Secretary + under such subsection to 20. <<NOTE: Criteria.>> In determining + which States to include in such expansion, the Secretary shall + use the same criteria and data that the Secretary used to + determine the States under such subsection for purposes of the + initial 5-year period. + ``(3) Increase in maximum number of hospitals participating + in the demonstration program.--Notwithstanding subsection + (a)(4), during the 5-year extension period, not more + +[[Page 124 STAT. 944]] + + than 30 rural community hospitals may participate in the + demonstration program under this section. + ``(4) Hospitals in demonstration program on date of + enactment.--In the case of a rural community hospital that is + participating in the demonstration program under this section as + of the last day of the initial 5-year period, the Secretary-- + ``(A) shall provide for the continued participation + of such rural community hospital in the demonstration + program during the 5-year extension period unless the + rural community hospital makes an election, in such form + and manner as the Secretary may specify, to discontinue + such participation; and + ``(B) in calculating the amount of payment under + subsection (b) to the rural community hospital for + covered inpatient hospital services furnished by the + hospital during such 5-year extension period, shall + substitute, under paragraph (1)(A) of such subsection-- + ``(i) the reasonable costs of providing such + services for discharges occurring in the first + cost reporting period beginning on or after the + first day of the 5-year extension period, for + ``(ii) the reasonable costs of providing such + services for discharges occurring in the first + cost reporting period beginning on or after the + implementation of the demonstration program.''. + + (b) Conforming Amendments.--Subsection (a)(5) of section 410A of the +Medicare Prescription Drug, Improvement, and Modernization Act of 2003 +(Public Law 108-173; 117 Stat. 2272), as amended by section 3123(b) of +this Act, is amended by striking ``1-year extension'' and inserting ``5- +year extension''. + +SEC. 10314. ADJUSTMENT TO LOW-VOLUME HOSPITAL PROVISION. + + Section 1886(d)(12) of the Social Security Act (42 U.S.C. +1395ww(d)(12), as amended by section 3125, is amended-- + (1) in subparagraph (C)(i), by striking ``1,500 discharges'' + and inserting ``1,600 discharges''; and + (2) in subparagraph (D), by striking ``1,500 discharges'' + and inserting ``1,600 discharges''. + +SEC. 10315. REVISIONS TO HOME HEALTH CARE PROVISIONS. + + (a) Rebasing.--Section 1895(b)(3)(A)(iii) of the Social Security +Act, as added by section 3131, <<NOTE: 42 USC 1395fff.>> is amended-- + (1) in the clause heading, by striking ``2013'' and + inserting ``2014''; + (2) in subclause (I), by striking ``2013'' and inserting + ``2014''; and + (3) in subclause (II), by striking ``2016'' and inserting + ``2017''. + + (b) <<NOTE: 42 USC 1395fff note.>> Revision of Home Health Study and +Report.--Section 3131(d) is amended to read as follows: + + ``(d) Study and Report on the Development of Home Health Payment +Revisions in Order to Ensure Access to Care and Payment for Severity of +Illness.-- + ``(1) In general.--The Secretary of Health and Human + Services (in this section referred to as the `Secretary') shall + conduct a study on home health agency costs involved with + +[[Page 124 STAT. 945]] + + providing ongoing access to care to low-income Medicare + beneficiaries or beneficiaries in medically underserved areas, + and in treating beneficiaries with varying levels of severity of + illness. In conducting the study, the Secretary may analyze + items such as the following: + ``(A) Methods to potentially revise the home health + prospective payment system under section 1895 of the + Social Security Act (42 U.S.C. 1395fff) to account for + costs related to patient severity of illness or to + improving beneficiary access to care, such as-- + ``(i) payment adjustments for services that + may involve additional or fewer resources; + ``(ii) changes to reflect resources involved + with providing home health services to low-income + Medicare beneficiaries or Medicare beneficiaries + residing in medically underserved areas; + ``(iii) ways outlier payments might be revised + to reflect costs of treating Medicare + beneficiaries with high levels of severity of + illness; and + ``(iv) other issues determined appropriate by + the Secretary. + ``(B) Operational issues involved with potential + implementation of potential revisions to the home health + payment system, including impacts for both home health + agencies and administrative and systems issues for the + Centers for Medicare & Medicaid Services, and any + possible payment vulnerabilities associated with + implementing potential revisions. + ``(C) Whether additional research might be needed. + ``(D) Other items determined appropriate by the + Secretary. + ``(2) Considerations.--In conducting the study under + paragraph (1), the Secretary may consider whether patient + severity of illness and access to care could be measured by + factors, such as-- + ``(A) population density and relative patient access + to care; + ``(B) variations in service costs for providing care + to individuals who are dually eligible under the + Medicare and Medicaid programs; + ``(C) the presence of severe or chronic diseases, + which might be measured by multiple, discontinuous home + health episodes; + ``(D) poverty status, such as evidenced by the + receipt of Supplemental Security Income under title XVI + of the Social Security Act; and + ``(E) other factors determined appropriate by the + Secretary. + ``(3) Report.--Not later than March 1, 2014, the Secretary + shall submit to Congress a report on the study conducted under + paragraph (1), together with recommendations for such + legislation and administrative action as the Secretary + determines appropriate. + ``(4) Consultations.--In conducting the study under + paragraph (1), the Secretary shall consult with appropriate + stakeholders, such as groups representing home health agencies + and groups representing Medicare beneficiaries. + +[[Page 124 STAT. 946]] + + ``(5) Medicare demonstration project based on the results of + the study.-- + ``(A) In general.--Subject to subparagraph (D), + taking into account the results of the study conducted + under paragraph (1), the Secretary may, as determined + appropriate, provide for a demonstration project to test + whether making payment adjustments for home health + services under the Medicare program would substantially + improve access to care for patients with high severity + levels of illness or for low-income or underserved + Medicare beneficiaries. + ``(B) Waiving budget neutrality.--The Secretary + shall not reduce the standard prospective payment amount + (or amounts) under section 1895 of the Social Security + Act (42 U.S.C. 1395fff) applicable to home health + services furnished during a period to offset any + increase in payments during such period resulting from + the application of the payment adjustments under + subparagraph (A). + ``(C) No effect on subsequent periods.--A payment + adjustment resulting from the application of + subparagraph (A) for a period-- + ``(i) shall not apply to payments for home + health services under title XVIII after such + period; and + ``(ii) shall not be taken into account in + calculating the payment amounts applicable for + such services after such period. + ``(D) <<NOTE: Determination.>> Duration.--If the + Secretary determines it appropriate to conduct the + demonstration project under this subsection, the + Secretary shall conduct the project for a four year + period beginning not later than January 1, 2015. + ``(E) Funding.--The Secretary shall provide for the + transfer from the Federal Hospital Insurance Trust Fund + under section 1817 of the Social Security Act (42 U.S.C. + 1395i) and the Federal Supplementary Medical Insurance + Trust Fund established under section 1841 of such Act + (42 U.S.C. 1395t), in such proportion as the Secretary + determines appropriate, of $500,000,000 for the period + of fiscal years 2015 through 2018. Such funds shall be + made available for the study described in paragraph (1) + and the design, implementation and evaluation of the + demonstration described in this paragraph. Amounts + available under this subparagraph shall be available + until expended. + ``(F) Evaluation and report.--If the Secretary + determines it appropriate to conduct the demonstration + project under this subsection, the Secretary shall-- + ``(i) provide for an evaluation of the + project; and + ``(ii) submit to Congress, by a date specified + by the Secretary, a report on the project. + ``(G) Administration.--Chapter 35 of title 44, + United States Code, shall not apply with respect to this + subsection.''. + +SEC. 10316. MEDICARE DSH. + + Section 1886(r)(2)(B) of the Social Security Act, as added by +section 3133, <<NOTE: 42 USC 1395ww.>> is amended-- + (1) in clause (i)-- + (A) in the matter preceding subclause (I), by + striking ``(divided by 100)''; + +[[Page 124 STAT. 947]] + + (B) in subclause (I), by striking ``2012'' and + inserting ``2013''; + (C) in subclause (II), by striking the period at the + end and inserting a comma; and + (D) by adding at the end the following flush matter: + ``minus 1.5 percentage points.''. + (2) in clause (ii)-- + (A) in the matter preceding subclause (I), by + striking ``(divided by 100)''; + (B) in subclause (I), by striking ``2012'' and + inserting ``2013''; + (C) in subclause (II), by striking the period at the + end and inserting a comma; and + (D) by adding at the end the following flush matter: + ``and, for each of 2018 and 2019, minus 1.5 + percentage points.''. + +SEC. 10317. <<NOTE: 42 USC 1395ww note.>> REVISIONS TO EXTENSION OF + SECTION 508 HOSPITAL PROVISIONS. + + Section 3137(a) is amended to read as follows: + ``(a) Extension.-- + ``(1) In general.--Subsection (a) of section 106 of division + B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395 + note), as amended by section 117 of the Medicare, Medicaid, and + SCHIP Extension Act of 2007 (Public Law 110-173) and section 124 + of the Medicare Improvements for Patients and Providers Act of + 2008 (Public Law 110-275), is amended by striking `September 30, + 2009' and inserting `September 30, 2010'. + ``(2) Special rule for fiscal year 2010.-- + ``(A) In general.--Subject to subparagraph (B), for + purposes of implementation of the amendment made by + paragraph (1), including (notwithstanding paragraph (3) + of section 117(a) of the Medicare, Medicaid and SCHIP + Extension Act of 2007 (Public Law 110-173), as amended + by section 124(b) of the Medicare Improvements for + Patients and Providers Act of 2008 (Public Law 110-275)) + for purposes of the implementation of paragraph (2) of + such section 117(a), during fiscal year 2010, the + Secretary of Health and Human Services (in this + subsection referred to as the `Secretary') shall use the + hospital wage index that was promulgated by the + Secretary in the Federal Register on August 27, 2009 (74 + Fed. Reg. 43754), and any subsequent corrections. + ``(B) <<NOTE: Effective date.>> Exception.-- + Beginning on April 1, 2010, in determining the wage + index applicable to hospitals that qualify for wage + index reclassification, the Secretary shall include the + average hourly wage data of hospitals whose + reclassification was extended pursuant to the amendment + made by paragraph (1) only if including such data + results in a higher applicable reclassified wage index. + ``(3) Adjustment for certain hospitals in fiscal year + 2010.-- + ``(A) In general.--In the case of a subsection (d) + hospital (as defined in subsection (d)(1)(B) of section + 1886 of the Social Security Act (42 U.S.C. 1395ww)) with + respect to which-- + +[[Page 124 STAT. 948]] + + ``(i) a reclassification of its wage index for + purposes of such section was extended pursuant to + the amendment made by paragraph (1); and + ``(ii) <<NOTE: Time period.>> the wage index + applicable for such hospital for the period + beginning on October 1, 2009, and ending on March + 31, 2010, was lower than for the period beginning + on April 1, 2010, and ending on September 30, + 2010, by reason of the application of paragraph + (2)(B); + the Secretary shall pay such hospital an additional + payment that reflects the difference between the wage + index for such periods. + ``(B) Timeframe for payments.--The Secretary shall + make payments required under subparagraph by not later + than December 31, 2010.''. + +SEC. 10318. REVISIONS TO TRANSITIONAL EXTRA BENEFITS UNDER MEDICARE + ADVANTAGE. + + Section 1853(p)(3)(A) of the Social Security Act, as added by +section 3201(h), <<NOTE: 42 USC 1395w-23.>> is amended by inserting ``in +2009'' before the period at the end. + +SEC. 10319. REVISIONS TO MARKET BASKET ADJUSTMENTS. + + (a) Inpatient Acute Hospitals.--Section 1886(b)(3)(B)(xii) of the +Social Security Act, as added by section 3401(a), <<NOTE: 42 USC +1395ww.>> is amended-- + (1) in subclause (I), by striking ``and'' at the end; + (2) by redesignating subclause (II) as subclause (III); + (3) by inserting after subclause (II) the following new + subclause: + ``(II) for each of fiscal years 2012 and 2013, by 0.1 + percentage point; and''; and + (4) in subclause (III), as redesignated by paragraph (2), by + striking ``2012'' and inserting ``2014''. + + (b) Long-term Care Hospitals.--Section 1886(m)(4) of the Social +Security Act, as added by section 3401(c), is amended-- + (1) in subparagraph (A)-- + (A) in clause (i)-- + (i) by striking ``each of rate years 2010 and + 2011'' and inserting ``rate year 2010''; and + (ii) by striking ``and'' at the end; + (B) by redesignating clause (ii) as clause (iv); + (C) by inserting after clause (i) the following new + clauses: + ``(ii) for rate year 2011, 0.50 percentage + point; + ``(iii) for each of the rate years beginning + in 2012 and 2013, 0.1 percentage point; and''; and + (D) in clause (iv), as redesignated by subparagraph + (B), by striking ``2012'' and inserting ``2014''; and + (2) in subparagraph (B), by striking ``(A)(ii)'' and + inserting ``(A)(iv)''. + + (c) Inpatient Rehabilitation Facilities.--Section 1886(j)(3)(D)(i) +of the Social Security Act, as added by section 3401(d), is amended-- + (1) in subclause (I), by striking ``and'' at the end; + (2) by redesignating subclause (II) as subclause (III); + (3) by inserting after subclause (II) the following new + subclause: + +[[Page 124 STAT. 949]] + + ``(II) for each of fiscal years 2012 + and 2013, 0.1 percentage point; and''; + and + (4) in subclause (III), as redesignated by paragraph (2), by + striking ``2012'' and inserting ``2014''. + + (d) Home Health Agencies.--Section 1895(b)(3)(B)(vi)(II) of such +Act, as added by section 3401(e), <<NOTE: 42 USC 1395fff.>> is amended +by striking ``and 2012'' and inserting ``, 2012, and 2013''. + + (e) Psychiatric Hospitals.--Section 1886(s)(3)(A) of the Social +Security Act, as added by section 3401(f), <<NOTE: 42 USC 1395ww.>> is +amended-- + (1) in clause (i), by striking ``and'' at the end; + (2) by redesignating clause (ii) as clause (iii); + (3) by inserting after clause (ii) the following new clause: + ``(ii) for each of the rate years beginning in + 2012 and 2013, 0.1 percentage point; and''; and + (4) in clause (iii), as redesignated by paragraph (2), by + striking ``2012'' and inserting ``2014''. + + (f) Hospice Care.--Section 1814(i)(1)(C) of the Social Security Act +(42 U.S.C. 1395f(i)(1)(C)), as amended by section 3401(g), is amended-- + (1) in clause (iv)(II), by striking ``0.5'' and inserting + ``0.3''; and + (2) in clause (v), in the matter preceding subclause (I), by + striking ``0.5'' and inserting ``0.3''. + + (g) Outpatient Hospitals.--Section 1833(t)(3)(G)(i) of the Social +Security Act, as added by section 3401(i), <<NOTE: 42 USC 1395l.>> is +amended-- + (1) in subclause (I), by striking ``and'' at the end; + (2) by redesignating subclause (II) as subclause (III); + (3) by inserting after subclause (II) the following new + subclause: + ``(II) for each of 2012 and 2013, + 0.1 percentage point; and''; and + (4) in subclause (III), as redesignated by paragraph (2), by + striking ``2012'' and inserting ``2014''. + +SEC. 10320. EXPANSION OF THE SCOPE OF, AND ADDITIONAL IMPROVEMENTS TO, + THE INDEPENDENT MEDICARE ADVISORY BOARD. + + (a) In General.--Section 1899A of the Social Security Act, as added +by section 3403, <<NOTE: 42 USC 1395kkk.>> is amended-- + (1) in subsection (c)-- + (A) in paragraph (1)(B), by adding at the end the + following new sentence: <<NOTE: Reports.>> ``In any year + (beginning with 2014) that the Board is not required to + submit a proposal under this section, the Board shall + submit to Congress an advisory report on matters related + to the Medicare program.''; + (B) in paragraph (2)(A)-- + (i) in clause (iv), by inserting ``or the full + premium subsidy under section 1860D-14(a)'' before + the period at the end of the last sentence; and + (ii) by adding at the end the following new + clause: + ``(vii) <<NOTE: Determination.>> If the Chief + Actuary of the Centers for Medicare & Medicaid + Services has made a determination described in + subsection (e)(3)(B)(i)(II) in the determination + year, the proposal shall be designed to help + reduce the growth rate described in paragraph (8) + while maintaining or enhancing beneficiary access + to quality care under this title.''; + +[[Page 124 STAT. 950]] + + (C) in paragraph (2)(B)-- + (i) in clause (v), by striking ``and'' at the + end; + (ii) in clause (vi), by striking the period at + the end and inserting ``; and''; and + (iii) by adding at the end the following new + clause: + ``(vii) take into account the data and + findings contained in the annual reports under + subsection (n) in order to develop proposals that + can most effectively promote the delivery of + efficient, high quality care to Medicare + beneficiaries.''; + (D) in paragraph (3)-- + (i) in the heading, by striking ``Transmission + of board proposal to president'' and inserting + ``Submission of board proposal to congress and the + president''; + (ii) in subparagraph (A)(i), by striking + ``transmit a proposal under this section to the + President'' and insert ``submit a proposal under + this section to Congress and the President''; and + (iii) in subparagraph (A)(ii)-- + (I) in subclause (I), by inserting + ``or'' at the end; + (II) in subclause (II), by striking + ``; or'' and inserting a period; and + (III) by striking subclause (III); + (E) in paragraph (4)-- + (i) by striking ``the Board under paragraph + (3)(A)(i) or''; and + (ii) by striking ``immediately'' and inserting + ``within 2 days''; + (F) in paragraph (5)-- + (i) by striking ``to but'' and inserting + ``but''; and + (ii) by inserting ``Congress and'' after + ``submit a proposal to''; and + (G) in paragraph (6)(B)(i), by striking ``per + unduplicated enrollee'' and inserting ``(calculated as + the sum of per capita spending under each of parts A, B, + and D)''; + (2) in subsection (d)-- + (A) in paragraph (1)(A)-- + (i) by inserting ``the Board or'' after ``a + proposal is submitted by''; and + (ii) by inserting ``subsection (c)(3)(A)(i) + or'' after ``the Senate under''; and + (B) in paragraph (2)(A), by inserting ``the Board + or'' after ``a proposal is submitted by''; + (3) in subsection (e)-- + (A) in paragraph (1), by inserting ``the Board or'' + after ``a proposal submitted by''; and + (B) in paragraph (3)-- + (i) by striking ``Exception.--The Secretary + shall not be required to implement the + recommendations contained in a proposal submitted + in a proposal year by'' and inserting + ``Exceptions.-- + ``(A) In general.--The Secretary shall not implement + the recommendations contained in a proposal submitted in + a proposal year by the Board or''; + +[[Page 124 STAT. 951]] + + (ii) by redesignating subparagraphs (A) and + (B) as clauses (i) and (ii), respectively, and + indenting appropriately; and + (iii) by adding at the end the following new + subparagraph: + ``(B) Limited additional exception.-- + ``(i) In general.--Subject to clause (ii), the + Secretary shall not implement the recommendations + contained in a proposal submitted by the Board or + the President to Congress pursuant to this section + in a proposal year (beginning with proposal year + 2019) if-- + ``(I) the Board was required to + submit a proposal to Congress under this + section in the year preceding the + proposal year; and + ``(II) <<NOTE: Determination.>> the + Chief Actuary of the Centers for + Medicare & Medicaid Services makes a + determination in the determination year + that the growth rate described in + subsection (c)(8) exceeds the growth + rate described in subsection + (c)(6)(A)(i). + ``(ii) Limited additional exception may not be + applied in two consecutive years.--This + subparagraph shall not apply if the + recommendations contained in a proposal submitted + by the Board or the President to Congress pursuant + to this section in the year preceding the proposal + year were not required to be implemented by reason + of this subparagraph. + ``(iii) No affect on requirement to submit + proposals or for congressional consideration of + proposals.--Clause (i) and (ii) shall not affect-- + ``(I) the requirement of the Board + or the President to submit a proposal to + Congress in a proposal year in + accordance with the provisions of this + section; or + ``(II) Congressional consideration + of a legislative proposal (described in + subsection (c)(3)(B)(iv)) contained such + a proposal in accordance with subsection + (d).''; + (4) in subsection (f)(3)(B)-- + (A) by striking ``or advisory reports to Congress'' + and inserting ``, advisory reports, or advisory + recommendations''; and + (B) by inserting ``or produce the public report + under subsection (n)'' after ``this section''; and + (5) by adding at the end the following new subsections: + + ``(n) Annual Public Report.-- + ``(1) In general.--Not later than July 1, 2014, and annually + thereafter, the Board shall produce a public report containing + standardized information on system-wide health care costs, + patient access to care, utilization, and quality-of-care that + allows for comparison by region, types of services, types of + providers, and both private payers and the program under this + title. + ``(2) Requirements.--Each report produced pursuant to + paragraph (1) shall include information with respect to the + following areas: + ``(A) The quality and costs of care for the + population at the most local level determined practical + by the Board + +[[Page 124 STAT. 952]] + + (with quality and costs compared to national benchmarks + and reflecting rates of change, taking into account + quality measures described in section 1890(b)(7)(B)). + ``(B) Beneficiary and consumer access to care, + patient and caregiver experience of care, and the cost- + sharing or out-of-pocket burden on patients. + ``(C) Epidemiological shifts and demographic + changes. + ``(D) The proliferation, effectiveness, and + utilization of health care technologies, including + variation in provider practice patterns and costs. + ``(E) Any other areas that the Board determines + affect overall spending and quality of care in the + private sector. + + ``(o) Advisory Recommendations for Non-Federal Health Care +Programs.-- + ``(1) In general.-- <<NOTE: Deadlines.>> Not later than + January 15, 2015, and at least once every two years thereafter, + the Board shall submit to Congress and the President + recommendations to slow the growth in national health + expenditures (excluding expenditures under this title and in + other Federal health care programs) while preserving or + enhancing quality of care, such as recommendations-- + ``(A) that the Secretary or other Federal agencies + can implement administratively; + ``(B) that may require legislation to be enacted by + Congress in order to be implemented; + ``(C) that may require legislation to be enacted by + State or local governments in order to be implemented; + ``(D) that private sector entities can voluntarily + implement; and + ``(E) with respect to other areas determined + appropriate by the Board. + ``(2) Coordination.--In making recommendations under + paragraph (1), the Board shall coordinate such recommendations + with recommendations contained in proposals and advisory reports + produced by the Board under subsection (c). + ``(3) Available to public.--The Board shall make + recommendations submitted to Congress and the President under + this subsection available to the public.''. + + (b) Name Change.-- <<NOTE: 42 USC 1395kkk and note.>> Any reference +in the provisions of, or amendments made by, section 3403 to the +``Independent Medicare Advisory Board'' shall be deemed to be a +reference to the ``Independent Payment Advisory Board''. + + (c) Rule of Construction.-- <<NOTE: 42 USC 1395kkk note.>> Nothing +in the amendments made by this section shall preclude the Independent +Medicare Advisory Board, as established under section 1899A of the +Social Security Act (as added by section 3403), from solely using data +from public or private sources to carry out the amendments made by +subsection (a)(4). + +SEC. 10321. REVISION TO COMMUNITY HEALTH TEAMS. + + Section 3502(c)(2)(A) <<NOTE: 42 USC 256a-1.>> is amended by +inserting ``or other primary care providers'' after ``physicians''. + +SEC. 10322. QUALITY REPORTING FOR PSYCHIATRIC HOSPITALS. + + (a) In General.--Section 1886(s) of the Social Security Act, as +added by section 3401(f), <<NOTE: 42 USC 1395ww.>> is amended by adding +at the end the following new paragraph: + ``(4) Quality reporting.-- + +[[Page 124 STAT. 953]] + + ``(A) Reduction in update for failure to report.-- + ``(i) In general.--Under the system described + in paragraph (1), for rate year 2014 and each + subsequent rate year, in the case of a psychiatric + hospital or psychiatric unit that does not submit + data to the Secretary in accordance with + subparagraph (C) with respect to such a rate year, + any annual update to a standard Federal rate for + discharges for the hospital during the rate year, + and after application of paragraph (2), shall be + reduced by 2 percentage points. + ``(ii) Special rule.--The application of this + subparagraph may result in such annual update + being less than 0.0 for a rate year, and may + result in payment rates under the system described + in paragraph (1) for a rate year being less than + such payment rates for the preceding rate year. + ``(B) Noncumulative application.--Any reduction + under subparagraph (A) shall apply only with respect to + the rate year involved and the Secretary shall not take + into account such reduction in computing the payment + amount under the system described in paragraph (1) for a + subsequent rate year. + ``(C) Submission of quality data.--For rate year + 2014 and each subsequent rate year, each psychiatric + hospital and psychiatric unit shall submit to the + Secretary data on quality measures specified under + subparagraph (D). Such data shall be submitted in a form + and manner, and at a time, specified by the Secretary + for purposes of this subparagraph. + ``(D) Quality measures.-- + ``(i) In general.--Subject to clause (ii), any + measure specified by the Secretary under this + subparagraph must have been endorsed by the entity + with a contract under section 1890(a). + ``(ii) Exception.--In the case of a specified + area or medical topic determined appropriate by + the Secretary for which a feasible and practical + measure has not been endorsed by the entity with a + contract under section 1890(a), the Secretary may + specify a measure that is not so endorsed as long + as due consideration is given to measures that + have been endorsed or adopted by a consensus + organization identified by the Secretary. + ``(iii) Time frame.--Not later than October 1, + 2012, the Secretary shall publish the measures + selected under this subparagraph that will be + applicable with respect to rate year 2014. + ``(E) Public availability of data submitted.-- + <<NOTE: Procedures.>> The Secretary shall establish + procedures for making data submitted under subparagraph + (C) available to the public. Such procedures shall + ensure that a psychiatric hospital and a psychiatric + unit has the opportunity to review the data that is to + be made public with respect to the hospital or unit + prior to such data being made + public. <<NOTE: Reports.>> The Secretary shall report + quality measures that relate to services furnished in + inpatient settings in psychiatric hospitals and + +[[Page 124 STAT. 954]] + + psychiatric units on the Internet website of the Centers + for Medicare & Medicaid Services.''. + + (b) Conforming Amendment.--Section 1890(b)(7)(B)(i)(I) of the Social +Security Act, as added by section 3014, <<NOTE: 42 USC 1395aaa.>> is +amended by inserting ``1886(s)(4)(D),'' after ``1886(o)(2),''. + +SEC. 10323. MEDICARE COVERAGE FOR INDIVIDUALS EXPOSED TO ENVIRONMENTAL + HEALTH HAZARDS. + + (a) In General.--Title XVIII of the Social Security Act (42 U.S.C. +1395 et seq.) is amended by inserting after section 1881 the following +new section: + +``SEC. 1881A. <<NOTE: 42 USC 1395rr-1.>> MEDICARE COVERAGE FOR + INDIVIDUALS EXPOSED TO ENVIRONMENTAL HEALTH HAZARDS. + + ``(a) Deeming of Individuals as Eligible for Medicare Benefits.-- + ``(1) In general.--For purposes of eligibility for benefits + under this title, an individual determined under subsection (c) + to be an environmental exposure affected individual described in + subsection (e)(2) shall be deemed to meet the conditions + specified in section 226(a). + ``(2) Discretionary deeming.--For purposes of eligibility + for benefits under this title, the Secretary may deem an + individual determined under subsection (c) to be an + environmental exposure affected individual described in + subsection (e)(3) to meet the conditions specified in section + 226(a). + ``(3) Effective date of coverage.--An Individual who is + deemed eligible for benefits under this title under paragraph + (1) or (2) shall be-- + ``(A) entitled to benefits under the program under + Part A as of the date of such deeming; and + ``(B) eligible to enroll in the program under Part B + beginning with the month in which such deeming occurs. + + ``(b) Pilot Program for Care of Certain Individuals Residing in +Emergency Declaration Areas.-- + ``(1) Program; purpose.-- + ``(A) Primary pilot program.--The Secretary shall + establish a pilot program in accordance with this + subsection to provide innovative approaches to + furnishing comprehensive, coordinated, and cost- + effective care under this title to individuals described + in paragraph (2)(A). + ``(B) Optional pilot programs.--The Secretary may + establish a separate pilot program, in accordance with + this subsection, with respect to each geographic area + subject to an emergency declaration (other than the + declaration of June 17, 2009), in order to furnish such + comprehensive, coordinated and cost-effective care to + individuals described in subparagraph (2)(B) who reside + in each such area. + ``(2) Individual described.--For purposes of paragraph (1), + an individual described in this paragraph is an individual who + enrolls in part B, submits to the Secretary an application to + participate in the applicable pilot program under this + subsection, and-- + ``(A) is an environmental exposure affected + individual described in subsection (e)(2) who resides in + or around the geographic area subject to an emergency + declaration made as of June 17, 2009; or + +[[Page 124 STAT. 955]] + + ``(B) is an environmental exposure affected + individual described in subsection (e)(3) who-- + ``(i) is deemed under subsection (a)(2); and + ``(ii) meets such other criteria or conditions + for participation in a pilot program under + paragraph (1)(B) as the Secretary specifies. + ``(3) Flexible benefits and services.--A pilot program under + this subsection may provide for the furnishing of benefits, + items, or services not otherwise covered or authorized under + this title, if the Secretary determines that furnishing such + benefits, items, or services will further the purposes of such + pilot program (as described in paragraph (1)). + ``(4) Innovative reimbursement methodologies.--For purposes + of the pilot program under this subsection, the Secretary-- + ``(A) shall develop and implement appropriate + methodologies to reimburse providers for furnishing + benefits, items, or services for which payment is not + otherwise covered or authorized under this title, if + such benefits, items, or services are furnished pursuant + to paragraph (3); and + ``(B) may develop and implement innovative + approaches to reimbursing providers for any benefits, + items, or services furnished under this subsection. + ``(5) Limitation.--Consistent with section 1862(b), no + payment shall be made under the pilot program under this + subsection with respect to benefits, items, or services + furnished to an environmental exposure affected individual (as + defined in subsection (e)) to the extent that such individual is + eligible to receive such benefits, items, or services through + any other public or private benefits plan or legal agreement. + ``(6) Waiver authority.--The Secretary may waive such + provisions of this title and title XI as are necessary to carry + out pilot programs under this subsection. + ``(7) Funding.--For purposes of carrying out pilot programs + under this subsection, the Secretary shall provide for the + transfer, from the Federal Hospital Insurance Trust Fund under + section 1817 and the Federal Supplementary Medical Insurance + Trust Fund under section 1841, in such proportion as the + Secretary determines appropriate, of such sums as the Secretary + determines necessary, to the Centers for Medicare & Medicaid + Services Program Management Account. + ``(8) Waiver of budget neutrality.--The Secretary shall not + require that pilot programs under this subsection be budget + neutral with respect to expenditures under this title. + + ``(c) Determinations.-- + ``(1) By the commissioner of social security.--For purposes + of this section, the Commissioner of Social Security, in + consultation with the Secretary, and using the cost allocation + method prescribed in section 201(g), shall determine whether + individuals are environmental exposure affected individuals. + ``(2) By the secretary.--The Secretary shall determine + eligibility for pilot programs under subsection (b). + + ``(d) Emergency Declaration Defined.--For purposes of this section, +the term `emergency declaration' means a declaration of a public health +emergency under section 104(a) of the Comprehensive Environmental +Response, Compensation, and Liability Act of 1980. + +[[Page 124 STAT. 956]] + + ``(e) Environmental Exposure Affected Individual Defined.-- + ``(1) In general.--For purposes of this section, the term + `environmental exposure affected individual' means-- + ``(A) an individual described in paragraph (2); and + ``(B) an individual described in paragraph (3). + ``(2) Individual described.-- + ``(A) In general.--An individual described in this + paragraph is any individual who-- + ``(i) is diagnosed with 1 or more conditions + described in subparagraph (B); + ``(ii) as demonstrated in such manner as the + Secretary determines appropriate, has been present + for an aggregate total of 6 months in the + geographic area subject to an emergency + declaration specified in subsection (b)(2)(A), + during a period ending-- + ``(I) not less than 10 years prior + to such diagnosis; and + ``(II) prior to the implementation + of all the remedial and removal actions + specified in the Record of Decision for + Operating Unit 4 and the Record of + Decision for Operating Unit 7; + ``(iii) files an application for benefits + under this title (or has an application filed on + behalf of the individual), including pursuant to + this section; and + ``(iv) is determined under this section to + meet the criteria in this subparagraph. + ``(B) Conditions described.--For purposes of + subparagraph (A), the following conditions are described + in this subparagraph: + ``(i) Asbestosis, pleural thickening, or + pleural plaques as established by-- + ``(I) interpretation by a `B Reader' + qualified physician of a plain chest x- + ray or interpretation of a computed + tomographic radiograph of the chest by a + qualified physician, as determined by + the Secretary; or + ``(II) such other diagnostic + standards as the Secretary specifies, + except that this clause shall not apply to pleural + thickening or pleural plaques unless there are + symptoms or conditions requiring medical treatment + as a result of these diagnoses. + ``(ii) Mesothelioma, or malignancies of the + lung, colon, rectum, larynx, stomach, esophagus, + pharynx, or ovary, as established by-- + ``(I) pathologic examination of + biopsy tissue; + ``(II) cytology from + bronchioalveolar lavage; or + ``(III) such other diagnostic + standards as the Secretary specifies. + ``(iii) Any other diagnosis which the + Secretary, in consultation with the Commissioner + of Social Security, determines is an asbestos- + related medical condition, as established by such + diagnostic standards as the Secretary specifies. + ``(3) Other individual described.--An individual described + in this paragraph is any individual who-- + +[[Page 124 STAT. 957]] + + ``(A) is not an individual described in paragraph + (2); + ``(B) is diagnosed with a medical condition caused + by the exposure of the individual to a public health + hazard to which an emergency declaration applies, based + on such medical conditions, diagnostic standards, and + other criteria as the Secretary specifies; + ``(C) as demonstrated in such manner as the + Secretary determines appropriate, has been present for + an aggregate total of 6 months in the geographic area + subject to the emergency declaration involved, during a + period determined appropriate by the Secretary; + ``(D) files an application for benefits under this + title (or has an application filed on behalf of the + individual), including pursuant to this section; and + ``(E) is determined under this section to meet the + criteria in this paragraph.''. + + (b) Program for Early Detection of Certain Medical Conditions +Related to Environmental Health Hazards.--Title XX of the Social +Security Act (42 U.S.C. 1397 et seq.), as amended by section 5507, is +amended by adding at the end the following: + +``SEC. 2009. <<NOTE: 42 USC 1397h.>> PROGRAM FOR EARLY DETECTION OF + CERTAIN MEDICAL CONDITIONS RELATED TO ENVIRONMENTAL HEALTH + HAZARDS. + + ``(a) Program Establishment.--The Secretary shall establish a +program in accordance with this section to make competitive grants to +eligible entities specified in subsection (b) for the purpose of-- + ``(1) screening at-risk individuals (as defined in + subsection (c)(1)) for environmental health conditions (as + defined in subsection (c)(3)); and + ``(2) developing and disseminating public information and + education concerning-- + ``(A) the availability of screening under the + program under this section; + ``(B) the detection, prevention, and treatment of + environmental health conditions; and + ``(C) the availability of Medicare benefits for + certain individuals diagnosed with environmental health + conditions under section 1881A. + + ``(b) Eligible Entities.-- + ``(1) In general.--For purposes of this section, an eligible + entity is an entity described in paragraph (2) which submits an + application to the Secretary in such form and manner, and + containing such information and assurances, as the Secretary + determines appropriate. + ``(2) Types of eligible entities.--The entities described in + this paragraph are the following: + ``(A) A hospital or community health center. + ``(B) A Federally qualified health center. + ``(C) A facility of the Indian Health Service. + ``(D) A National Cancer Institute-designated cancer + center. + ``(E) An agency of any State or local government. + ``(F) A nonprofit organization. + ``(G) Any other entity the Secretary determines + appropriate. + +[[Page 124 STAT. 958]] + + ``(c) Definitions.--In this section: + ``(1) At-risk individual.--The term `at-risk individual' + means an individual who-- + ``(A)(i) as demonstrated in such manner as the + Secretary determines appropriate, has been present for + an aggregate total of 6 months in the geographic area + subject to an emergency declaration specified under + paragraph (2), during a period ending-- + ``(I) not less than 10 years prior to the date + of such individual's application under + subparagraph (B); and + ``(II) prior to the implementation of all the + remedial and removal actions specified in the + Record of Decision for Operating Unit 4 and the + Record of Decision for Operating Unit 7; or + ``(ii) meets such other criteria as the Secretary + determines appropriate considering the type of + environmental health condition at issue; and + ``(B) has submitted an application (or has an + application submitted on the individual's behalf), to an + eligible entity receiving a grant under this section, + for screening under the program under this section. + ``(2) Emergency declaration.--The term `emergency + declaration' means a declaration of a public health emergency + under section 104(a) of the Comprehensive Environmental + Response, Compensation, and Liability Act of 1980. + ``(3) Environmental health condition.--The term + `environmental health condition' means-- + ``(A) asbestosis, pleural thickening, or pleural + plaques, as established by-- + ``(i) interpretation by a `B Reader' qualified + physician of a plain chest x-ray or interpretation + of a computed tomographic radiograph of the chest + by a qualified physician, as determined by the + Secretary; or + ``(ii) such other diagnostic standards as the + Secretary specifies; + ``(B) mesothelioma, or malignancies of the lung, + colon, rectum, larynx, stomach, esophagus, pharynx, or + ovary, as established by-- + ``(i) pathologic examination of biopsy tissue; + ``(ii) cytology from bronchioalveolar lavage; + or + ``(iii) such other diagnostic standards as the + Secretary specifies; and + ``(C) any other medical condition which the + Secretary determines is caused by exposure to a + hazardous substance or pollutant or contaminant at a + Superfund site to which an emergency declaration + applies, based on such criteria and as established by + such diagnostic standards as the Secretary specifies. + ``(4) Hazardous substance; pollutant; contaminant.--The + terms `hazardous substance', `pollutant', and `contaminant' have + the meanings given those terms in section 101 of the + Comprehensive Environmental Response, Compensation, and + Liability Act of 1980 (42 U.S.C. 9601). + ``(5) Superfund site.--The term `Superfund site' means a + site included on the National Priorities List developed by the + President in accordance with section 105(a)(8)(B) of the + +[[Page 124 STAT. 959]] + + Comprehensive Environmental Response, Compensation, and + Liability Act of 1980 (42 U.S.C. 9605(a)(8)(B)). + + ``(d) Health Coverage Unaffected.--Nothing in this section shall be +construed to affect any coverage obligation of a governmental or private +health plan or program relating to an at-risk individual. + ``(e) Funding.-- + ``(1) In general.--Out of any funds in the Treasury not + otherwise appropriated, there are appropriated to the Secretary, + to carry out the program under this section-- + ``(A) $23,000,000 for the period of fiscal years + 2010 through 2014; and + ``(B) $20,000,000 for each 5-fiscal year period + thereafter. + ``(2) Availability.--Funds appropriated under paragraph (1) + shall remain available until expended. + + ``(f) Nonapplication.-- + ``(1) In general.--Except as provided in paragraph (2), the + preceding sections of this title shall not apply to grants + awarded under this section. + ``(2) Limitations on use of grants.--Section 2005(a) shall + apply to a grant awarded under this section to the same extent + and in the same manner as such section applies to payments to + States under this title, except that paragraph (4) of such + section shall not be construed to prohibit grantees from + conducting screening for environmental health conditions as + authorized under this section.''. + +SEC. 10324. PROTECTIONS FOR FRONTIER STATES. + + (a) Floor on Area Wage Index for Hospitals in Frontier States.-- + (1) In general.--Section 1886(d)(3)(E) of the Social + Security Act (42 U.S.C. 1395ww(d)(3)(E)) is amended-- + (A) in clause (i), by striking ``clause (ii)'' and + inserting ``clause (ii) or (iii)''; and + (B) by adding at the end the following new clause: + ``(iii) Floor on area wage index for hospitals + in frontier states.-- + ``(I) In general.--Subject to + subclause (IV), for discharges occurring + on or after October 1, 2010, the area + wage index applicable under this + subparagraph to any hospital which is + located in a frontier State (as defined + in subclause (II)) may not be less than + 1.00. + ``(II) Frontier state defined.--In + this clause, the term `frontier State' + means a State in which at least 50 + percent of the counties in the State are + frontier counties. + ``(III) Frontier county defined.--In + this clause, the term `frontier county' + means a county in which the population + per square mile is less than 6. + ``(IV) Limitation.--This clause + shall not apply to any hospital located + in a State that receives a non-labor + related share adjustment under paragraph + (5)(H).''. + +[[Page 124 STAT. 960]] + + (2) Waiving budget neutrality.--Section 1886(d)(3)(E) of the + Social Security Act (42 U.S.C. 1395ww(d)(3)(E)), as amended by + subsection (a), is amended in the third sentence by inserting + ``and the amendments made by section 10324(a)(1) of the Patient + Protection and Affordable Care Act'' after ``2003''. + + (b) Floor on Area Wage Adjustment Factor for Hospital Outpatient +Department Services in Frontier States.--Section 1833(t) of the Social +Security Act (42 U.S.C. 1395l(t)), as amended by section 3138, is +amended-- + (1) in paragraph (2)(D), by striking ``the Secretary'' and + inserting ``subject to paragraph (19), the Secretary''; and + (2) by adding at the end the following new paragraph: + ``(19) Floor on area wage adjustment factor for hospital + outpatient department services in frontier states.-- + ``(A) In general.--Subject to subparagraph (B), with + respect to covered OPD services furnished on or after + January 1, 2011, the area wage adjustment factor + applicable under the payment system established under + this subsection to any hospital outpatient department + which is located in a frontier State (as defined in + section 1886(d)(3)(E)(iii)(II)) may not be less than + 1.00. The preceding sentence shall not be applied in a + budget neutral manner. + ``(B) Limitation.--This paragraph shall not apply to + any hospital outpatient department located in a State + that receives a non-labor related share adjustment under + section 1886(d)(5)(H).''. + + (c) Floor for Practice Expense Index for Physicians' Services +Furnished in Frontier States.--Section 1848(e)(1) of the Social Security +Act (42 U.S.C. 1395w-4(e)(1)), as amended by section 3102, is amended-- + (1) in subparagraph (A), by striking ``and (H)'' and + inserting ``(H), and (I)''; and + (2) by adding at the end the following new subparagraph: + ``(I) Floor for practice expense index for services + furnished in frontier states.-- + ``(i) In general.--Subject to clause (ii), for + purposes of payment for services furnished in a + frontier State (as defined in section + 1886(d)(3)(E)(iii)(II)) on or after January 1, + 2011, after calculating the practice expense index + in subparagraph (A)(i), the Secretary shall + increase any such index to 1.00 if such index + would otherwise be less that 1.00. The preceding + sentence shall not be applied in a budget neutral + manner. + ``(ii) Limitation.--This subparagraph shall + not apply to services furnished in a State that + receives a non-labor related share adjustment + under section 1886(d)(5)(H).''. + +SEC. 10325. REVISION TO SKILLED NURSING FACILITY PROSPECTIVE PAYMENT + SYSTEM. + + (a) Temporary Delay of RUG-IV.-- <<NOTE: Implementation +dates.>> Notwithstanding any other provision of law, the Secretary of +Health and Human Services shall not, prior to October 1, 2011, implement +Version 4 of the Resource Utilization Groups (in this subsection +refereed to as ``RUG-IV'') published in the Federal Register on August +11, 2009, entitled ``Prospective Payment System and Consolidated Billing +for + +[[Page 124 STAT. 961]] + +Skilled Nursing Facilities for FY 2010; Minimum Data Set, Version 3.0 +for Skilled Nursing Facilities and Medicaid Nursing Facilities'' (74 +Fed. Reg. 40288). Beginning on October 1, 2010, the Secretary of Health +and Human Services shall implement the change specific to therapy +furnished on a concurrent basis that is a component of RUG-IV and +changes to the lookback period to ensure that only those services +furnished after admission to a skilled nursing facility are used as +factors in determining a case mix classification under the skilled +nursing facility prospective payment system under section 1888(e) of the +Social Security Act (42 U.S.C. 1395yy(e)). + + (b) Construction.--Nothing in this section shall be interpreted as +delaying the implementation of Version 3.0 of the Minimum Data Sets (MDS +3.0) beyond the planned implementation date of October 1, 2010. + +SEC. 10326. <<NOTE: 42 USC 1395b-1 note.>> PILOT TESTING PAY-FOR- + PERFORMANCE PROGRAMS FOR CERTAIN MEDICARE PROVIDERS. + + (a) In General.-- <<NOTE: Deadline.>> Not later than January 1, +2016, the Secretary of Health and Human Services (in this section +referred to as the ``Secretary'') shall, for each provider described in +subsection (b), conduct a separate pilot program under title XVIII of +the Social Security Act to test the implementation of a value-based +purchasing program for payments under such title for the provider. + + (b) Providers Described.--The providers described in this paragraph +are the following: + (1) Psychiatric hospitals (as described in clause (i) of + section 1886(d)(1)(B) of such Act (42 U.S.C. 1395ww(d)(1)(B))) + and psychiatric units (as described in the matter following + clause (v) of such section). + (2) Long-term care hospitals (as described in clause (iv) of + such section). + (3) Rehabilitation hospitals (as described in clause (ii) of + such section). + (4) PPS-exempt cancer hospitals (as described in clause (v) + of such section). + (5) Hospice programs (as defined in section 1861(dd)(2) of + such Act (42 U.S.C. 1395x(dd)(2))). + + (c) Waiver Authority.--The Secretary may waive such requirements of +titles XI and XVIII of the Social Security Act as may be necessary +solely for purposes of carrying out the pilot programs under this +section. + (d) No Additional Program Expenditures.--Payments under this section +under the separate pilot program for value based purchasing (as +described in subsection (a)) for each provider type described in +paragraphs (1) through (5) of subsection (b) for applicable items and +services under title XVIII of the Social Security Act for a year shall +be established in a manner that does not result in spending more under +each such value based purchasing program for such year than would +otherwise be expended for such provider type for such year if the pilot +program were not implemented, as estimated by the Secretary. + (e) <<NOTE: Determinations.>> Expansion of Pilot Program.--The +Secretary may, at any point after January 1, 2018, expand the duration +and scope of a pilot program conducted under this subsection, to the +extent determined appropriate by the Secretary, if-- + (1) the Secretary determines that such expansion is expected + to-- + +[[Page 124 STAT. 962]] + + (A) reduce spending under title XVIII of the Social + Security Act without reducing the quality of care; or + (B) improve the quality of care and reduce spending; + (2) <<NOTE: Certification.>> the Chief Actuary of the + Centers for Medicare & Medicaid Services certifies that such + expansion would reduce program spending under such title XVIII; + and + (3) the Secretary determines that such expansion would not + deny or limit the coverage or provision of benefits under such + title XIII for Medicare beneficiaries. + +SEC. 10327. IMPROVEMENTS TO THE PHYSICIAN QUALITY REPORTING SYSTEM. + + (a) In General.--Section 1848(m) of the Social Security Act (42 +U.S.C. 1395w-4(m)) is amended by adding at the end the following new +paragraph: + ``(7) Additional incentive payment.-- + ``(A) In general.-- <<NOTE: Time period.>> For 2011 + through 2014, if an eligible professional meets the + requirements described in subparagraph (B), the + applicable quality percent for such year, as described + in clauses (iii) and (iv) of paragraph (1)(B), shall be + increased by 0.5 percentage points. + ``(B) Requirements described.--In order to qualify + for the additional incentive payment described in + subparagraph (A), an eligible professional shall meet + the following requirements: + ``(i) The eligible professional shall-- + ``(I) satisfactorily submit data on + quality measures for purposes of + paragraph (1) for a year; and + ``(II) have such data submitted on + their behalf through a Maintenance of + Certification Program (as defined in + subparagraph (C)(i)) that meets-- + ``(aa) the criteria for a + registry (as described in + subsection (k)(4)); or + ``(bb) an alternative form + and manner determined + appropriate by the Secretary. + ``(ii) The eligible professional, more + frequently than is required to qualify for or + maintain board certification status-- + ``(I) participates in such a + Maintenance of Certification program for + a year; and + ``(II) successfully completes a + qualified Maintenance of Certification + Program practice assessment (as defined + in subparagraph (C)(ii)) for such year. + ``(iii) A Maintenance of Certification program + submits to the Secretary, on behalf of the + eligible professional, information-- + ``(I) in a form and manner specified + by the Secretary, that the eligible + professional has successfully met the + requirements of clause (ii) (which may + be in the form of a structural measure); + ``(II) if requested by the + Secretary, on the survey of patient + experience with care (as described in + subparagraph (C)(ii)(II)); and + ``(III) as the Secretary may + require, on the methods, measures, and + data used under the Maintenance of + Certification Program and the + +[[Page 124 STAT. 963]] + + qualified Maintenance of Certification + Program practice assessment. + ``(C) Definitions.--For purposes of this paragraph: + ``(i) The term `Maintenance of Certification + Program' means a continuous assessment program, + such as qualified American Board of Medical + Specialties Maintenance of Certification program + or an equivalent program (as determined by the + Secretary), that advances quality and the lifelong + learning and self-assessment of board certified + specialty physicians by focusing on the + competencies of patient care, medical knowledge, + practice-based learning, interpersonal and + communication skills and professionalism. Such a + program shall include the following: + ``(I) The program requires the + physician to maintain a valid, + unrestricted medical license in the + United States. + ``(II) The program requires a + physician to participate in educational + and self-assessment programs that + require an assessment of what was + learned. + ``(III) The program requires a + physician to demonstrate, through a + formalized, secure examination, that the + physician has the fundamental diagnostic + skills, medical knowledge, and clinical + judgment to provide quality care in + their respective specialty. + ``(IV) The program requires + successful completion of a qualified + Maintenance of Certification Program + practice assessment as described in + clause (ii). + ``(ii) The term `qualified Maintenance of + Certification Program practice assessment' means + an assessment of a physician's practice that-- + ``(I) includes an initial assessment + of an eligible professional's practice + that is designed to demonstrate the + physician's use of evidence-based + medicine; + ``(II) includes a survey of patient + experience with care; and + ``(III) requires a physician to + implement a quality improvement + intervention to address a practice + weakness identified in the initial + assessment under subclause (I) and then + to remeasure to assess performance + improvement after such intervention.''. + + (b) Authority.--Section 3002(c) of this Act <<NOTE: 42 USC 1395w-4 +note.>> is amended by adding at the end the following new paragraph: + ``(3) Authority.-- <<NOTE: Determination.>> For years after + 2014, if the Secretary of Health and Human Services determines + it to be appropriate, the Secretary may incorporate + participation in a Maintenance of Certification Program and + successful completion of a qualified Maintenance of + Certification Program practice assessment into the composite of + measures of quality of care furnished pursuant to the physician + fee schedule payment modifier, as described in section + 1848(p)(2) of the Social Security Act (42 U.S.C. 1395w- + 4(p)(2)).''. + +[[Page 124 STAT. 964]] + + (c) Elimination of MA Regional Plan Stabilization Fund.-- + (1) In general.--Section 1858 of the Social Security Act (42 + U.S.C. 1395w-27a) is amended by striking subsection (e). + (2) <<NOTE: 42 USC 1395w-27a note.>> Transition.--Any amount + contained in the MA Regional Plan Stabilization Fund as of the + date of the enactment of this Act shall be transferred to the + Federal Supplementary Medical Insurance Trust Fund. + +SEC. 10328. IMPROVEMENT IN PART D MEDICATION THERAPY MANAGEMENT (MTM) + PROGRAMS. + + (a) In General.--Section 1860D-4(c)(2) of the Social Security Act +(42 U.S.C. 1395w-104(c)(2)) is amended-- + (1) by redesignating subparagraphs (C), (D), and (E) as + subparagraphs (E), (F), and (G), respectively; and + (2) by inserting after subparagraph (B) the following new + subparagraphs: + ``(C) Required interventions.--For plan years + beginning on or after the date that is 2 years after the + date of the enactment of the Patient Protection and + Affordable Care Act, prescription drug plan sponsors + shall offer medication therapy management services to + targeted beneficiaries described in subparagraph (A)(ii) + that include, at a minimum, the following to increase + adherence to prescription medications or other goals + deemed necessary by the Secretary: + ``(i) An annual comprehensive medication + review furnished person-to-person or using + telehealth technologies (as defined by the + Secretary) by a licensed pharmacist or other + qualified provider. The comprehensive medication + review-- + ``(I) shall include a review of the + individual's medications and may result + in the creation of a recommended + medication action plan or other actions + in consultation with the individual and + with input from the prescriber to the + extent necessary and practicable; and + ``(II) shall include providing the + individual with a written or printed + summary of the results of the review. + The Secretary, in consultation with relevant + stakeholders, shall develop a standardized format + for the action plan under subclause (I) and the + summary under subclause (II). + ``(ii) Follow-up interventions as warranted + based on the findings of the annual medication + review or the targeted medication enrollment and + which may be provided person-to-person or using + telehealth technologies (as defined by the + Secretary). + ``(D) Assessment.--The prescription drug plan + sponsor shall have in place a process to assess, at + least on a quarterly basis, the medication use of + individuals who are at risk but not enrolled in the + medication therapy management program, including + individuals who have experienced a transition in care, + if the prescription drug plan sponsor has access to that + information. + +[[Page 124 STAT. 965]] + + ``(E) Automatic enrollment with ability to opt- + out.--The prescription drug plan sponsor shall have in + place a process to-- + ``(i) subject to clause (ii), automatically + enroll targeted beneficiaries described in + subparagraph (A)(ii), including beneficiaries + identified under subparagraph (D), in the + medication therapy management program required + under this subsection; and + ``(ii) permit such beneficiaries to opt-out of + enrollment in such program.''. + + (b) <<NOTE: 42 USC 1395w-104 note.>> Rule of Construction.--Nothing +in this section shall limit the authority of the Secretary of Health and +Human Services to modify or broaden requirements for a medication +therapy management program under part D of title XVIII of the Social +Security Act or to study new models for medication therapy management +through the Center for Medicare and Medicaid Innovation under section +1115A of such Act, as added by section 3021. + +SEC. 10329. DEVELOPING METHODOLOGY TO ASSESS HEALTH PLAN VALUE. + + (a) Development.--The Secretary of Health and Human Services +(referred to in this section as the ``Secretary''), in consultation with +relevant stakeholders including health insurance issuers, health care +consumers, employers, health care providers, and other entities +determined appropriate by the Secretary, shall develop a methodology to +measure health plan value. Such methodology shall take into +consideration, where applicable-- + (1) the overall cost to enrollees under the plan; + (2) the quality of the care provided for under the plan; + (3) the efficiency of the plan in providing care; + (4) the relative risk of the plan's enrollees as compared to + other plans; + (5) the actuarial value or other comparative measure of the + benefits covered under the plan; and + (6) other factors determined relevant by the Secretary. + + (b) Report.--Not later than 18 months after the date of enactment of +this Act, the Secretary shall submit to Congress a report concerning the +methodology developed under subsection (a). + +SEC. 10330. MODERNIZING COMPUTER AND DATA SYSTEMS OF THE CENTERS FOR + MEDICARE & MEDICAID SERVICES TO SUPPORT IMPROVEMENTS IN CARE + DELIVERY. + + (a) In General.-- <<NOTE: Plan.>> The Secretary of Health and Human +Services (in this section referred to as the ``Secretary'') shall +develop a plan (and detailed budget for the resources needed to +implement such plan) to modernize the computer and data systems of the +Centers for Medicare & Medicaid Services (in this section referred to as +``CMS''). + + (b) Considerations.--In developing the plan, the Secretary shall +consider how such modernized computer system could-- + (1) in accordance with the regulations promulgated under + section 264(c) of the Health Insurance Portability and + Accountability Act of 1996, make available data in a reliable + and timely manner to providers of services and suppliers to + support their efforts to better manage and coordinate care + furnished to beneficiaries of CMS programs; and + (2) support consistent evaluations of payment and delivery + system reforms under CMS programs. + +[[Page 124 STAT. 966]] + + (c) Posting of Plan.-- <<NOTE: Deadline. Web posting.>> By not later +than 9 months after the date of the enactment of this Act, the Secretary +shall post on the website of the Centers for Medicare & Medicaid +Services the plan described in subsection (a). + +SEC. 10331. <<NOTE: 42 USC 1395w-5.>> PUBLIC REPORTING OF PERFORMANCE + INFORMATION. + + (a) <<NOTE: Deadline.>> In General.-- + (1) Development.-- <<NOTE: Web site.>> Not later than + January 1, 2011, the Secretary shall develop a Physician Compare + Internet website with information on physicians enrolled in the + Medicare program under section 1866(j) of the Social Security + Act (42 U.S.C. 1395cc(j)) and other eligible professionals who + participate in the Physician Quality Reporting Initiative under + section 1848 of such Act (42 U.S.C. 1395w-4). + (2) Plan.-- <<NOTE: Time period.>> Not later than January 1, + 2013, and with respect to reporting periods that begin no + earlier than January 1, 2012, the Secretary shall also implement + a plan for making publicly available through Physician Compare, + consistent with subsection (c), information on physician + performance that provides comparable information for the public + on quality and patient experience measures with respect to + physicians enrolled in the Medicare program under such section + 1866(j). To the extent scientifically sound measures that are + developed consistent with the requirements of this section are + available, such information, to the extent practicable, shall + include-- + (A) measures collected under the Physician Quality + Reporting Initiative; + (B) an assessment of patient health outcomes and the + functional status of patients; + (C) an assessment of the continuity and coordination + of care and care transitions, including episodes of care + and risk-adjusted resource use; + (D) an assessment of efficiency; + (E) an assessment of patient experience and patient, + caregiver, and family engagement; + (F) an assessment of the safety, effectiveness, and + timeliness of care; and + (G) other information as determined appropriate by + the Secretary. + + (b) Other Required Considerations.--In developing and implementing +the plan described in subsection (a)(2), the Secretary shall, to the +extent practicable, include-- + (1) processes to assure that data made public, either by the + Centers for Medicare & Medicaid Services or by other entities, + is statistically valid and reliable, including risk adjustment + mechanisms used by the Secretary; + (2) processes by which a physician or other eligible + professional whose performance on measures is being publicly + reported has a reasonable opportunity, as determined by the + Secretary, to review his or her individual results before they + are made public; + (3) processes by the Secretary to assure that the + implementation of the plan and the data made available on + Physician Compare provide a robust and accurate portrayal of a + physician's performance; + (4) data that reflects the care provided to all patients + seen by physicians, under both the Medicare program and, + +[[Page 124 STAT. 967]] + + to the extent practicable, other payers, to the extent such + information would provide a more accurate portrayal of physician + performance; + (5) processes to ensure appropriate attribution of care when + multiple physicians and other providers are involved in the care + of a patient; + (6) processes to ensure timely statistical performance + feedback is provided to physicians concerning the data reported + under any program subject to public reporting under this + section; and + (7) implementation of computer and data systems of the + Centers for Medicare & Medicaid Services that support valid, + reliable, and accurate public reporting activities authorized + under this section. + + (c) Ensuring Patient Privacy.--The Secretary shall ensure that +information on physician performance and patient experience is not +disclosed under this section in a manner that violates sections 552 or +552a of title 5, United States Code, with regard to the privacy of +individually identifiable health information. + (d) Feedback From Multi-stakeholder Groups.--The Secretary shall +take into consideration input provided by multi-stakeholder groups, +consistent with sections 1890(b)(7) and 1890A of the Social Security +Act, as added by section 3014 of this Act, in selecting quality measures +for use under this section. + (e) Consideration of Transition to Value-based Purchasing.--In +developing the plan under this subsection (a)(2), the Secretary shall, +as the Secretary determines appropriate, consider the plan to transition +to a value-based purchasing program for physicians and other +practitioners developed under section 131 of the Medicare Improvements +for Patients and Providers Act of 2008 (Public Law 110-275). + (f) Report to Congress.--Not later than January 1, 2015, the +Secretary shall submit to Congress a report on the Physician Compare +Internet website developed under subsection (a)(1). Such report shall +include information on the efforts of and plans made by the Secretary to +collect and publish data on physician quality and efficiency and on +patient experience of care in support of value-based purchasing and +consumer choice, together with recommendations for such legislation and +administrative action as the Secretary determines appropriate. + (g) Expansion.--At any time before the date on which the report is +submitted under subsection (f), the Secretary may expand (including +expansion to other providers of services and suppliers under title XVIII +of the Social Security Act) the information made available on such +website. + (h) Financial Incentives To Encourage Consumers To Choose High +Quality Providers.-- <<NOTE: Deadline.>> The Secretary may establish a +demonstration program, not later than January 1, 2019, to provide +financial incentives to Medicare beneficiaries who are furnished +services by high quality physicians, as determined by the Secretary +based on factors in subparagraphs (A) through (G) of subsection (a)(2). +In no case may Medicare beneficiaries be required to pay increased +premiums or cost sharing or be subject to a reduction in benefits under +title XVIII of the Social Security Act as a result of such demonstration +program. The Secretary shall ensure that + +[[Page 124 STAT. 968]] + +any such demonstration program does not disadvantage those beneficiaries +without reasonable access to high performing physicians or create +financial inequities under such title. + + (i) Definitions.--In this section: + (1) Eligible professional.--The term ``eligible + professional'' has the meaning given that term for purposes of + the Physician Quality Reporting Initiative under section 1848 of + the Social Security Act (42 U.S.C. 1395w-4). + (2) Physician.--The term ``physician'' has the meaning given + that term in section 1861(r) of such Act (42 U.S.C. 1395x(r)). + (3) Physician compare.--The term ``Physician Compare'' means + the Internet website developed under subsection (a)(1). + (4) Secretary.--The term ``Secretary'' means the Secretary + of Health and Human Services. + +SEC. 10332. AVAILABILITY OF MEDICARE DATA FOR PERFORMANCE MEASUREMENT. + + (a) In General.--Section 1874 of the Social Security Act (42 U.S.C. +1395kk) is amended by adding at the end the following new subsection: + ``(e) Availability of Medicare Data.-- + ``(1) In general.--Subject to paragraph (4), the Secretary + shall make available to qualified entities (as defined in + paragraph (2)) data described in paragraph (3) for the + evaluation of the performance of providers of services and + suppliers. + ``(2) Qualified entities.--For purposes of this subsection, + the term `qualified entity' means a public or private entity + that-- + ``(A) is qualified (as determined by the Secretary) + to use claims data to evaluate the performance of + providers of services and suppliers on measures of + quality, efficiency, effectiveness, and resource use; + and + ``(B) agrees to meet the requirements described in + paragraph (4) and meets such other requirements as the + Secretary may specify, such as ensuring security of + data. + ``(3) Data described.--The data described in this paragraph + are standardized extracts (as determined by the Secretary) of + claims data under parts A, B, and D for items and services + furnished under such parts for one or more specified geographic + areas and time periods requested by a qualified entity. The + Secretary shall take such actions as the Secretary deems + necessary to protect the identity of individuals entitled to or + enrolled for benefits under such parts. + ``(4) Requirements.-- + ``(A) Fee.--Data described in paragraph (3) shall be + made available to a qualified entity under this + subsection at a fee equal to the cost of making such + data available. Any fee collected pursuant to the + preceding sentence shall be deposited into the Federal + Supplementary Medical Insurance Trust Fund under section + 1841. + ``(B) Specification of uses and methodologies.--A + qualified entity requesting data under this subsection + shall-- + ``(i) submit to the Secretary a description of + the methodologies that such qualified entity will + use to + +[[Page 124 STAT. 969]] + + evaluate the performance of providers of services + and suppliers using such data; + ``(ii)(I) except as provided in subclause + (II), if available, use standard measures, such as + measures endorsed by the entity with a contract + under section 1890(a) and measures developed + pursuant to section 931 of the Public Health + Service Act; or + ``(II) use alternative measures if the + Secretary, in consultation with appropriate + stakeholders, determines that use of such + alternative measures would be more valid, + reliable, responsive to consumer preferences, + cost-effective, or relevant to dimensions of + quality and resource use not addressed by such + standard measures; + ``(iii) include data made available under this + subsection with claims data from sources other + than claims data under this title in the + evaluation of performance of providers of services + and suppliers; + ``(iv) only include information on the + evaluation of performance of providers and + suppliers in reports described in subparagraph + (C); + ``(v) make available to providers of services + and suppliers, upon their request, data made + available under this subsection; and + ``(vi) prior to their release, submit to the + Secretary the format of reports under subparagraph + (C). + ``(C) Reports.--Any report by a qualified entity + evaluating the performance of providers of services and + suppliers using data made available under this + subsection shall-- + ``(i) include an understandable description of + the measures, which shall include quality measures + and the rationale for use of other measures + described in subparagraph (B)(ii)(II), risk + adjustment methods, physician attribution methods, + other applicable methods, data specifications and + limitations, and the sponsors, so that consumers, + providers of services and suppliers, health plans, + researchers, and other stakeholders can assess + such reports; + ``(ii) be made available confidentially, to + any provider of services or supplier to be + identified in such report, prior to the public + release of such report, and provide an opportunity + to appeal and correct errors; + ``(iii) only include information on a provider + of services or supplier in an aggregate form as + determined appropriate by the Secretary; and + ``(iv) <<NOTE: Public information.>> except as + described in clause (ii), be made available to the + public. + ``(D) Approval and limitation of uses.--The + Secretary shall not make data described in paragraph (3) + available to a qualified entity unless the qualified + entity agrees to release the information on the + evaluation of performance of providers of services and + suppliers. Such entity shall only use such data, and + information derived from such evaluation, for the + reports under subparagraph (C). Data released to a + qualified entity under this subsection shall not be + subject to discovery or admission as + +[[Page 124 STAT. 970]] + + evidence in judicial or administrative proceedings + without consent of the applicable provider of services + or supplier.''. + + (b) <<NOTE: 42 USC 1395kk note.>> Effective Date.--The amendment +made by subsection (a) shall take effect on January 1, 2012. + +SEC. 10333. COMMUNITY-BASED COLLABORATIVE CARE NETWORKS. + + Part D of title III of the Public Health Service Act (42 U.S.C. 254b +et seq.) is amended by adding at the end the following new subpart: + + ``Subpart XI--Community-Based Collaborative Care Network Program + +``SEC. 340H. <<NOTE: 42 USC 256i.>> COMMUNITY-BASED COLLABORATIVE CARE + NETWORK PROGRAM. + + ``(a) In General.--The Secretary may award grants to eligible +entities to support community-based collaborative care networks that +meet the requirements of subsection (b). + ``(b) Community-based Collaborative Care Networks.-- + ``(1) Description.--A community-based collaborative care + network (referred to in this section as a `network') shall be a + consortium of health care providers with a joint governance + structure (including providers within a single entity) that + provides comprehensive coordinated and integrated health care + services (as defined by the Secretary) for low-income + populations. + ``(2) Required inclusion.--A network shall include the + following providers (unless such provider does not exist within + the community, declines or refuses to participate, or places + unreasonable conditions on their participation): + ``(A) A hospital that meets the criteria in section + 1923(b)(1) of the Social Security Act; and + ``(B) All Federally qualified health centers (as + defined in section 1861(aa) of the Social Security Act + located in the community. + ``(3) Priority.--In awarding grants, the Secretary shall + give priority to networks that include-- + ``(A) the capability to provide the broadest range + of services to low-income individuals; + ``(B) the broadest range of providers that currently + serve a high volume of low-income individuals; and + ``(C) a county or municipal department of health. + + ``(c) Application.-- + ``(1) Application.--A network described in subsection (b) + shall submit an application to the Secretary. + ``(2) Renewal.--In subsequent years, based on the + performance of grantees, the Secretary may provide renewal + grants to prior year grant recipients. + + ``(d) Use of Funds.-- + ``(1) Use by grantees.--Grant funds may be used for the + following activities: + ``(A) Assist low-income individuals to-- + ``(i) access and appropriately use health + services; + ``(ii) enroll in health coverage programs; and + ``(iii) obtain a regular primary care provider + or a medical home. + ``(B) Provide case management and care management. + +[[Page 124 STAT. 971]] + + ``(C) Perform health outreach using neighborhood + health workers or through other means. + ``(D) Provide transportation. + ``(E) Expand capacity, including through telehealth, + after-hours services or urgent care. + ``(F) Provide direct patient care services. + ``(2) Grant funds to hrsa grantees.--The Secretary may limit + the percent of grant funding that may be spent on direct care + services provided by grantees of programs administered by the + Health Resources and Services Administration or impose other + requirements on such grantees deemed necessary. + + ``(e) Authorization of Appropriations.--There are authorized to be +appropriated to carry out this section such sums as may be necessary for +each of fiscal years 2011 through 2015.''. + +SEC. 10334. MINORITY HEALTH. + + (a) Office of Minority Health.-- + (1) In general.--Section 1707 of the Public Health Service + Act (42 U.S.C. 300u-6) is amended-- + (A) <<NOTE: Establishment.>> in subsection (a), by + striking ``within the Office of Public Health and + Science'' and all that follows through the end and + inserting ``. The Office of Minority Health as existing + on the date of enactment of the Patient Protection and + Affordable Care Act shall be transferred to the Office + of the Secretary in such manner that there is + established in the Office of the Secretary, the Office + of Minority Health, which shall be headed by the Deputy + Assistant Secretary for Minority Health who shall report + directly to the Secretary, and shall retain and + strengthen authorities (as in existence on such date of + enactment) for the purpose of improving minority health + and the quality of health care minorities receive, and + eliminating racial and ethnic + disparities. <<NOTE: Grants. Contracts. Memorandum.>> In + carrying out this subsection, the Secretary, acting + through the Deputy Assistant Secretary, shall award + grants, contracts, enter into memoranda of + understanding, cooperative, interagency, intra-agency + and other agreements with public and nonprofit private + entities, agencies, as well as Departmental and Cabinet + agencies and organizations, and with organizations that + are indigenous human resource providers in communities + of color to assure improved health status of racial and + ethnic minorities, and shall develop measures to + evaluate the effectiveness of activities aimed at + reducing health disparities and supporting the local + community. Such measures shall evaluate community + outreach activities, language services, workforce + cultural competence, and other areas as determined by + the Secretary.''; and + (B) by striking subsection (h) and inserting the + following: + + ``(h) Authorization of Appropriations.--For the purpose of carrying +out this section, there are authorized to be appropriated such sums as +may be necessary for each of fiscal years 2011 through 2016.''. + (2) <<NOTE: 42 USC 300u-6 note.>> Transfer of functions.-- + There are transferred to the Office of Minority Health in the + office of the Secretary of Health and Human Services, all + duties, responsibilities, authorities, accountabilities, + functions, staff, funds, award + +[[Page 124 STAT. 972]] + + mechanisms, and other entities under the authority of the Office + of Minority Health of the Public Health Service as in effect on + the date before the date of enactment of this Act, which shall + continue in effect according to the terms in effect on the date + before such date of enactment, until modified, terminated, + superseded, set aside, or revoked in accordance with law by the + President, the Secretary, a court of competent jurisdiction, or + by operation of law. + (3) Reports.-- <<NOTE: 42 USC 300u-6 note.>> Not later than + 1 year after the date of enactment of this section, and + biennially thereafter, the Secretary of Health and Human + Services shall prepare and submit to the appropriate committees + of Congress a report describing the activities carried out under + section 1707 of the Public Health Service Act (as amended by + this subsection) during the period for which the report is being + prepared. Not later than 1 year after the date of enactment of + this section, and biennially thereafter, the heads of each of + the agencies of the Department of Health and Human Services + shall submit to the Deputy Assistant Secretary for Minority + Health a report summarizing the minority health activities of + each of the respective agencies. + + (b) Establishment of Individual Offices of Minority Health Within +the Department of Health and Human Services.-- + (1) In general.--Title XVII of the Public Health Service Act + (42 U.S.C. 300u et seq.) is amended by inserting after section + 1707 the following section: + +``SEC. 1707A. <<NOTE: 42 USC 300u-6a.>> INDIVIDUAL OFFICES OF MINORITY + HEALTH WITHIN THE DEPARTMENT. + + ``(a) In General.--The head of each agency specified in subsection +(b)(1) shall establish within the agency an office to be known as the +Office of Minority Health. <<NOTE: Appointment.>> The head of each such +Office shall be appointed by the head of the agency within which the +Office is established, and shall report directly to the head of the +agency. The head of such agency shall carry out this section (as this +section relates to the agency) acting through such Director. + + ``(b) Specified Agencies.--The agencies referred to in subsection +(a) are the Centers for Disease Control and Prevention, the Health +Resources and Services Administration, the Substance Abuse and Mental +Health Services Administration, the Agency for Healthcare Research and +Quality, the Food and Drug Administration, and the Centers for Medicare +& Medicaid Services. + ``(c) Director; Appointment.--Each Office of Minority Health +established in an agency listed in subsection (a) shall be headed by a +director, with documented experience and expertise in minority health +services research and health disparities elimination. + ``(d) References.--Except as otherwise specified, any reference in +Federal law to an Office of Minority Health (in the Department of Health +and Human Services) is deemed to be a reference to the Office of +Minority Health in the Office of the Secretary. + ``(e) Funding.-- + ``(1) Allocations.--Of the amounts appropriated for a + specified agency for a fiscal year, the Secretary must designate + an appropriate amount of funds for the purpose of carrying out + activities under this section through the minority health office + of the agency. In reserving an amount under the preceding + +[[Page 124 STAT. 973]] + + sentence for a minority health office for a fiscal year, the + Secretary shall reduce, by substantially the same percentage, + the amount that otherwise would be available for each of the + programs of the designated agency involved. + ``(2) Availability of funds for staffing.--The purposes for + which amounts made available under paragraph may be expended by + a minority health office include the costs of employing staff + for such office.''. + (2) <<NOTE: 42 USC 300u-6a note.>> No new regulatory + authority.--Nothing in this subsection and the amendments made + by this subsection may be construed as establishing regulatory + authority or modifying any existing regulatory authority. + (3) <<NOTE: 42 USC 300u-6a note.>> Limitation on + termination.--Notwithstanding any other provision of law, a + Federal office of minority health or Federal appointive position + with primary responsibility over minority health issues that is + in existence in an office of agency of the Department of Health + and Human Services on the date of enactment of this section + shall not be terminated, reorganized, or have any of its power + or duties transferred unless such termination, reorganization, + or transfer is approved by an Act of Congress. + + (c) Redesignation of National Center on Minority Health and Health +Disparities.-- + (1) Redesignation.--Title IV of the Public Health Service + Act (42 U.S.C. 281 et seq.) is amended-- + (A) by redesignating subpart 6 of part E as subpart + 20; + (B) by transferring subpart 20, as so redesignated, + to part C of such title IV; + (C) by inserting subpart 20, as so redesignated, + after subpart 19 of such part C; and + (D) in subpart 20, as so redesignated-- + (i) by redesignating <<NOTE: 42 USC 285t-- + 285t-3.>> sections 485E through 485H as sections + 464z-3 through 464z-6, respectively; + (ii) <<NOTE: 42 USC 285t.>> by striking + ``National Center on Minority Health and Health + Disparities'' each place such term appears and + inserting ``National Institute on Minority Health + and Health Disparities''; and + (iii) <<NOTE: 42 USC 285t--285t-3.>> by + striking ``Center'' each place such term appears + and inserting ``Institute''. + (2) Purpose of institute; duties.--Section 464z-3 of the + Public Health Service Act, as so redesignated, <<NOTE: 42 USC + 285t.>> is amended-- + (A) in subsection (h)(1), by striking ``research + endowments at centers of excellence under section 736.'' + and inserting the following: ``research endowments-- + ``(1) at centers of excellence under section 736; and + ``(2) at centers of excellence under section 464z-4.''; + (B) in subsection (h)(2)(A), by striking ``average'' + and inserting ``median''; and + (C) by adding at the end the following: + + ``(h) Interagency Coordination.--The Director of the Institute, as +the primary Federal officials with responsibility for coordinating all +research and activities conducted or supported by the National +Institutes of Health on minority health and health disparities, shall +plan, coordinate, review and evaluate research and other activities +conducted or supported by the Institutes and Centers of the National +Institutes of Health.''. + +[[Page 124 STAT. 974]] + + (3) Technical and conforming amendments.-- + (A) Section 401(b)(24) of the Public Health Service + Act (42 U.S.C. 281(b)(24)) is amended by striking + ``Center'' and inserting ``Institute''. + (B) Subsection (d)(1) of section 903 of the Public + Health Service Act (42 U.S.C. 299a-1(d)(1)) is amended + by striking ``section 485E'' and inserting ``section + 464z-3''. + +SEC. 10335. TECHNICAL CORRECTION TO THE HOSPITAL VALUE-BASED PURCHASING + PROGRAM. + + Section 1886(o)(2)A) of the Social Security Act, as added by section +3001, <<NOTE: 42 USC 1395ww.>> is amended, in the first sentence, by +inserting ``, other than measures of readmissions,'' after ``shall +select measures''. + +SEC. 10336. GAO STUDY AND REPORT ON MEDICARE BENEFICIARY ACCESS TO HIGH- + QUALITY DIALYSIS SERVICES. + + (a) Study.-- + (1) In general.--The Comptroller General of the United + States shall conduct a study on the impact on Medicare + beneficiary access to high-quality dialysis services of + including specified oral drugs that are furnished to such + beneficiaries for the treatment of end stage renal disease in + the bundled prospective payment system under section 1881(b)(14) + of the Social Security Act (42 U.S.C. 1395rr(b)(14)) (pursuant + to the proposed rule published by the Secretary of Health and + Human Services in the Federal Register on September 29, 2009 (74 + Fed. Reg. 49922 et seq.)). Such study shall include an analysis + of-- + (A) the ability of providers of services and renal + dialysis facilities to furnish specified oral drugs or + arrange for the provision of such drugs; + (B) the ability of providers of services and renal + dialysis facilities to comply, if necessary, with + applicable State laws (such as State pharmacy licensure + requirements) in order to furnish specified oral drugs; + (C) whether appropriate quality measures exist to + safeguard care for Medicare beneficiaries being + furnished specified oral drugs by providers of services + and renal dialysis facilities; and + (D) other areas determined appropriate by the + Comptroller General. + (2) Specified oral drug defined.--For purposes of paragraph + (1), the term ``specified oral drug'' means a drug or biological + for which there is no injectable equivalent (or other non-oral + form of administration). + + (b) Report.--Not later than 1 year after the date of the enactment +of this Act, the Comptroller General of the United States shall submit +to Congress a report containing the results of the study conducted under +subsection (a), together with recommendations for such legislation and +administrative action as the Comptroller General determines appropriate. + + Subtitle D--Provisions Relating to Title IV + +SEC. 10401. AMENDMENTS TO SUBTITLE A. + + (a) Section 4001(h)(4) and (5) of this Act <<NOTE: 42 USC 300u- +10.>> is amended by striking ``2010'' each place such appears and +inserting ``2020''. + + (b) Section 4002(c) of this Act <<NOTE: 42 USC 300u-11.>> is +amended-- + +[[Page 124 STAT. 975]] + + (1) by striking ``research and health screenings'' and + inserting ``research, health screenings, and initiatives''; and + (2) by striking ``for Preventive'' and inserting ``Regarding + Preventive''. + + (c) Section 4004(a)(4) of this Act <<NOTE: 42 USC 300u-12.>> is +amended by striking ``a Gateway'' and inserting ``an Exchange''. + +SEC. 10402. AMENDMENTS TO SUBTITLE B. + + (a) Section 399Z-1(a)(1(A) of the Public Health Service Act, as +added by section 4101(b) of this Act, <<NOTE: 42 USC 280n-5.>> is +amended by inserting ``and vision'' after ``oral''. + + (b) Section 1861(hhh)(4)(G) of the Social Security Act, as added by +section 4103(b), <<NOTE: 42 USC 1395k.>> is amended to read as follows: + ``(G) A beneficiary shall be eligible to receive + only an initial preventive physical examination (as + defined under subsection (ww)(1)) during the 12-month + period after the date that the beneficiary's coverage + begins under part B and shall be eligible to receive + personalized prevention plan services under this + subsection each year thereafter provided that the + beneficiary has not received either an initial + preventive physical examination or personalized + prevention plan services within the preceding 12-month + period.''. + +SEC. 10403. AMENDMENTS TO SUBTITLE C. + + Section 4201 of this Act <<NOTE: 42 USC 300u-13.>> is amended-- + (1) in subsection (a), by adding before the period the + following: ``, with not less than 20 percent of such grants + being awarded to rural and frontier areas''; + (2) in subsection (c)(2)(B)(vii), by striking ``both urban + and rural areas'' and inserting ``urban, rural, and frontier + areas''; and + (3) in subsection (f), by striking ``each fiscal years'' and + inserting ``each of fiscal year''. + +SEC. 10404. AMENDMENTS TO SUBTITLE D. + + Section 399MM(2) of the Public Health Service Act, as added by +section 4303 of this Act, <<NOTE: 42 USC 280l.>> is amended by striking +``by ensuring'' and inserting ``and ensuring''. + +SEC. 10405. AMENDMENTS TO SUBTITLE E. + + Subtitle E of title IV of this Act is amended by striking section +4401. + +SEC. 10406. AMENDMENT RELATING TO WAIVING COINSURANCE FOR PREVENTIVE + SERVICES. + + Section 4104(b) of this Act is amended to read as follows: + ``(b) Payment and Elimination of Coinsurance in All Settings.-- +Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), +as amended by section 4103(c)(1), is amended-- + ``(1) in subparagraph (T), by inserting `(or 100 percent if + such services are recommended with a grade of A or B by the + United States Preventive Services Task Force for any indication + or population and are appropriate for the individual)' after `80 + percent'; + ``(2) in subparagraph (W)-- + +[[Page 124 STAT. 976]] + + ``(A) in clause (i), by inserting `(if such + subparagraph were applied, by substituting ``100 + percent'' for ``80 percent'')' after `subparagraph (D)'; + and + ``(B) in clause (ii), by striking `80 percent' and + inserting `100 percent'; + ``(3) by striking `and' before `(X)'; and + ``(4) by inserting before the semicolon at the end the + following: `, and (Y) with respect to preventive services + described in subparagraphs (A) and (B) of section 1861(ddd)(3) + that are appropriate for the individual and, in the case of such + services described in subparagraph (A), are recommended with a + grade of A or B by the United States Preventive Services Task + Force for any indication or population, the amount paid shall be + 100 percent of (i) except as provided in clause (ii), the lesser + of the actual charge for the services or the amount determined + under the fee schedule that applies to such services under this + part, and (ii) in the case of such services that are covered OPD + services (as defined in subsection (t)(1)(B)), the amount + determined under subsection (t)'.''. + +SEC. 10407. <<NOTE: Catalyst to Better Diabetes Care Act of 2009. 42 USC + 247b-9g.>> BETTER DIABETES CARE. + + (a) Short Title.--This section may be cited as the ``Catalyst to +Better Diabetes Care Act of 2009''. + (b) National Diabetes Report Card.-- + (1) In general.--The Secretary, in collaboration with the + Director of the Centers for Disease Control and Prevention + (referred to in this section as the ``Director''), shall prepare + on a biennial basis a national diabetes report card (referred to + in this section as a ``Report Card'') and, to the extent + possible, for each State. + (2) Contents.-- + (A) In general.--Each Report Card shall include + aggregate health outcomes related to individuals + diagnosed with diabetes and prediabetes including-- + (i) preventative care practices and quality of + care; + (ii) risk factors; and + (iii) outcomes. + (B) Updated reports.--Each Report Card that is + prepared after the initial Report Card shall include + trend analysis for the Nation and, to the extent + possible, for each State, for the purpose of-- + (i) tracking progress in meeting established + national goals and objectives for improving + diabetes care, costs, and prevalence (including + Healthy People 2010); and + (ii) informing policy and program development. + (3) <<NOTE: Public information. Web + posting.>> Availability.--The Secretary, in collaboration with + the Director, shall make each Report Card publicly available, + including by posting the Report Card on the Internet. + + (c) Improvement of Vital Statistics Collection.-- + (1) In general.--The Secretary, acting through the Director + of the Centers for Disease Control and Prevention and in + collaboration with appropriate agencies and States, shall-- + (A) promote the education and training of physicians + on the importance of birth and death certificate data + and how to properly complete these documents, including + the + +[[Page 124 STAT. 977]] + + collection of such data for diabetes and other chronic + diseases; + (B) encourage State adoption of the latest standard + revisions of birth and death certificates; and + (C) work with States to re-engineer their vital + statistics systems in order to provide cost-effective, + timely, and accurate vital systems data. + (2) Death certificate additional language.--In carrying out + this subsection, the Secretary may promote improvements to the + collection of diabetes mortality data, including the addition of + a question for the individual certifying the cause of death + regarding whether the deceased had diabetes. + + (d) Study on Appropriate Level of Diabetes Medical Education.-- + (1) In general.--The Secretary shall, in collaboration with + the Institute of Medicine and appropriate associations and + councils, conduct a study of the impact of diabetes on the + practice of medicine in the United States and the + appropriateness of the level of diabetes medical education that + should be required prior to licensure, board certification, and + board recertification. + (2) Report.--Not later than 2 years after the date of the + enactment of this Act, the Secretary shall submit a report on + the study under paragraph (1) to the Committees on Ways and + Means and Energy and Commerce of the House of Representatives + and the Committees on Finance and Health, Education, Labor, and + Pensions of the Senate. + + (e) Authorization of Appropriations.--There are authorized to be +appropriated to carry out this section such sums as may be necessary. + +SEC. 10408. GRANTS FOR SMALL BUSINESSES TO PROVIDE COMPREHENSIVE + WORKPLACE WELLNESS PROGRAMS. + + (a) Establishment.--The Secretary shall award grants to eligible +employers to provide their employees with access to comprehensive +workplace wellness programs (as described under subsection (c)). + (b) Scope.-- + (1) Duration.--The grant program established under this + section shall be conducted for a 5-year period. + (2) Eligible employer.-- <<NOTE: Definition.>> The term + ``eligible employer'' means an employer (including a non-profit + employer) that-- + (A) employs less than 100 employees who work 25 + hours or greater per week; and + (B) does not provide a workplace wellness program as + of the date of enactment of this Act. + + (c) Comprehensive Workplace Wellness Programs.-- + (1) Criteria.--The Secretary shall develop program criteria + for comprehensive workplace wellness programs under this section + that are based on and consistent with evidence-based research + and best practices, including research and practices as provided + in the Guide to Community Preventive Services, the Guide to + Clinical Preventive Services, and the National Registry for + Effective Programs. + (2) Requirements.--A comprehensive workplace wellness + program shall be made available by an eligible employer to all + employees and include the following components: + +[[Page 124 STAT. 978]] + + (A) Health awareness initiatives (including health + education, preventive screenings, and health risk + assessments). + (B) Efforts to maximize employee engagement + (including mechanisms to encourage employee + participation). + (C) Initiatives to change unhealthy behaviors and + lifestyle choices (including counseling, seminars, + online programs, and self-help materials). + (D) Supportive environment efforts (including + workplace policies to encourage healthy lifestyles, + healthy eating, increased physical activity, and + improved mental health). + + (d) Application.--An eligible employer desiring to participate in +the grant program under this section shall submit an application to the +Secretary, in such manner and containing such information as the +Secretary may require, which shall include a proposal for a +comprehensive workplace wellness program that meet the criteria and +requirements described under subsection (c). + (e) Authorization of Appropriation.--For purposes of carrying out +the grant program under this section, there is authorized to be +appropriated $200,000,000 for the period of fiscal years 2011 through +2015. Amounts appropriated pursuant to this subsection shall remain +available until expended. + +SEC. 10409. <<NOTE: Cures Acceleration Network Act of 2009. 42 USC 201 + note.>> CURES ACCELERATION NETWORK. + + (a) Short Title.--This section may be cited as the ``Cures +Acceleration Network Act of 2009''. + (b) Requirement for the Director of NIH To Establish a Cures +Acceleration Network.--Section 402(b) of the Public Health Service Act +(42 U.S.C. 282(b)) is amended-- + (1) in paragraph (22), by striking ``and'' at the end; + (2) in paragraph (23), by striking the period and inserting + ``; and''; and + (3) by inserting after paragraph (23), the following: + ``(24) implement the Cures Acceleration Network described in + section 402C.''. + + (c) Accepting Gifts To Support the Cures Acceleration Network.-- +Section 499(c)(1) of the Public Health Service Act (42 U.S.C. +290b(c)(1)) is amended by adding at the end the following: + ``(E) The Cures Acceleration Network described in + section 402C.''. + + (d) Establishment of the Cures Acceleration Network.--Part A of +title IV of the Public Health Service Act is amended by inserting after +section 402B (42 U.S.C. 282b) the following: + +``SEC. 402C. <<NOTE: 42 USC 282d.>> CURES ACCELERATION NETWORK. + + ``(a) Definitions.--In this section: + ``(1) Biological product.--The term `biological product' has + the meaning given such term in section 351 of the Public Health + Service Act. + ``(2) Drug; device.--The terms `drug' and `device' have the + meanings given such terms in section 201 of the Federal Food, + Drug, and Cosmetic Act. + ``(3) High need cure.--The term `high need cure' means a + drug (as that term is defined by section 201(g)(1) of the + Federal Food, Drug, and Cosmetic Act, biological product (as + that term is defined by section 262(i)), or device (as that term + is defined by section 201(h) of the Federal Food, Drug, and + +[[Page 124 STAT. 979]] + + Cosmetic Act) that, in the determination of the Director of + NIH-- + ``(A) is a priority to diagnose, mitigate, prevent, + or treat harm from any disease or condition; and + ``(B) for which the incentives of the commercial + market are unlikely to result in its adequate or timely + development. + ``(4) Medical product.--The term `medical product' means a + drug, device, biological product, or product that is a + combination of drugs, devices, and biological products. + + ``(b) Establishment of the Cures Acceleration Network.--Subject to +the appropriation of funds as described in subsection (g), there is +established within the Office of the Director of NIH a program to be +known as the Cures Acceleration Network (referred to in this section as +`CAN'), which shall-- + ``(1) be under the direction of the Director of NIH, taking + into account the recommendations of a CAN Review Board (referred + to in this section as the `Board'), described in subsection (d); + and + ``(2) <<NOTE: Grants. Contracts.>> award grants and + contracts to eligible entities, as described in subsection (e), + to accelerate the development of high need cures, including + through the development of medical products and behavioral + therapies. + + ``(c) Functions.--The functions of the CAN are to-- + ``(1) conduct and support revolutionary advances in basic + research, translating scientific discoveries from bench to + bedside; + ``(2) award grants and contracts to eligible entities to + accelerate the development of high need cures; + ``(3) provide the resources necessary for government + agencies, independent investigators, research organizations, + biotechnology companies, academic research institutions, and + other entities to develop high need cures; + ``(4) reduce the barriers between laboratory discoveries and + clinical trials for new therapies; and + ``(5) facilitate review in the Food and Drug Administration + for the high need cures funded by the CAN, through activities + that may include-- + ``(A) the facilitation of regular and ongoing + communication with the Food and Drug Administration + regarding the status of activities conducted under this + section; + ``(B) ensuring that such activities are coordinated + with the approval requirements of the Food and Drug + Administration, with the goal of expediting the + development and approval of countermeasures and + products; and + ``(C) connecting interested persons with additional + technical assistance made available under section 565 of + the Federal Food, Drug, and Cosmetic Act. + + ``(d) CAN Board.-- + ``(1) Establishment.--There is established a Cures + Acceleration Network Review Board (referred to in this section + as the `Board'), which shall advise the Director of NIH on the + conduct of the activities of the Cures Acceleration Network. + ``(2) Membership.-- + ``(A) In general.-- + ``(i) Appointment.--The Board shall be + comprised of 24 members who are appointed by the + Secretary and who serve at the pleasure of the + Secretary. + +[[Page 124 STAT. 980]] + + ``(ii) Chairperson and vice chairperson.--The + Secretary shall designate, from among the 24 + members appointed under clause (i), one + Chairperson of the Board (referred to in this + section as the `Chairperson') and one Vice + Chairperson. + ``(B) Terms.-- + ``(i) In general.--Each member shall be + appointed to serve a 4-year term, except that any + member appointed to fill a vacancy occurring prior + to the expiration of the term for which the + member's predecessor was appointed shall be + appointed for the remainder of such term. + ``(ii) Consecutive appointments; maximum + terms.--A member may be appointed to serve not + more than 3 terms on the Board, and may not serve + more than 2 such terms consecutively. + ``(C) Qualifications.-- + ``(i) In general.--The Secretary shall appoint + individuals to the Board based solely upon the + individual's established record of distinguished + service in one of the areas of expertise described + in clause (ii). Each individual appointed to the + Board shall be of distinguished achievement and + have a broad range of disciplinary interests. + ``(ii) Expertise.--The Secretary shall select + individuals based upon the following requirements: + ``(I) For each of the fields of-- + ``(aa) basic research; + ``(bb) medicine; + ``(cc) biopharmaceuticals; + ``(dd) discovery and + delivery of medical products; + ``(ee) bioinformatics and + gene therapy; + ``(ff) medical + instrumentation; and + ``(gg) regulatory review and + approval of medical products, + the Secretary shall select at least 1 + individual who is eminent in such + fields. + ``(II) At least 4 individuals shall + be recognized leaders in professional + venture capital or private equity + organizations and have demonstrated + experience in private equity investing. + ``(III) At least 8 individuals shall + represent disease advocacy + organizations. + ``(3) Ex-officio members.-- + ``(A) Appointment.--In addition to the 24 Board + members described in paragraph (2), the Secretary shall + appoint as ex-officio members of the Board-- + ``(i) a representative of the National + Institutes of Health, recommended by the Secretary + of the Department of Health and Human Services; + ``(ii) a representative of the Office of the + Assistant Secretary of Defense for Health Affairs, + recommended by the Secretary of Defense; + +[[Page 124 STAT. 981]] + + ``(iii) a representative of the Office of the + Under Secretary for Health for the Veterans Health + Administration, recommended by the Secretary of + Veterans Affairs; + ``(iv) a representative of the National + Science Foundation, recommended by the Chair of + the National Science Board; and + ``(v) a representative of the Food and Drug + Administration, recommended by the Commissioner of + Food and Drugs. + ``(B) Terms.--Each ex-officio member shall serve a + 3-year term on the Board, except that the Chairperson + may adjust the terms of the initial ex-officio members + in order to provide for a staggered term of appointment + for all such members. + ``(4) Responsibilities of the board and the director of + nih.-- + ``(A) Responsibilities of the board.-- + ``(i) In general.-- <<NOTE: Recommenda- + tions.>> The Board shall advise, and provide + recommendations to, the Director of NIH with + respect to-- + ``(I) policies, programs, and + procedures for carrying out the duties + of the Director of NIH under this + section; and + ``(II) significant barriers to + successful translation of basic science + into clinical application (including + issues under the purview of other + agencies and departments). + ``(ii) Report.--In the case that the Board + identifies a significant barrier, as described in + clause (i)(II), the Board shall submit to the + Secretary a report regarding such barrier. + ``(B) Responsibilities of the director of nih.--With + respect to each recommendation provided by the Board + under subparagraph (A)(i), the Director of NIH shall + respond in writing to the Board, indicating whether such + Director will implement such recommendation. In the case + that the Director of NIH indicates a recommendation of + the Board will not be implemented, such Director shall + provide an explanation of the reasons for not + implementing such recommendation. + ``(5) Meetings.-- + ``(A) In general.--The Board shall meet 4 times per + calendar year, at the call of the Chairperson. + ``(B) Quorum; requirements; limitations.-- + ``(i) Quorum.--A quorum shall consist of a + total of 13 members of the Board, excluding ex- + officio members, with diverse representation as + described in clause (iii). + ``(ii) Chairperson or vice chairperson.--Each + meeting of the Board shall be attended by either + the Chairperson or the Vice Chairperson. + ``(iii) Diverse representation.--At each + meeting of the Board, there shall be not less than + one scientist, one representative of a disease + advocacy organization, and one representative of a + professional venture capital or private equity + organization. + +[[Page 124 STAT. 982]] + + ``(6) Compensation and travel expenses.-- + ``(A) Compensation.--Members shall receive + compensation at a rate to be fixed by the Chairperson + but not to exceed a rate equal to the daily equivalent + of the annual rate of basic pay prescribed for level IV + of the Executive Schedule under section 5315 of title 5, + United States Code, for each day (including travel time) + during which the member is engaged in the performance of + the duties of the Board. All members of the Board who + are officers or employees of the United States shall + serve without compensation in addition to that received + for their services as officers or employees of the + United States. + ``(B) Travel expenses.--Members of the Board shall + be allowed travel expenses, including per diem in lieu + of subsistence, at rates authorized for persons employed + intermittently by the Federal Government under section + 5703(b) of title 5, United States Code, while away from + their homes or regular places of business in the + performance of services for the Board. + + ``(e) Grant Program.-- + ``(1) Supporting innovation.-- <<NOTE: Contracts.>> To carry + out the purposes described in this section, the Director of NIH + shall award contracts, grants, or cooperative agreements to the + entities described in paragraph (2), to-- + ``(A) promote innovation in technologies supporting + the advanced research and development and production of + high need cures, including through the development of + medical products and behavioral therapies. + ``(B) accelerate the development of high need cures, + including through the development of medical products, + behavioral therapies, and biomarkers that demonstrate + the safety or effectiveness of medical products; or + ``(C) help the award recipient establish protocols + that comply with Food and Drug Administration standards + and otherwise permit the recipient to meet regulatory + requirements at all stages of development, + manufacturing, review, approval, and safety surveillance + of a medical product. + ``(2) Eligible entities.--To receive assistance under + paragraph (1), an entity shall-- + ``(A) be a public or private entity, which may + include a private or public research institution, an + institution of higher education, a medical center, a + biotechnology company, a pharmaceutical company, a + disease advocacy organization, a patient advocacy + organization, or an academic research institution; + ``(B) submit an application containing-- + ``(i) a detailed description of the project + for which the entity seeks such grant or contract; + ``(ii) a timetable for such project; + ``(iii) an assurance that the entity will + submit-- + ``(I) interim reports describing the + entity's-- + ``(aa) progress in carrying + out the project; and + ``(bb) compliance with all + provisions of this section and + conditions of receipt of such + grant or contract; and + +[[Page 124 STAT. 983]] + + ``(II) a final report at the + conclusion of the grant period, + describing the outcomes of the project; + and + ``(iv) a description of the protocols the + entity will follow to comply with Food and Drug + Administration standards and regulatory + requirements at all stages of development, + manufacturing, review, approval, and safety + surveillance of a medical product; and + ``(C) provide such additional information as the + Director of NIH may require. + ``(3) Awards.-- + ``(A) The cures acceleration partnership awards.-- + ``(i) Initial award amount.--Each award under + this subparagraph shall be not more than + $15,000,000 per project for the first fiscal year + for which the project is funded, which shall be + payable in one payment. + ``(ii) Funding in subsequent fiscal years.--An + eligible entity receiving an award under clause + (i) may apply for additional funding for such + project by submitting to the Director of NIH the + information required under subparagraphs (B) and + (C) of paragraph (2). The Director may fund a + project of such eligible entity in an amount not + to exceed $15,000,000 for a fiscal year subsequent + to the initial award under clause (i). + ``(iii) Matching funds.-- <<NOTE: Waiver + authority.>> As a condition for receiving an award + under this subsection, an eligible entity shall + contribute to the project non-Federal funds in the + amount of $1 for every $3 awarded under clauses + (i) and (ii), except that the Director of NIH may + waive or modify such matching requirement in any + case where the Director determines that the goals + and objectives of this section cannot adequately + be carried out unless such requirement is waived. + ``(B) The cures acceleration grant awards.-- + ``(i) Initial award amount.--Each award under + this subparagraph shall be not more than + $15,000,000 per project for the first fiscal year + for which the project is funded, which shall be + payable in one payment. + ``(ii) Funding in subsequent fiscal years.--An + eligible entity receiving an award under clause + (i) may apply for additional funding for such + project by submitting to the Board the information + required under subparagraphs (B) and (C) of + paragraph (2). The Director of NIH may fund a + project of such eligible entity in an amount not + to exceed $15,000,000 for a fiscal year subsequent + to the initial award under clause (i). + ``(C) The cures acceleration flexible research + awards.-- <<NOTE: Determination.>> If the Director of + NIH determines that the goals and objectives of this + section cannot adequately be carried out through a + contract, grant, or cooperative agreement, the Director + of NIH shall have flexible research authority to use + other transactions to fund projects in accordance with + the terms and conditions of this section. Awards made + under such flexible research authority for a fiscal year + shall not exceed 20 percent of the total funds + appropriated under subsection (g)(1) for such fiscal + year. + +[[Page 124 STAT. 984]] + + ``(4) Suspension of awards for defaults, noncompliance with + provisions and plans, and diversion of funds; repayment of + funds.--The Director of NIH may suspend the award to any entity + upon noncompliance by such entity with provisions and plans + under this section or diversion of funds. + ``(5) Audits.--The Director of NIH may enter into agreements + with other entities to conduct periodic audits of the projects + funded by grants or contracts awarded under this subsection. + ``(6) Closeout procedures.--At the end of a grant or + contract period, a recipient shall follow the closeout + procedures under section 74.71 of title 45, Code of Federal + Regulations (or any successor regulation). + ``(7) Review.--A determination by the Director of NIH as to + whether a drug, device, or biological product is a high need + cure (for purposes of subsection (a)(3)) shall not be subject to + judicial review. + + ``(f) Competitive Basis of Awards.--Any grant, cooperative +agreement, or contract awarded under this section shall be awarded on a +competitive basis. + ``(g) Authorization of Appropriations.-- + ``(1) In general.--For purposes of carrying out this + section, there are authorized to be appropriated $500,000,000 + for fiscal year 2010, and such sums as may be necessary for + subsequent fiscal years. Funds appropriated under this section + shall be available until expended. + ``(2) Limitation on use of funds otherwise appropriated.--No + funds appropriated under this Act, other than funds appropriated + under paragraph (1), may be allocated to the Cures Acceleration + Network.''. + +SEC. 10410. <<NOTE: Establishing a Network of Health-Advancing National + Centers of Excellence for Depression Act of 2009. 42 USC 201 + note.>> CENTERS OF EXCELLENCE FOR DEPRESSION. + + (a) Short Title.--This section may be cited as the ``Establishing a +Network of Health-Advancing National Centers of Excellence for +Depression Act of 2009'' or the ``ENHANCED Act of 2009''. + (b) Centers of Excellence for Depression.--Subpart 3 of part B of +title V of the Public Health Service Act (42 U.S.C. 290bb et seq.) is +amended by inserting after section 520A the following: + +``SEC. 520B. <<NOTE: 42 USC 290bb-33.>> NATIONAL CENTERS OF EXCELLENCE + FOR DEPRESSION. + + ``(a) Depressive Disorder Defined.--In this section, the term +`depressive disorder' means a mental or brain disorder relating to +depression, including major depression, bipolar disorder, and related +mood disorders. + ``(b) Grant Program.-- + ``(1) In general.--The Secretary, acting through the + Administrator, shall award grants on a competitive basis to + eligible entities to establish national centers of excellence + for depression (referred to in this section as `Centers'), which + shall engage in activities related to the treatment of + depressive disorders. + ``(2) Allocation of awards.-- <<NOTE: Deadlines.>> If the + funds authorized under subsection (f) are appropriated in the + amounts provided for under such subsection, the Secretary shall + allocate such amounts so that-- + +[[Page 124 STAT. 985]] + + ``(A) not later than 1 year after the date of + enactment of the ENHANCED Act of 2009, not more than 20 + Centers may be established; and + ``(B) not later than September 30, 2016, not more + than 30 Centers may be established. + ``(3) Grant period.-- + ``(A) In general.--A grant awarded under this + section shall be for a period of 5 years. + ``(B) Renewal.--A grant awarded under subparagraph + (A) may be renewed, on a competitive basis, for 1 + additional 5-year period, at the discretion of the + Secretary. In determining whether to renew a grant, the + Secretary shall consider the report cards issued under + subsection (e)(2). + ``(4) Use of funds.--Grant funds awarded under this + subsection shall be used for the establishment and ongoing + activities of the recipient of such funds. + ``(5) Eligible entities.-- + ``(A) Requirements.--To be eligible to receive a + grant under this section, an entity shall-- + ``(i) be an institution of higher education or + a public or private nonprofit research + institution; and + ``(ii) submit an application to the Secretary + at such time and in such manner as the Secretary + may require, as described in subparagraph (B). + ``(B) Application.--An application described in + subparagraph (A)(ii) shall include-- + ``(i) evidence that such entity-- + ``(I) provides, or is capable of + coordinating with other entities to + provide, comprehensive health services + with a focus on mental health services + and subspecialty expertise for + depressive disorders; + ``(II) collaborates with other + mental health providers, as necessary, + to address co-occurring mental + illnesses; + ``(III) is capable of training + health professionals about mental + health; and + ``(ii) such other information, as the + Secretary may require. + ``(C) Priorities.--In awarding grants under this + section, the Secretary shall give priority to eligible + entities that meet 1 or more of the following criteria: + ``(i) Demonstrated capacity and expertise to + serve the targeted population. + ``(ii) Existing infrastructure or expertise to + provide appropriate, evidence-based and culturally + and linguistically competent services. + ``(iii) A location in a geographic area with + disproportionate numbers of underserved and at- + risk populations in medically underserved areas + and health professional shortage areas. + ``(iv) Proposed innovative approaches for + outreach to initiate or expand services. + ``(v) Use of the most up-to-date science, + practices, and interventions available. + ``(vi) Demonstrated capacity to establish + cooperative and collaborative agreements with + community mental health centers and other + community entities + +[[Page 124 STAT. 986]] + + to provide mental health, social, and human + services to individuals with depressive disorders. + ``(6) National coordinating center.-- + ``(A) In general.-- <<NOTE: Designation.>> The + Secretary, acting through the Administrator, shall + designate 1 recipient of a grant under this section to + be the coordinating center of excellence for depression + (referred to in this section as the `coordinating + center'). The Secretary shall select such coordinating + center on a competitive basis, based upon the + demonstrated capacity of such center to perform the + duties described in subparagraph (C). + ``(B) Application.--A Center that has been awarded a + grant under paragraph (1) may apply for designation as + the coordinating center by submitting an application to + the Secretary at such time, in such manner, and + containing such information as the Secretary may + require. + ``(C) Duties.--The coordinating center shall-- + ``(i) develop, administer, and coordinate the + network of Centers under this section; + ``(ii) oversee and coordinate the national + database described in subsection (d); + ``(iii) lead a strategy to disseminate the + findings and activities of the Centers through + such database; and + ``(iv) serve as a liaison with the + Administration, the National Registry of Evidence- + based Programs and Practices of the + Administration, and any Federal interagency or + interagency forum on mental health. + ``(7) Matching funds.--The Secretary may not award a grant + or contract under this section to an entity unless the entity + agrees that it will make available (directly or through + contributions from other public or private entities) non-Federal + contributions toward the activities to be carried out under the + grant or contract in an amount equal to $1 for each $5 of + Federal funds provided under the grant or contract. Such non- + Federal matching funds may be provided directly or through + donations from public or private entities and may be in cash or + in-kind, fairly evaluated, including plant, equipment, or + services. + + ``(c) Activities of the Centers.--Each Center shall carry out the +following activities: + ``(1) General activities.--Each Center shall-- + ``(A) integrate basic, clinical, or health services + interdisciplinary research and practice in the + development, implementation, and dissemination of + evidence-based interventions; + ``(B) involve a broad cross-section of stakeholders, + such as researchers, clinicians, consumers, families of + consumers, and voluntary health organizations, to + develop a research agenda and disseminate findings, and + to provide support in the implementation of evidence- + based practices; + ``(C) provide training and technical assistance to + mental health professionals, and engage in and + disseminate translational research with a focus on + meeting the needs of individuals with depressive + disorders; and + +[[Page 124 STAT. 987]] + + ``(D) educate policy makers, employers, community + leaders, and the public about depressive disorders to + reduce stigma and raise awareness of treatments. + ``(2) Improved treatment standards, clinical guidelines, + diagnostic protocols, and care coordination practice.--Each + Center shall collaborate with other Centers in the network to-- + ``(A) develop and implement treatment standards, + clinical guidelines, and protocols that emphasize + primary prevention, early intervention, treatment for, + and recovery from, depressive disorders; + ``(B) foster communication with other providers + attending to co-occurring physical health conditions + such as cardiovascular, diabetes, cancer, and substance + abuse disorders; + ``(C) leverage available community resources, + develop and implement improved self-management programs, + and, when appropriate, involve family and other + providers of social support in the development and + implementation of care plans; and + ``(D) use electronic health records and telehealth + technology to better coordinate and manage, and improve + access to, care, as determined by the coordinating + center. + ``(3) Translational research through collaboration of + centers and community-based organizations.--Each Center shall-- + ``(A) demonstrate effective use of a public-private + partnership to foster collaborations among members of + the network and community-based organizations such as + community mental health centers and other social and + human services providers; + ``(B) expand interdisciplinary, translational, and + patient-oriented research and treatment; and + ``(C) coordinate with accredited academic programs + to provide ongoing opportunities for the professional + and continuing education of mental health providers. + + ``(d) National Database.-- + ``(1) In general.--The coordinating center shall establish + and maintain a national, publicly available database to improve + prevention programs, evidence-based interventions, and disease + management programs for depressive disorders, using data + collected from the Centers, as described in paragraph (2). + ``(2) Data collection.--Each Center shall submit data + gathered at such center, as appropriate, to the coordinating + center regarding-- + ``(A) the prevalence and incidence of depressive + disorders; + ``(B) the health and social outcomes of individuals + with depressive disorders; + ``(C) the effectiveness of interventions designed, + tested, and evaluated; + ``(D) other information, as the Secretary may + require. + ``(3) Submission of data to the administrator.--The + coordinating center shall submit to the Administrator the data + and financial information gathered under paragraph (2). + ``(4) Publication using data from the database.--A Center, + or an individual affiliated with a Center, may publish + +[[Page 124 STAT. 988]] + + findings using the data described in paragraph (2) only if such + center submits such data to the coordinating center, as required + under such paragraph. + + ``(e) Establishment of Standards; Report Cards and Recommendations; +Third Party Review.-- + ``(1) Establishment of standards.--The Secretary, acting + through the Administrator, shall establish performance standards + for-- + ``(A) each Center; and + ``(B) the network of Centers as a whole. + ``(2) Report cards.--The Secretary, acting through the + Administrator, shall-- + ``(A) for each Center, not later than 3 years after + the date on which such center of excellence is + established and annually thereafter, issue a report card + to the coordinating center to rate the performance of + such Center; and + ``(B) not later than 3 years after the date on which + the first grant is awarded under subsection (b)(1) and + annually thereafter, issue a report card to Congress to + rate the performance of the network of centers of + excellence as a whole. + ``(3) Recommendations.--Based upon the report cards + described in paragraph (2), the Secretary shall, not later than + September 30, 2015-- + ``(A) make recommendations to the Centers regarding + improvements such centers shall make; and + ``(B) make recommendations to Congress for expanding + the Centers to serve individuals with other types of + mental disorders. + ``(4) Third party review.--Not later than 3 years after the + date on which the first grant is awarded under subsection (b)(1) + and annually thereafter, the Secretary shall arrange for an + independent third party to conduct an evaluation of the network + of Centers to ensure that such centers are meeting the goals of + this section. + + ``(f) Authorization of Appropriations.-- + ``(1) In general.--To carry out this section, there are + authorized to be appropriated-- + ``(A) $100,000,000 for each of the fiscal years 2011 + through 2015; and + ``(B) $150,000,000 for each of the fiscal years 2016 + through 2020. + ``(2) Allocation of funds authorized.-- + <<NOTE: Determination.>> Of the amount appropriated under + paragraph (1) for a fiscal year, the Secretary shall determine + the allocation of each Center receiving a grant under this + section, but in no case may the allocation be more than + $5,000,000, except that the Secretary may allocate not more than + $10,000,000 to the coordinating center.''. + +SEC. 10411. <<NOTE: Congenital Heart Futures Act. 42 USC 201 + note.>> PROGRAMS RELATING TO CONGENITAL HEART DISEASE. + + (a) Short Title.--This subtitle may be cited as the ``Congenital +Heart Futures Act''. + (b) Programs Relating to Congenital Heart Disease.-- + (1) National congenital heart disease surveillance system.-- + Part P of title III of the Public Health Service Act (42 U.S.C. + 280g et seq.), as amended by section 5405, is further amended by + adding at the end the following: + +[[Page 124 STAT. 989]] + +``SEC. 399V-2. <<NOTE: 42 USC 280g-13.>> NATIONAL CONGENITAL HEART + DISEASE SURVEILLANCE SYSTEM. + + ``(a) In General.--The Secretary, acting through the Director of the +Centers for Disease Control and Prevention, may-- + ``(1) enhance and expand infrastructure to track the + epidemiology of congenital heart disease and to organize such + information into a nationally-representative, population-based + surveillance system that compiles data concerning actual + occurrences of congenital heart disease, to be known as the + `National Congenital Heart Disease Surveillance System'; or + ``(2) award a grant to one eligible entity to undertake the + activities described in paragraph (1). + + ``(b) Purpose.--The purpose of the Congenital Heart Disease +Surveillance System shall be to facilitate further research into the +types of health services patients use and to identify possible areas for +educational outreach and prevention in accordance with standard +practices of the Centers for Disease Control and Prevention. + ``(c) Content.--The Congenital Heart Disease Surveillance System-- + ``(1) may include information concerning the incidence and + prevalence of congenital heart disease in the United States; + ``(2) may be used to collect and store data on congenital + heart disease, including data concerning-- + ``(A) demographic factors associated with congenital + heart disease, such as age, race, ethnicity, sex, and + family history of individuals who are diagnosed with the + disease; + ``(B) risk factors associated with the disease; + ``(C) causation of the disease; + ``(D) treatment approaches; and + ``(E) outcome measures, such that analysis of the + outcome measures will allow derivation of evidence-based + best practices and guidelines for congenital heart + disease patients; and + ``(3) may ensure the collection and analysis of longitudinal + data related to individuals of all ages with congenital heart + disease, including infants, young children, adolescents, and + adults of all ages. + + ``(d) Public Access.--The Congenital Heart Disease Surveillance +System shall be made available to the public, as appropriate, including +congenital heart disease researchers. + ``(e) Patient Privacy.--The Secretary shall ensure that the +Congenital Heart Disease Surveillance System is maintained in a manner +that complies with the regulations promulgated under section 264 of the +Health Insurance Portability and Accountability Act of 1996. + ``(f) Eligibility for Grant.--To be eligible to receive a grant +under subsection (a)(2), an entity shall-- + ``(1) be a public or private nonprofit entity with + specialized experience in congenital heart disease; and + ``(2) submit to the Secretary an application at such time, + in such manner, and containing such information as the Secretary + may require.''. + (2) Congenital heart disease research.--Subpart 2 of part C + of title IV of the Public Health Service Act (42 U.S.C. 285b et + seq.) is amended by adding at the end the following: + +[[Page 124 STAT. 990]] + +``SEC. 425. <<NOTE: 42 USC 285b-8.>> CONGENITAL HEART DISEASE. + + ``(a) In General.--The Director of the Institute may expand, +intensify, and coordinate research and related activities of the +Institute with respect to congenital heart disease, which may include +congenital heart disease research with respect to-- + ``(1) causation of congenital heart disease, including + genetic causes; + ``(2) long-term outcomes in individuals with congenital + heart disease, including infants, children, teenagers, adults, + and elderly individuals; + ``(3) diagnosis, treatment, and prevention; + ``(4) studies using longitudinal data and retrospective + analysis to identify effective treatments and outcomes for + individuals with congenital heart disease; and + ``(5) identifying barriers to life-long care for individuals + with congenital heart disease. + + ``(b) Coordination of Research Activities.--The Director of the +Institute may coordinate research efforts related to congenital heart +disease among multiple research institutions and may develop research +networks. + ``(c) Minority and Medically Underserved Communities.--In carrying +out the activities described in this section, the Director of the +Institute shall consider the application of such research and other +activities to minority and medically underserved communities.''. + (c) Authorization of Appropriations.--There are authorized to be +appropriated to carry out the amendments made by this section such sums +as may be necessary for each of fiscal years 2011 through 2015. + +SEC. 10412. AUTOMATED DEFIBRILLATION IN ADAM'S MEMORY ACT. + + Section 312 of the Public Health Service Act (42 U.S.C. 244) is +amended-- + (1) in subsection (c)(6), after ``clearinghouse'' insert ``, + that shall be administered by an organization that has + substantial expertise in pediatric education, pediatric + medicine, and electrophysiology and sudden death,''; and + (2) in the first sentence of subsection (e), by striking + ``fiscal year 2003'' and all that follows through ``2006'' and + inserting ``for each of fiscal years 2003 through 2014''. + +SEC. 10413. <<NOTE: Young Women's Breast Health Education and Awareness + Requires Learning Young Act of 2009. 42 USC 201 + note.>> YOUNG WOMEN'S BREAST HEALTH AWARENESS AND SUPPORT OF + YOUNG WOMEN DIAGNOSED WITH BREAST CANCER. + + (a) Short Title.--This section may be cited as the ``Young Women's +Breast Health Education and Awareness Requires Learning Young Act of +2009'' or the ``EARLY Act''. + (b) Amendment.--Title III of the Public Health Service Act (42 +U.S.C. 241 et seq.), as amended by this Act, is further amended by +adding at the end the following: + +[[Page 124 STAT. 991]] + + ``PART V--PROGRAMS RELATING TO BREAST HEALTH AND CANCER + +``SEC. 399NN. <<NOTE: 42 USC 280m.>> YOUNG WOMEN'S BREAST HEALTH + AWARENESS AND SUPPORT OF YOUNG WOMEN DIAGNOSED WITH BREAST + CANCER. + + ``(a) Public Education Campaign.-- + ``(1) In general.--The Secretary, acting through the + Director of the Centers for Disease Control and Prevention, + shall conduct a national evidence-based education campaign to + increase awareness of young women's knowledge regarding-- + ``(A) breast health in young women of all racial, + ethnic, and cultural backgrounds; + ``(B) breast awareness and good breast health + habits; + ``(C) the occurrence of breast cancer and the + general and specific risk factors in women who may be at + high risk for breast cancer based on familial, racial, + ethnic, and cultural backgrounds such as Ashkenazi + Jewish populations; + ``(D) evidence-based information that would + encourage young women and their health care professional + to increase early detection of breast cancers; and + ``(E) the availability of health information and + other resources for young women diagnosed with breast + cancer. + ``(2) Evidence-based, age appropriate messages.--The + campaign shall provide evidence-based, age-appropriate messages + and materials as developed by the Centers for Disease Control + and Prevention and the Advisory Committee established under + paragraph (4). + ``(3) Media campaign.-- <<NOTE: Grants.>> In conducting the + education campaign under paragraph (1), the Secretary shall + award grants to entities to establish national multimedia + campaigns oriented to young women that may include advertising + through television, radio, print media, billboards, posters, all + forms of existing and especially emerging social networking + media, other Internet media, and any other medium determined + appropriate by the Secretary. + ``(4) Advisory committee.-- + ``(A) Establishment.-- <<NOTE: Deadline.>> Not later + than 60 days after the date of the enactment of this + section, the Secretary, acting through the Director of + the Centers for Disease Control and Prevention, shall + establish an advisory committee to assist in creating + and conducting the education campaigns under paragraph + (1) and subsection (b)(1). + ``(B) Membership.-- <<NOTE: Appointment.>> The + Secretary, acting through the Director of the Centers + for Disease Control and Prevention, shall appoint to the + advisory committee under subparagraph (A) such members + as deemed necessary to properly advise the Secretary, + and shall include organizations and individuals with + expertise in breast cancer, disease prevention, early + detection, diagnosis, public health, social marketing, + genetic screening and counseling, treatment, + rehabilitation, palliative care, and survivorship in + young women. + + ``(b) Health Care Professional Education Campaign.--The Secretary, +acting through the Director of the Centers for Disease + +[[Page 124 STAT. 992]] + +Control and Prevention, and in consultation with the Administrator of +the Health Resources and Services Administration, shall conduct an +education campaign among physicians and other health care professionals +to increase awareness-- + ``(1) of breast health, symptoms, and early diagnosis and + treatment of breast cancer in young women, including specific + risk factors such as family history of cancer and women that may + be at high risk for breast cancer, such as Ashkenazi Jewish + population; + ``(2) on how to provide counseling to young women about + their breast health, including knowledge of their family cancer + history and importance of providing regular clinical breast + examinations; + ``(3) concerning the importance of discussing healthy + behaviors, and increasing awareness of services and programs + available to address overall health and wellness, and making + patient referrals to address tobacco cessation, good nutrition, + and physical activity; + ``(4) on when to refer patients to a health care provider + with genetics expertise; + ``(5) on how to provide counseling that addresses long-term + survivorship and health concerns of young women diagnosed with + breast cancer; and + ``(6) on when to provide referrals to organizations and + institutions that provide credible health information and + substantive assistance and support to young women diagnosed with + breast cancer. + + ``(c) Prevention Research Activities.--The Secretary, acting +through-- + ``(1) the Director of the Centers for Disease Control and + Prevention, shall conduct prevention research on breast cancer + in younger women, including-- + ``(A) behavioral, survivorship studies, and other + research on the impact of breast cancer diagnosis on + young women; + ``(B) formative research to assist with the + development of educational messages and information for + the public, targeted populations, and their families + about breast health, breast cancer, and healthy + lifestyles; + ``(C) testing and evaluating existing and new social + marketing strategies targeted at young women; and + ``(D) surveys of health care providers and the + public regarding knowledge, attitudes, and practices + related to breast health and breast cancer prevention + and control in high-risk populations; and + ``(2) the Director of the National Institutes of Health, + shall conduct research to develop and validate new screening + tests and methods for prevention and early detection of breast + cancer in young women. + + ``(d) Support for Young Women Diagnosed With Breast Cancer.-- + ``(1) In general.-- <<NOTE: Grants.>> The Secretary shall + award grants to organizations and institutions to provide health + information from credible sources and substantive assistance + directed to young women diagnosed with breast cancer and pre- + neoplastic breast diseases. + +[[Page 124 STAT. 993]] + + ``(2) Priority.--In making grants under paragraph (1), the + Secretary shall give priority to applicants that deal + specifically with young women diagnosed with breast cancer and + pre-neoplastic breast disease. + + ``(e) No Duplication of Effort.--In conducting an education campaign +or other program under subsections (a), (b), (c), or (d), the Secretary +shall avoid duplicating other existing Federal breast cancer education +efforts. + ``(f) Measurement; Reporting.--The Secretary, acting through the +Director of the Centers for Disease Control and Prevention, shall-- + ``(1) measure-- + ``(A) young women's awareness regarding breast + health, including knowledge of family cancer history, + specific risk factors and early warning signs, and young + women's proactive efforts at early detection; + ``(B) the number or percentage of young women + utilizing information regarding lifestyle interventions + that foster healthy behaviors; + ``(C) the number or percentage of young women + receiving regular clinical breast exams; and + ``(D) the number or percentage of young women who + perform breast self exams, and the frequency of such + exams, before the implementation of this section; + ``(2) not less than every 3 years, measure the impact of + such activities; and + ``(3) submit reports to the Congress on the results of such + measurements. + + ``(g) Definition.--In this section, the term `young women' means +women 15 to 44 years of age. + ``(h) Authorization of Appropriations.--To carry out subsections +(a), (b), (c)(1), and (d), there are authorized to be appropriated +$9,000,000 for each of the fiscal years 2010 through 2014.''. + + Subtitle E--Provisions Relating to Title V + +SEC. 10501. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT, THE SOCIAL + SECURITY ACT, AND TITLE V OF THIS ACT. + + (a) Section 5101 of this Act <<NOTE: 42 USC 294q.>> is amended-- + (1) in subsection (c)(2)(B)(i)(II), by inserting ``, + including representatives of small business and self-employed + individuals'' after ``employers''; + (2) in subsection (d)(4)(A)-- + (A) by redesignating clause (iv) as clause (v); and + (B) by inserting after clause (iii) the following: + ``(iv) An analysis of, and recommendations + for, eliminating the barriers to entering and + staying in primary care, including provider + compensation.''; and + (3) in subsection (i)(2)(B), by inserting ``optometrists, + ophthalmologists,'' after ``occupational therapists,''. + + (b) Subtitle B of title V of this Act is amended by adding at the +end the following: + +[[Page 124 STAT. 994]] + +``SEC. 5104. INTERAGENCY TASK FORCE TO ASSESS AND IMPROVE ACCESS TO + HEALTH CARE IN THE STATE OF ALASKA. + + ``(a) Establishment.--There is established a task force to be known +as the `Interagency Access to Health Care in Alaska Task Force' +(referred to in this section as the `Task Force'). + ``(b) Duties.--The Task Force shall-- + ``(1) assess access to health care for beneficiaries of + Federal health care systems in Alaska; and + ``(2) develop a strategy for the Federal Government to + improve delivery of health care to Federal beneficiaries in the + State of Alaska. + + ``(c) Membership.-- <<NOTE: Deadline.>> The Task Force shall be +comprised of Federal members who shall be appointed, not later than 45 +days after the date of enactment of this Act, as follows: + ``(1) The Secretary of Health and Human Services shall + appoint one representative of each of the following: + ``(A) The Department of Health and Human Services. + ``(B) The Centers for Medicare and Medicaid + Services. + ``(C) The Indian Health Service. + ``(2) The Secretary of Defense shall appoint one + representative of the TRICARE Management Activity. + ``(3) The Secretary of the Army shall appoint one + representative of the Army Medical Department. + ``(4) The Secretary of the Air Force shall appoint one + representative of the Air Force, from among officers at the Air + Force performing medical service functions. + ``(5) The Secretary of Veterans Affairs shall appoint one + representative of each of the following: + ``(A) The Department of Veterans Affairs. + ``(B) The Veterans Health Administration. + ``(6) The Secretary of Homeland Security shall appoint one + representative of the United States Coast Guard. + + ``(d) Chairperson.--One chairperson of the Task Force shall be +appointed by the Secretary at the time of appointment of members under +subsection (c), selected from among the members appointed under +paragraph (1). + ``(e) Meetings.--The Task Force shall meet at the call of the +chairperson. + ``(f) Report.--Not later than 180 days after the date of enactment +of this Act, the Task Force shall submit to Congress a report detailing +the activities of the Task Force and containing the findings, +strategies, recommendations, policies, and initiatives developed +pursuant to the duty described in subsection (b)(2). In preparing such +report, the Task Force shall consider completed and ongoing efforts by +Federal agencies to improve access to health care in the State of +Alaska. + ``(g) Termination.--The Task Force shall be terminated on the date +of submission of the report described in subsection (f).''. + (c) Section 399V of the Public Health Service Act, as added by +section 5313, <<NOTE: 42 USC 280g-11.>> is amended-- + (1) in subsection (b)(4), by striking ``identify, educate, + refer, and enroll'' and inserting ``identify and refer''; and + (2) in subsection (k)(1), by striking ``, as defined by the + Department of Labor as Standard Occupational Classification [21- + 1094]''. + +[[Page 124 STAT. 995]] + + (d) Section 738(a)(3) of the Public Health Service Act (42 U.S.C. +293b(a)(3)) is amended by inserting ``schools offering physician +assistant education programs,'' after ``public health,''. + (e) Subtitle D of title V of this Act is amended by adding at the +end the following: + +``SEC. 5316. <<NOTE: 42 USC 296j-1.>> DEMONSTRATION GRANTS FOR FAMILY + NURSE PRACTITIONER TRAINING PROGRAMS. + + ``(a) Establishment of Program.--The Secretary of Health and Human +Services (referred to in this section as the `Secretary') shall +establish a training demonstration program for family nurse +practitioners (referred to in this section as the `program') to employ +and provide 1-year training for nurse practitioners who have graduated +from a nurse practitioner program for careers as primary care providers +in Federally qualified health centers (referred to in this section as +`FQHCs') and nurse-managed health clinics (referred to in this section +as `NMHCs'). + ``(b) Purpose.--The purpose of the program is to enable each grant +recipient to-- + ``(1) provide new nurse practitioners with clinical training + to enable them to serve as primary care providers in FQHCs and + NMHCs; + ``(2) train new nurse practitioners to work under a model of + primary care that is consistent with the principles set forth by + the Institute of Medicine and the needs of vulnerable + populations; and + ``(3) create a model of FQHC and NMHC training for nurse + practitioners that may be replicated nationwide. + + ``(c) Grants.--The Secretary shall award 3-year grants to eligible +entities that meet the requirements established by the Secretary, for +the purpose of operating the nurse practitioner primary care programs +described in subsection (a) in such entities. + ``(d) Eligible Entities.--To be eligible to receive a grant under +this section, an entity shall-- + ``(1)(A) be a FQHC as defined in section 1861(aa) of the + Social Security Act (42 U.S.C. 1395x(aa)); or + ``(B) be a nurse-managed health clinic, as defined in + section 330A-1 of the Public Health Service Act (as added by + section 5208 of this Act); and + ``(2) submit to the Secretary an application at such time, + in such manner, and containing such information as the Secretary + may require. + + ``(e) Priority in Awarding Grants.--In awarding grants under this +section, the Secretary shall give priority to eligible entities that-- + ``(1) demonstrate sufficient infrastructure in size, scope, + and capacity to undertake the requisite training of a minimum of + 3 nurse practitioners per year, and to provide to each awardee + 12 full months of full-time, paid employment and benefits + consistent with the benefits offered to other full-time + employees of such entity; + ``(2) will assign not less than 1 staff nurse practitioner + or physician to each of 4 precepted clinics; + ``(3) will provide to each awardee specialty rotations, + including specialty training in prenatal care and women's + health, adult and child psychiatry, orthopedics, geriatrics, and + at least 3 other high-volume, high-burden specialty areas; + +[[Page 124 STAT. 996]] + + ``(4) provide sessions on high-volume, high-risk health + problems and have a record of training health care professionals + in the care of children, older adults, and underserved + populations; and + ``(5) collaborate with other safety net providers, schools, + colleges, and universities that provide health professions + training. + + ``(f) Eligibility of Nurse Practitioners.-- + ``(1) In general.--To be eligible for acceptance to a + program funded through a grant awarded under this section, an + individual shall-- + ``(A) be licensed or eligible for licensure in the + State in which the program is located as an advanced + practice registered nurse or advanced practice nurse and + be eligible or board-certified as a family nurse + practitioner; and + ``(B) demonstrate commitment to a career as a + primary care provider in a FQHC or in a NMHC. + ``(2) Preference.--In selecting awardees under the program, + each grant recipient shall give preference to bilingual + candidates that meet the requirements described in paragraph + (1). + ``(3) Deferral of certain service.--The starting date of + required service of individuals in the National Health Service + Corps Service program under title II of the Public Health + Service Act (42 U.S.C. 202 et seq.) who receive training under + this section shall be deferred until the date that is 22 days + after the date of completion of the program. + + ``(g) Grant Amount.--Each grant awarded under this section shall be +in an amount not to exceed $600,000 per year. A grant recipient may +carry over funds from 1 fiscal year to another without obtaining +approval from the Secretary. + ``(h) Technical Assistance Grants.--The Secretary may award +technical assistance grants to 1 or more FQHCs or NMHCs that have +demonstrated expertise in establishing a nurse practitioner residency +training program. Such technical assistance grants shall be for the +purpose of providing technical assistance to other recipients of grants +under subsection (c). + ``(i) Authorization of Appropriations.--To carry out this section, +there is authorized to be appropriated such sums as may be necessary for +each of fiscal years 2011 through 2014.''. + (f)(1) Section 399W of the Public Health Service Act, as added by +section 5405, <<NOTE: 42 USC 280g-12.>> is redesignated as section 399V- +1. + + (2) Section 399V-1 of the Public Health Service Act, as so +redesignated, is amended in subsection (b)(2)(A) by striking ``and the +departments of 1 or more health professions schools in the State that +train providers in primary care'' and inserting ``and the departments +that train providers in primary care in 1 or more health professions +schools in the State''. + (3) Section 934 of the Public Health Service Act, as added by +section 3501, <<NOTE: 42 USC 299b-34.>> is amended by striking ``399W'' +each place such term appears and inserting ``399V-1''. + + (4) Section 935(b) of the Public Health Service Act, as added by +section 3503, <<NOTE: 42 USC 299b-35.>> is amended by striking ``399W'' +and inserting ``399V-1''. + + (g) Part P of title III of the Public Health Service Act 42 U.S.C. +280g et seq.), as amended by section 10411, is amended by adding at the +end the following: + +[[Page 124 STAT. 997]] + +``SEC. 399V-3. <<NOTE: 42 USC 280g-14.>> NATIONAL DIABETES PREVENTION + PROGRAM. + + ``(a) In General.--The Secretary, acting through the Director of the +Centers for Disease Control and Prevention, shall establish a national +diabetes prevention program (referred to in this section as the +`program') targeted at adults at high risk for diabetes in order to +eliminate the preventable burden of diabetes. + ``(b) Program Activities.--The program described in subsection (a) +shall include-- + ``(1) a grant program for community-based diabetes + prevention program model sites; + ``(2) a program within the Centers for Disease Control and + Prevention to determine eligibility of entities to deliver + community-based diabetes prevention services; + ``(3) a training and outreach program for lifestyle + intervention instructors; and + ``(4) evaluation, monitoring and technical assistance, and + applied research carried out by the Centers for Disease Control + and Prevention. + + ``(c) Eligible Entities.--To be eligible for a grant under +subsection (b)(1), an entity shall be a State or local health +department, a tribal organization, a national network of community-based +non-profits focused on health and wellbeing, an academic institution, or +other entity, as the Secretary determines. + ``(d) Authorization of Appropriations.--For the purpose of carrying +out this section, there are authorized to be appropriated such sums as +may be necessary for each of fiscal years 2010 through 2014.''. + (h) The provisions of, and amendment made by, section 5501(c) of +this Act <<NOTE: Repeals. 42 USC 1395w-4.>> are repealed. + + (i)(1) The provisions of, and amendments made by, section 5502 of +this Act <<NOTE: 42 USC 1395m, 1395x and note. 42 USC 1395x.>> are +repealed. + + (2)(A) Section 1861(aa)(3)(A) of the Social Security Act (42 U.S.C. +1395w(aa)(3)(A)) is amended to read as follows: + ``(A) services of the type described in subparagraphs (A) + through (C) of paragraph (1) and preventive services (as defined + in section 1861(ddd)(3)); and''. + + (B) <<NOTE: Applicability. 42 USC 1395x note.>> The amendment made +by subparagraph (A) shall apply to services furnished on or after +January 1, 2011. + + (3)(A) Section 1834 of the Social Security Act (42 U.S.C. 1395m), as +amended by section 4105, is amended by adding at the end the following +new subsection: + ``(o) Development and Implementation of Prospective Payment +System.-- + ``(1) Development.-- + ``(A) In general.--The Secretary shall develop a + prospective payment system for payment for Federally + qualified health center services furnished by Federally + qualified health centers under this title. Such system + shall include a process for appropriately describing the + services furnished by Federally qualified health centers + and shall establish payment rates for specific payment + codes based on such appropriate descriptions of + services. Such system shall be established to take into + account the type, intensity, and duration of services + furnished by Federally qualified health centers. Such + system may include adjustments, including geographic + adjustments, determined appropriate by the Secretary. + +[[Page 124 STAT. 998]] + + ``(B) Collection of data and evaluation.-- + <<NOTE: Deadline.>> By not later than January 1, 2011, + the Secretary shall require Federally qualified health + centers to submit to the Secretary such information as + the Secretary may require in order to develop and + implement the prospective payment system under this + subsection, including the reporting of services using + HCPCS codes. + ``(2) Implementation.-- + ``(A) In general.--Notwithstanding section + 1833(a)(3)(A), the Secretary shall provide, for cost + reporting periods beginning on or after October 1, 2014, + for payments of prospective payment rates for Federally + qualified health center services furnished by Federally + qualified health centers under this title in accordance + with the prospective payment system developed by the + Secretary under paragraph (1). + ``(B) Payments.-- + ``(i) Initial payments.--The Secretary shall + implement such prospective payment system so that + the estimated aggregate amount of prospective + payment rates (determined prior to the application + of section 1833(a)(1)(Z)) under this title for + Federally qualified health center services in the + first year that such system is implemented is + equal to 100 percent of the estimated amount of + reasonable costs (determined without the + application of a per visit payment limit or + productivity screen and prior to the application + of section 1866(a)(2)(A)(ii)) that would have + occurred for such services under this title in + such year if the system had not been implemented. + ``(ii) Payments in subsequent years.--Payment + rates in years after the year of implementation of + such system shall be the payment rates in the + previous year increased-- + ``(I) in the first year after + implementation of such system, by the + percentage increase in the MEI (as + defined in section 1842(i)(3)) for the + year involved; and + ``(II) in subsequent years, by the + percentage increase in a market basket + of Federally qualified health center + goods and services as promulgated + through regulations, or if such an index + is not available, by the percentage + increase in the MEI (as defined in + section 1842(i)(3)) for the year + involved. + ``(C) Preparation for pps implementation.-- + Notwithstanding any other provision of law, the + Secretary may establish and implement by program + instruction or otherwise the payment codes to be used + under the prospective payment system under this + section.''. + + (B) Section 1833(a)(1) of the Social Security Act (42 U.S.C. +1395l(a)(1)), as amended by section 4104, is amended-- + (i) by striking ``and'' before ``(Y)''; and + (ii) by inserting before the semicolon at the end the + following: ``, and (Z) with respect to Federally qualified + health center services for which payment is made under section + 1834(o), the amounts paid shall be 80 percent of the lesser + +[[Page 124 STAT. 999]] + + of the actual charge or the amount determined under such + section''. + + (C) Section 1833(a) of the Social Security Act (42 U.S.C. 1395l(a)) +is amended-- + (i) in paragraph (3)(B)(i)-- + (I) by inserting ``(I)'' after ``otherwise been + provided''; and + (II) by inserting ``, or (II) in the case of such + services furnished on or after the implementation date + of the prospective payment system under section 1834(o), + under such section (calculated as if `100 percent' were + substituted for `80 percent' in such section) for such + services if the individual had not been so enrolled'' + after ``been so enrolled''; and + (ii) by adding at the end the following flush sentence: + ``Paragraph (3)(A) shall not apply to Federally qualified health + center services furnished on or after the implementation date of + the prospective payment system under section 1834(0).''. + + (j) Section 5505 <<NOTE: 42 USC 1395ww note.>> is amended by adding +at the end the following new subsection: + + ``(d) Application.--The amendments made by this section shall not be +applied in a manner that requires reopening of any settled cost reports +as to which there is not a jurisdictionally proper appeal pending as of +the date of the enactment of this Act on the issue of payment for +indirect costs of medical education under section 1886(d)(5)(B) of the +Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) or for direct graduate +medical education costs under section 1886(h) of such Act (42 U.S.C. +1395ww(h)).''. + (k) Subtitle G of title V of this Act is amended by adding at the +end the following: + +``SEC. 5606. <<NOTE: 42 USC 254b-1.>> STATE GRANTS TO HEALTH CARE + PROVIDERS WHO PROVIDE SERVICES TO A HIGH PERCENTAGE OF + MEDICALLY UNDERSERVED POPULATIONS OR OTHER SPECIAL + POPULATIONS. + + ``(a) In General.--A State may award grants to health care providers +who treat a high percentage, as determined by such State, of medically +underserved populations or other special populations in such State. + ``(b) Source of Funds.--A grant program established by a State under +subsection (a) may not be established within a department, agency, or +other entity of such State that administers the Medicaid program under +title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), and no +Federal or State funds allocated to such Medicaid program, the Medicare +program under title XVIII of the Social Security Act (42 U.S.C. 1395 et +seq.), or the TRICARE program under chapter 55 of title 10, United +States Code, may be used to award grants or to pay administrative costs +associated with a grant program established under subsection (a).''. + (l) Part C of title VII of the Public Health Service Act (42 U.S.C. +293k et seq.) is amended-- + (1) after the part heading, by inserting the following: + + ``Subpart I--Medical Training Generally''; + + and + (2) by inserting at the end the following: + +[[Page 124 STAT. 1000]] + + ``Subpart II--Training in Underserved Communities + +``SEC. 749B. <<NOTE: 42 USC 293m.>> RURAL PHYSICIAN TRAINING GRANTS. + + ``(a) In General.--The Secretary, acting through the Administrator +of the Health Resources and Services Administration, shall establish a +grant program for the purposes of assisting eligible entities in +recruiting students most likely to practice medicine in underserved +rural communities, providing rural-focused training and experience, and +increasing the number of recent allopathic and osteopathic medical +school graduates who practice in underserved rural communities. + ``(b) Eligible Entities.--In order to be eligible to receive a grant +under this section, an entity shall-- + ``(1) be a school of allopathic or osteopathic medicine + accredited by a nationally recognized accrediting agency or + association approved by the Secretary for this purpose, or any + combination or consortium of such schools; and + ``(2) submit an application to the Secretary that includes a + certification that such entity will use amounts provided to the + institution as described in subsection (d)(1). + + ``(c) Priority.--In awarding grant funds under this section, the +Secretary shall give priority to eligible entities that-- + ``(1) demonstrate a record of successfully training + students, as determined by the Secretary, who practice medicine + in underserved rural communities; + ``(2) demonstrate that an existing academic program of the + eligible entity produces a high percentage, as determined by the + Secretary, of graduates from such program who practice medicine + in underserved rural communities; + ``(3) demonstrate rural community institutional + partnerships, through such mechanisms as matching or + contributory funding, documented in-kind services for + implementation, or existence of training partners with + interprofessional expertise in community health center training + locations or other similar facilities; or + ``(4) submit, as part of the application of the entity under + subsection (b), a plan for the long-term tracking of where the + graduates of such entity practice medicine. + + ``(d) Use of Funds.-- + ``(1) Establishment.--An eligible entity receiving a grant + under this section shall use the funds made available under such + grant to establish, improve, or expand a rural-focused training + program (referred to in this section as the `Program') meeting + the requirements described in this subsection and to carry out + such program. + ``(2) Structure of program.--An eligible entity shall-- + ``(A) enroll no fewer than 10 students per class + year into the Program; and + ``(B) develop criteria for admission to the Program + that gives priority to students-- + ``(i) who have originated from or lived for a + period of 2 or more years in an underserved rural + community; and + ``(ii) who express a commitment to practice + medicine in an underserved rural community. + +[[Page 124 STAT. 1001]] + + ``(3) Curricula.--The Program shall require students to + enroll in didactic coursework and clinical experience + particularly applicable to medical practice in underserved rural + communities, including-- + ``(A) clinical rotations in underserved rural + communities, and in applicable specialties, or other + coursework or clinical experience deemed appropriate by + the Secretary; and + ``(B) in addition to core school curricula, + additional coursework or training experiences focused on + medical issues prevalent in underserved rural + communities. + ``(4) Residency placement assistance.--Where available, the + Program shall assist all students of the Program in obtaining + clinical training experiences in locations with postgraduate + programs offering residency training opportunities in + underserved rural communities, or in local residency training + programs that support and train physicians to practice in + underserved rural communities. + ``(5) Program student cohort support.--The Program shall + provide and require all students of the Program to participate + in group activities designed to further develop, maintain, and + reinforce the original commitment of such students to practice + in an underserved rural community. + + ``(e) Annual Reporting.--An eligible entity receiving a grant under +this section shall submit an annual report to the Secretary on the +success of the Program, based on criteria the Secretary determines +appropriate, including the residency program selection of graduating +students who participated in the Program. + ``(f) Regulations.-- <<NOTE: Deadline.>> Not later than 60 days +after the date of enactment of this section, the Secretary shall by +regulation define `underserved rural community' for purposes of this +section. + + ``(g) Supplement Not Supplant.--Any eligible entity receiving funds +under this section shall use such funds to supplement, not supplant, any +other Federal, State, and local funds that would otherwise be expended +by such entity to carry out the activities described in this section. + ``(h) Maintenance of Effort.--With respect to activities for which +funds awarded under this section are to be expended, the entity shall +agree to maintain expenditures of non-Federal amounts for such +activities at a level that is not less than the level of such +expenditures maintained by the entity for the fiscal year preceding the +fiscal year for which the entity receives a grant under this section. + ``(i) Authorization of Appropriations.--There are authorized to be +appropriated $4,000,000 for each of the fiscal years 2010 through +2013.''. + (m)(1) Section 768 of the Public Health Service Act (42 U.S.C. 295c) +is amended to read as follows: + +``SEC. 768. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING GRANT + PROGRAM. + + ``(a) Grants. <<NOTE: Contracts.>> --The Secretary, acting through +the Administrator of the Health Resources and Services Administration +and in consultation with the Director of the Centers for Disease Control +and Prevention, shall award grants to, or enter into contracts with, +eligible entities to provide training to graduate medical residents in +preventive medicine specialties. + +[[Page 124 STAT. 1002]] + + ``(b) Eligibility.--To be eligible for a grant or contract under +subsection (a), an entity shall be-- + ``(1) an accredited school of public health or school of + medicine or osteopathic medicine; + ``(2) an accredited public or private nonprofit hospital; + ``(3) a State, local, or tribal health department; or + ``(4) a consortium of 2 or more entities described in + paragraphs (1) through (3). + + ``(c) Use of Funds.--Amounts received under a grant or contract +under this section shall be used to-- + ``(1) plan, develop (including the development of + curricula), operate, or participate in an accredited residency + or internship program in preventive medicine or public health; + ``(2) defray the costs of practicum experiences, as required + in such a program; and + ``(3) establish, maintain, or improve-- + ``(A) academic administrative units (including + departments, divisions, or other appropriate units) in + preventive medicine and public health; or + ``(B) programs that improve clinical teaching in + preventive medicine and public health. + + ``(d) Report.--The Secretary shall submit to the Congress an annual +report on the program carried out under this section.''. + (2) Section 770(a) of the Public Health Service Act (42 + U.S.C. 295e(a)) is amended to read as follows: + + ``(a) In General.--For the purpose of carrying out this subpart, +there is authorized to be appropriated $43,000,000 for fiscal year 2011, +and such sums as may be necessary for each of the fiscal years 2012 +through 2015.''. + (n)(1) Subsection (i) of section 331 of the Public Health Service +Act (42 U.S.C. 254d) of the Public Health Service Act is amended-- + (A) in paragraph (1), by striking ``In carrying out subpart + III'' and all that follows through the period and inserting ``In + carrying out subpart III, the Secretary may, in accordance with + this subsection, issue waivers to individuals who have entered + into a contract for obligated service under the Scholarship + Program or the Loan Repayment Program under which the + individuals are authorized to satisfy the requirement of + obligated service through providing clinical practice that is + half time.''; + (B) in paragraph (2)-- + (i) in subparagraphs (A)(ii) and (B), by striking + ``less than full time'' each place it appears and + inserting ``half time''; + (ii) in subparagraphs (C) and (F), by striking + ``less than full-time service'' each place it appears + and inserting ``half-time service''; and + (iii) by amending subparagraphs (D) and (E) to read + as follows: + ``(D) the entity and the Corps member agree in writing that + the Corps member will perform half-time clinical practice; + ``(E) the Corps member agrees in writing to fulfill all of + the service obligations under section 338C through half-time + clinical practice and either-- + ``(i) double the period of obligated service that + would otherwise be required; or + +[[Page 124 STAT. 1003]] + + ``(ii) in the case of contracts entered into under + section 338B, accept a minimum service obligation of 2 + years with an award amount equal to 50 percent of the + amount that would otherwise be payable for full-time + service; and''; and + (C) in paragraph (3), by striking ``In evaluating a + demonstration project described in paragraph (1)'' and inserting + ``In evaluating waivers issued under paragraph (1)''. + + (2) Subsection (j) of section 331 of the Public Health Service Act +(42 U.S.C. 254d) is amended by adding at the end the following: + ``(5) <<NOTE: Definitions.>> The terms `full time' and + `full-time' mean a minimum of 40 hours per week in a clinical + practice, for a minimum of 45 weeks per year. + ``(6) The terms `half time' and `half-time' mean a minimum + of 20 hours per week (not to exceed 39 hours per week) in a + clinical practice, for a minimum of 45 weeks per year.''. + + (3) Section 337(b)(1) of the Public Health Service Act (42 U.S.C. +254j(b)(1)) is amended by striking ``Members may not be reappointed to +the Council.''. + (4) Section 338B(g)(2)(A) of the Public Health Service Act (42 +U.S.C. 254l-1(g)(2)(A)) is amended by striking ``$35,000'' and inserting +``$50,000, plus, beginning with fiscal year 2012, an amount determined +by the Secretary on an annual basis to reflect inflation,''. + (5) Subsection (a) of section 338C of the Public Health Service Act +(42 U.S.C. 254m), as amended by section 5508, is amended-- + (A) by striking the second sentence and inserting the + following: ``The Secretary may treat teaching as clinical + practice for up to 20 percent of such period of obligated + service.''; and + (B) by adding at the end the following: ``Notwithstanding + the preceding sentence, with respect to a member of the Corps + participating in the teaching health centers graduate medical + education program under section 340H, for the purpose of + calculating time spent in full-time clinical practice under this + section, up to 50 percent of time spent teaching by such member + may be counted toward his or her service obligation.''. + +SEC. 10502. INFRASTRUCTURE TO EXPAND ACCESS TO CARE. + + (a) Appropriation.--There are authorized to be appropriated, and +there are appropriated to the Department of Health and Human Services, +$100,000,000 for fiscal year 2010, to remain available for obligation +until September 30, 2011, to be used for debt service on, or direct +construction or renovation of, a health care facility that provides +research, inpatient tertiary care, or outpatient clinical services. Such +facility shall be affiliated with an academic health center at a public +research university in the United States that contains a State's sole +public academic medical and dental school. + (b) Requirement.-- <<NOTE: Certification.>> Amount appropriated +under subsection (a) may only be made available by the Secretary of +Health and Human Services upon the receipt of an application from the +Governor of a State that certifies that-- + (1) the new health care facility is critical for the + provision of greater access to health care within the State; + (2) such facility is essential for the continued financial + viability of the State's sole public medical and dental school + and its academic health center; + (3) the request for Federal support represents not more than + 40 percent of the total cost of the proposed new facility; and + +[[Page 124 STAT. 1004]] + + (4) the State has established a dedicated funding mechanism + to provide all remaining funds necessary to complete the + construction or renovation of the proposed facility. + +SEC. 10503. <<NOTE: 42 USC 254b-2.>> COMMUNITY HEALTH CENTERS AND THE + NATIONAL HEALTH SERVICE CORPS FUND. + + (a) Purpose.--It is the purpose of this section to establish a +Community Health Center Fund (referred to in this section as the ``CHC +Fund''), to be administered through the Office of the Secretary of the +Department of Health and Human Services to provide for expanded and +sustained national investment in community health centers under section +330 of the Public Health Service Act and the National Health Service +Corps. + (b) Funding.--There is authorized to be appropriated, and there is +appropriated, out of any monies in the Treasury not otherwise +appropriated, to the CHC Fund-- + (1) to be transferred to the Secretary of Health and Human + Services to provide enhanced funding for the community health + center program under section 330 of the Public Health Service + Act-- + (A) $700,000,000 for fiscal year 2011; + (B) $800,000,000 for fiscal year 2012; + (C) $1,000,000,000 for fiscal year 2013; + (D) $1,600,000,000 for fiscal year 2014; and + (E) $2,900,000,000 for fiscal year 2015; and + (2) to be transferred to the Secretary of Health and Human + Services to provide enhanced funding for the National Health + Service Corps-- + (A) $290,000,000 for fiscal year 2011; + (B) $295,000,000 for fiscal year 2012; + (C) $300,000,000 for fiscal year 2013; + (D) $305,000,000 for fiscal year 2014; and + (E) $310,000,000 for fiscal year 2015. + + (c) Construction.-- <<NOTE: Appropriation authorization.>> There is +authorized to be appropriated, and there is appropriated, out of any +monies in the Treasury not otherwise appropriated, $1,500,000,000 to be +available for fiscal years 2011 through 2015 to be used by the Secretary +of Health and Human Services for the construction and renovation of +community health centers. + + (d) Use of Fund.--The Secretary of Health and Human Services shall +transfer amounts in the CHC Fund to accounts within the Department of +Health and Human Services to increase funding, over the fiscal year 2008 +level, for community health centers and the National Health Service +Corps. + (e) Availability.--Amounts appropriated under subsections (b) and +(c) shall remain available until expended. + +SEC. 10504. <<NOTE: 42 USC 256 note.>> DEMONSTRATION PROJECT TO PROVIDE + ACCESS TO AFFORDABLE CARE. + + (a) In General.-- <<NOTE: Deadline.>> Not later than 6 months after +the date of enactment of this Act, the Secretary of Health and Human +Services (referred to in this section as the ``Secretary''), acting +through the Health Resources and Services Administration, shall +establish a 3 year demonstration project in up to 10 States to provide +access to comprehensive health care services to the uninsured at reduced +fees. <<NOTE: Evaluation.>> The Secretary shall evaluate the feasibility +of expanding the project to additional States. + +[[Page 124 STAT. 1005]] + + (b) Eligibility.--To be eligible to participate in the demonstration +project, an entity shall be a State-based, nonprofit, public-private +partnership that provides access to comprehensive health care services +to the uninsured at reduced fees. Each State in which a participant +selected by the Secretary is located shall receive not more than +$2,000,000 to establish and carry out the project for the 3-year +demonstration period. + (c) Authorization.--There is authorized to be appropriated such sums +as may be necessary to carry out this section. + + Subtitle F--Provisions Relating to Title VI + +SEC. 10601. REVISIONS TO LIMITATION ON MEDICARE EXCEPTION TO THE + PROHIBITION ON CERTAIN PHYSICIAN REFERRALS FOR HOSPITALS. + + (a) In General.--Section 1877(i) of the Social Security Act, as +added by section 6001(a), <<NOTE: 42 USC 1395nn.>> is amended-- + (1) in paragraph (1)(A)(i), by striking ``February 1, 2010'' + and inserting ``August 1, 2010''; and + (2) in paragraph (3)(A)-- + (A) in clause (iii), by striking ``August 1, 2011'' + and inserting ``February 1, 2012''; and + (B) in clause (iv), by striking ``July 1, 2011'' and + inserting ``January 1, 2012''. + + (b) Conforming Amendment.--Section 6001(b)(2) <<NOTE: 42 USC 1395nn +note.>> of this Act is amended by striking ``November 1, 2011'' and +inserting ``May 1, 2012''. + +SEC. 10602. CLARIFICATIONS TO PATIENT-CENTERED OUTCOMES RESEARCH. + + Section 1181 of the Social Security Act (as added by section +6301) <<NOTE: 42 USC 1320e.>> is amended-- + (1) in subsection (d)(2)(B)-- + (A) in clause (ii)(IV)-- + (i) by inserting ``, as described in + subparagraph (A)(ii),'' after ``original + research''; and + (ii) by inserting ``, as long as the + researcher enters into a data use agreement with + the Institute for use of the data from the + original research, as appropriate'' after + ``publication''; and + (B) by amending clause (iv) to read as follows: + ``(iv) Subsequent use of the data.--The + Institute shall not allow the subsequent use of + data from original research in work-for-hire + contracts with individuals, entities, or + instrumentalities that have a financial interest + in the results, unless approved under a data use + agreement with the Institute.''; + (2) in subsection (d)(8)(A)(iv), by striking ``not be + construed as mandates for'' and inserting ``do not include''; + and + (3) in subsection (f)(1)(C), by amending clause (ii) to read + as follows: + ``(ii) 7 members representing physicians and + providers, including 4 members representing + physicians (at least 1 of whom is a surgeon), 1 + nurse, 1 State-licensed integrative health care + practitioner, and 1 representative of a + hospital.''. + +[[Page 124 STAT. 1006]] + +SEC. 10603. STRIKING PROVISIONS RELATING TO INDIVIDUAL PROVIDER + APPLICATION FEES. + + (a) In General.--Section 1866(j)(2)(C) of the Social Security Act, +as added by section 6401(a), <<NOTE: 42 USC 1395cc.>> is amended-- + (1) by striking clause (i); + (2) by redesignating clauses (ii) through (iv), + respectively, as clauses (i) through (iii); and + (3) in clause (i), as redesignated by paragraph (2), by + striking ``clause (iii)'' and inserting ``clause (ii)''. + + (b) Technical Correction.--Section 6401(a)(2) of this Act is amended +to read as follows: + ``(2) by redesignating paragraph (2) as paragraph (8); + and''. + +SEC. 10604. TECHNICAL CORRECTION TO SECTION 6405. + + Paragraphs (1) and (2) of section 6405(b) are amended to read as +follows: + ``(1) Part a.--Section 1814(a)(2) of the Social Security Act + ( <<NOTE: 42 USC 1395f.>> 42 U.S.C. 1395(a)(2)) is amended in + the matter preceding subparagraph (A) by inserting `, or, in the + case of services described in subparagraph (C), a physician + enrolled under section 1866(j),' after `in collaboration with a + physician,'. + ``(2) Part b.--Section 1835(a)(2) of the Social Security Act + (42 U.S.C. 1395n(a)(2)) is amended in the matter preceding + subparagraph (A) by inserting `, or, in the case of services + described in subparagraph (A), a physician enrolled under + section 1866(j),' after `a physician'.''. + +SEC. 10605. CERTAIN OTHER PROVIDERS PERMITTED TO CONDUCT FACE TO FACE + ENCOUNTER FOR HOME HEALTH SERVICES. + + (a) Part A.--Section 1814(a)(2)(C) of the Social Security Act (42 +U.S.C. 1395f(a)(2)(C)), as amended by section 6407(a)(1), is amended by +inserting ``, or a nurse practitioner or clinical nurse specialist (as +those terms are defined in section 1861(aa)(5)) who is working in +collaboration with the physician in accordance with State law, or a +certified nurse-midwife (as defined in section 1861(gg)) as authorized +by State law, or a physician assistant (as defined in section +1861(aa)(5)) under the supervision of the physician,'' after ``himself +or herself''. + (b) Part B.--Section 1835(a)(2)(A)(iv) of the Social Security Act, +as added by section 6407(a)(2), is amended by inserting ``, or a nurse +practitioner or clinical nurse specialist (as those terms are defined in +section 1861(aa)(5)) who is working in collaboration with the physician +in accordance with State law, or a certified nurse-midwife (as defined +in section 1861(gg)) as authorized by State law, or a physician +assistant (as defined in section 1861(aa)(5)) under the supervision of +the physician,'' after ``must document that the physician''. + +SEC. 10606. HEALTH CARE FRAUD ENFORCEMENT. + + (a) <<NOTE: 28 USC 994 note.>> Fraud Sentencing Guidelines.-- + (1) Definition.--In this subsection, the term ``Federal + health care offense'' has the meaning given that term in section + 24 of title 18, United States Code, as amended by this Act. + (2) Review and amendments.--Pursuant to the authority under + section 994 of title 28, United States Code, and in accordance + with this subsection, the United States Sentencing Commission + shall-- + +[[Page 124 STAT. 1007]] + + (A) review the Federal Sentencing Guidelines and + policy statements applicable to persons convicted of + Federal health care offenses; + (B) amend the Federal Sentencing Guidelines and + policy statements applicable to persons convicted of + Federal health care offenses involving Government health + care programs to provide that the aggregate dollar + amount of fraudulent bills submitted to the Government + health care program shall constitute prima facie + evidence of the amount of the intended loss by the + defendant; and + (C) amend the Federal Sentencing Guidelines to + provide-- + (i) a 2-level increase in the offense level + for any defendant convicted of a Federal health + care offense relating to a Government health care + program which involves a loss of not less than + $1,000,000 and less than $7,000,000; + (ii) a 3-level increase in the offense level + for any defendant convicted of a Federal health + care offense relating to a Government health care + program which involves a loss of not less than + $7,000,000 and less than $20,000,000; + (iii) a 4-level increase in the offense level + for any defendant convicted of a Federal health + care offense relating to a Government health care + program which involves a loss of not less than + $20,000,000; and + (iv) if appropriate, otherwise amend the + Federal Sentencing Guidelines and policy + statements applicable to persons convicted of + Federal health care offenses involving Government + health care programs. + (3) Requirements.--In carrying this subsection, the United + States Sentencing Commission shall-- + (A) ensure that the Federal Sentencing Guidelines + and policy statements-- + (i) reflect the serious harms associated with + health care fraud and the need for aggressive and + appropriate law enforcement action to prevent such + fraud; and + (ii) provide increased penalties for persons + convicted of health care fraud offenses in + appropriate circumstances; + (B) consult with individuals or groups representing + health care fraud victims, law enforcement officials, + the health care industry, and the Federal judiciary as + part of the review described in paragraph (2); + (C) ensure reasonable consistency with other + relevant directives and with other guidelines under the + Federal Sentencing Guidelines; + (D) account for any aggravating or mitigating + circumstances that might justify exceptions, including + circumstances for which the Federal Sentencing + Guidelines, as in effect on the date of enactment of + this Act, provide sentencing enhancements; + (E) make any necessary conforming changes to the + Federal Sentencing Guidelines; and + (F) ensure that the Federal Sentencing Guidelines + adequately meet the purposes of sentencing. + +[[Page 124 STAT. 1008]] + + (b) Intent Requirement for Health Care Fraud.--Section 1347 of title +18, United States Code, is amended-- + (1) by inserting ``(a)'' before ``Whoever knowingly''; and + (2) by adding at the end the following: + + ``(b) With respect to violations of this section, a person need not +have actual knowledge of this section or specific intent to commit a +violation of this section.''. + (c) Health Care Fraud Offense.--Section 24(a) of title 18, United +States Code, is amended-- + (1) in paragraph (1), by striking the semicolon and + inserting ``or section 1128B of the Social Security Act (42 + U.S.C. 1320a-7b); or''; and + (2) in paragraph (2)-- + (A) by inserting ``1349,'' after ``1343,''; and + (B) by inserting ``section 301 of the Federal Food, + Drug, and Cosmetic Act (21 U.S.C. 331), or section 501 + of the Employee Retirement Income Security Act of 1974 + (29 U.S.C. 1131),'' after ``title,''. + + (d) Subpoena Authority Relating to Health Care.-- + (1) Subpoenas under the health insurance portability and + accountability act of 1996.--Section 1510(b) of title 18, United + States Code, is amended-- + (A) in paragraph (1), by striking ``to the grand + jury''; and + (B) in paragraph (2)-- + (i) in subparagraph (A), by striking ``grand + jury subpoena'' and inserting ``subpoena for + records''; and + (ii) in the matter following subparagraph (B), + by striking ``to the grand jury''. + (2) Subpoenas under the civil rights of institutionalized + persons act.--The Civil Rights of Institutionalized Persons Act + (42 U.S.C. 1997 et seq.) is amended by inserting after section 3 + the following: + +``SEC. 3A. <<NOTE: 42 USC 1997a-1.>> SUBPOENA AUTHORITY. + + ``(a) Authority.--The Attorney General, or at the direction of the +Attorney General, any officer or employee of the Department of Justice +may require by subpoena access to any institution that is the subject of +an investigation under this Act and to any document, record, material, +file, report, memorandum, policy, procedure, investigation, video or +audio recording, or quality assurance report relating to any institution +that is the subject of an investigation under this Act to determine +whether there are conditions which deprive persons residing in or +confined to the institution of any rights, privileges, or immunities +secured or protected by the Constitution or laws of the United States. + ``(b) Issuance and Enforcement of Subpoenas.-- + ``(1) Issuance.--Subpoenas issued under this section-- + ``(A) shall bear the signature of the Attorney + General or any officer or employee of the Department of + Justice as designated by the Attorney General; and + ``(B) shall be served by any person or class of + persons designated by the Attorney General or a + designated officer or employee for that purpose. + ``(2) Enforcement.--In the case of contumacy or failure to + obey a subpoena issued under this section, the United States + district court for the judicial district in which the + institution + +[[Page 124 STAT. 1009]] + + is located may issue an order requiring compliance. Any failure + to obey the order of the court may be punished by the court as a + contempt that court. + + ``(c) Protection of Subpoenaed Records and Information.--Any +document, record, material, file, report, memorandum, policy, procedure, +investigation, video or audio recording, or quality assurance report or +other information obtained under a subpoena issued under this section-- + ``(1) may not be used for any purpose other than to protect + the rights, privileges, or immunities secured or protected by + the Constitution or laws of the United States of persons who + reside, have resided, or will reside in an institution; + ``(2) may not be transmitted by or within the Department of + Justice for any purpose other than to protect the rights, + privileges, or immunities secured or protected by the + Constitution or laws of the United States of persons who reside, + have resided, or will reside in an institution; and + ``(3) shall be redacted, obscured, or otherwise altered if + used in any publicly available manner so as to prevent the + disclosure of any personally identifiable information.''. + +SEC. 10607. STATE DEMONSTRATION PROGRAMS TO EVALUATE ALTERNATIVES TO + CURRENT MEDICAL TORT LITIGATION. + + Part P of title III of the Public Health Service Act (42 U.S.C. 280g +et seq.), as amended by this Act, is further amended by adding at the +end the following: + +``SEC. 399V-4. <<NOTE: Grants. 42 USC 280g-15.>> STATE DEMONSTRATION + PROGRAMS TO EVALUATE ALTERNATIVES TO CURRENT MEDICAL TORT + LITIGATION. + + ``(a) In General.--The Secretary is authorized to award +demonstration grants to States for the development, implementation, and +evaluation of alternatives to current tort litigation for resolving +disputes over injuries allegedly caused by health care providers or +health care organizations. In awarding such grants, the Secretary shall +ensure the diversity of the alternatives so funded. + ``(b) Duration.--The Secretary may award grants under subsection (a) +for a period not to exceed 5 years. + ``(c) Conditions for Demonstration Grants.-- + ``(1) Requirements.--Each State desiring a grant under + subsection (a) shall develop an alternative to current tort + litigation that-- + ``(A) allows for the resolution of disputes over + injuries allegedly caused by health care providers or + health care organizations; and + ``(B) promotes a reduction of health care errors by + encouraging the collection and analysis of patient + safety data related to disputes resolved under + subparagraph (A) by organizations that engage in efforts + to improve patient safety and the quality of health + care. + ``(2) Alternative to current tort litigation.--Each State + desiring a grant under subsection (a) shall demonstrate how the + proposed alternative described in paragraph (1)(A)-- + ``(A) makes the medical liability system more + reliable by increasing the availability of prompt and + fair resolution of disputes; + ``(B) encourages the efficient resolution of + disputes; + ``(C) encourages the disclosure of health care + errors; + +[[Page 124 STAT. 1010]] + + ``(D) enhances patient safety by detecting, + analyzing, and helping to reduce medical errors and + adverse events; + ``(E) improves access to liability insurance; + ``(F) fully informs patients about the differences + in the alternative and current tort litigation; + ``(G) provides patients the ability to opt out of or + voluntarily withdraw from participating in the + alternative at any time and to pursue other options, + including litigation, outside the alternative; + ``(H) would not conflict with State law at the time + of the application in a way that would prohibit the + adoption of an alternative to current tort litigation; + and + ``(I) would not limit or curtail a patient's + existing legal rights, ability to file a claim in or + access a State's legal system, or otherwise abrogate a + patient's ability to file a medical malpractice claim. + ``(3) Sources of compensation.--Each State desiring a grant + under subsection (a) shall identify the sources from and methods + by which compensation would be paid for claims resolved under + the proposed alternative to current tort litigation, which may + include public or private funding sources, or a combination of + such sources. Funding methods shall to the extent practicable + provide financial incentives for activities that improve patient + safety. + ``(4) Scope.-- + ``(A) In general.--Each State desiring a grant under + subsection (a) shall establish a scope of jurisdiction + (such as Statewide, designated geographic region, a + designated area of health care practice, or a designated + group of health care providers or health care + organizations) for the proposed alternative to current + tort litigation that is sufficient to evaluate the + effects of the alternative. No scope of jurisdiction + shall be established under this paragraph that is based + on a health care payer or patient population. + ``(B) Notification of patients.--A State shall + demonstrate how patients would be notified that they are + receiving health care services that fall within such + scope, and the process by which they may opt out of or + voluntarily withdraw from participating in the + alternative. The decision of the patient whether to + participate or continue participating in the alternative + process shall be made at any time and shall not be + limited in any way. + ``(5) Preference in awarding demonstration grants.--In + awarding grants under subsection (a), the Secretary shall give + preference to States-- + ``(A) that have developed the proposed alternative + through substantive consultation with relevant + stakeholders, including patient advocates, health care + providers and health care organizations, attorneys with + expertise in representing patients and health care + providers, medical malpractice insurers, and patient + safety experts; + ``(B) that make proposals that are likely to enhance + patient safety by detecting, analyzing, and helping to + reduce medical errors and adverse events; and + ``(C) that make proposals that are likely to improve + access to liability insurance. + + ``(d) Application.-- + +[[Page 124 STAT. 1011]] + + ``(1) In general.--Each State desiring a grant under + subsection (a) shall submit to the Secretary an application, at + such time, in such manner, and containing such information as + the Secretary may require. + ``(2) Review panel.-- + ``(A) In general.-- <<NOTE: Establishment.>> In + reviewing applications under paragraph (1), the + Secretary shall consult with a review panel composed of + relevant experts appointed by the Comptroller General. + ``(B) Composition.-- + ``(i) Nominations.--The Comptroller General + shall solicit nominations from the public for + individuals to serve on the review panel. + ``(ii) Appointment.--The Comptroller General + shall appoint, at least 9 but not more than 13, + highly qualified and knowledgeable individuals to + serve on the review panel and shall ensure that + the following entities receive fair representation + on such panel: + ``(I) Patient advocates. + ``(II) Health care providers and + health care organizations. + ``(III) Attorneys with expertise in + representing patients and health care + providers. + ``(IV) Medical malpractice insurers. + ``(V) State officials. + ``(VI) Patient safety experts. + ``(C) Chairperson.--The Comptroller General, or an + individual within the Government Accountability Office + designated by the Comptroller General, shall be the + chairperson of the review panel. + ``(D) Availability of information.--The Comptroller + General shall make available to the review panel such + information, personnel, and administrative services and + assistance as the review panel may reasonably require to + carry out its duties. + ``(E) Information from agencies.--The review panel + may request directly from any department or agency of + the United States any information that such panel + considers necessary to carry out its duties. To the + extent consistent with applicable laws and regulations, + the head of such department or agency shall furnish the + requested information to the review panel. + + ``(e) Reports.-- + ``(1) By state.--Each State receiving a grant under + subsection (a) shall submit to the Secretary an annual report + evaluating the effectiveness of activities funded with grants + awarded under such subsection. Such report shall, at a minimum, + include the impact of the activities funded on patient safety + and on the availability and price of medical liability + insurance. + ``(2) By secretary.--The Secretary shall submit to Congress + an annual compendium of the reports submitted under paragraph + (1) and an analysis of the activities funded under subsection + (a) that examines any differences that result from such + activities in terms of the quality of care, number and nature of + medical errors, medical resources used, length of + +[[Page 124 STAT. 1012]] + + time for dispute resolution, and the availability and price of + liability insurance. + + ``(f) Technical Assistance.-- + ``(1) In general.--The Secretary shall provide technical + assistance to the States applying for or awarded grants under + subsection (a). + ``(2) Requirements.--Technical assistance under paragraph + (1) shall include-- + ``(A) guidance on non-economic damages, including + the consideration of individual facts and circumstances + in determining appropriate payment, guidance on + identifying avoidable injuries, and guidance on + disclosure to patients of health care errors and adverse + events; and + ``(B) the development, in consultation with States, + of common definitions, formats, and data collection + infrastructure for States receiving grants under this + section to use in reporting to facilitate aggregation + and analysis of data both within and between States. + ``(3) Use of common definitions, formats, and data + collection infrastructure.--States not receiving grants under + this section may also use the common definitions, formats, and + data collection infrastructure developed under paragraph (2)(B). + + ``(g) Evaluation.-- + ``(1) In general.-- + <<NOTE: Contracts. Deadlines. Reports.>> The Secretary, in + consultation with the review panel established under subsection + (d)(2), shall enter into a contract with an appropriate research + organization to conduct an overall evaluation of the + effectiveness of grants awarded under subsection (a) and to + annually prepare and submit a report to Congress. Such an + evaluation shall begin not later than 18 months following the + date of implementation of the first program funded by a grant + under subsection (a). + ``(2) Contents.--The evaluation under paragraph (1) shall + include-- + ``(A) an analysis of the effects of the grants + awarded under subsection (a) with regard to the measures + described in paragraph (3); + ``(B) for each State, an analysis of the extent to + which the alternative developed under subsection (c)(1) + is effective in meeting the elements described in + subsection (c)(2); + ``(C) a comparison among the States receiving grants + under subsection (a) of the effectiveness of the various + alternatives developed by such States under subsection + (c)(1); + ``(D) a comparison, considering the measures + described in paragraph (3), of States receiving grants + approved under subsection (a) and similar States not + receiving such grants; and + ``(E) a comparison, with regard to the measures + described in paragraph (3), of-- + ``(i) States receiving grants under subsection + (a); + ``(ii) States that enacted, prior to the date + of enactment of the Patient Protection and + Affordable Care Act, any cap on non-economic + damages; and + ``(iii) States that have enacted, prior to the + date of enactment of the Patient Protection and + Affordable Care Act, a requirement that the + complainant obtain + +[[Page 124 STAT. 1013]] + + an opinion regarding the merit of the claim, + although the substance of such opinion may have no + bearing on whether the complainant may proceed + with a case. + ``(3) Measures.--The evaluations under paragraph (2) shall + analyze and make comparisons on the basis of-- + ``(A) the nature and number of disputes over + injuries allegedly caused by health care providers or + health care organizations; + ``(B) the nature and number of claims in which tort + litigation was pursued despite the existence of an + alternative under subsection (a); + ``(C) the disposition of disputes and claims, + including the length of time and estimated costs to all + parties; + ``(D) the medical liability environment; + ``(E) health care quality; + ``(F) patient safety in terms of detecting, + analyzing, and helping to reduce medical errors and + adverse events; + ``(G) patient and health care provider and + organization satisfaction with the alternative under + subsection (a) and with the medical liability + environment; and + ``(H) impact on utilization of medical services, + appropriately adjusted for risk. + ``(4) Funding.--The Secretary shall reserve 5 percent of the + amount appropriated in each fiscal year under subsection (k) to + carry out this subsection. + + ``(h) MedPAC and MACPAC Reports.-- + ``(1) MedPAC.--The Medicare Payment Advisory Commission + shall conduct an independent review of the alternatives to + current tort litigation that are implemented under grants under + subsection (a) to determine the impact of such alternatives on + the Medicare program under title XVIII of the Social Security + Act, and its beneficiaries. + ``(2) MACPAC.--The Medicaid and CHIP Payment and Access + Commission shall conduct an independent review of the + alternatives to current tort litigation that are implemented + under grants under subsection (a) to determine the impact of + such alternatives on the Medicaid or CHIP programs under titles + XIX and XXI of the Social Security Act, and their beneficiaries. + ``(3) Reports.--Not later than December 31, 2016, the + Medicare Payment Advisory Commission and the Medicaid and CHIP + Payment and Access Commission shall each submit to Congress a + report that includes the findings and recommendations of each + respective Commission based on independent reviews conducted + under paragraphs (1) and (2), including an analysis of the + impact of the alternatives reviewed on the efficiency and + effectiveness of the respective programs. + + ``(i) Option To Provide for Initial Planning Grants.--Of the funds +appropriated pursuant to subsection (k), the Secretary may use a portion +not to exceed $500,000 per State to provide planning grants to such +States for the development of demonstration project applications meeting +the criteria described in subsection (c). In selecting States to receive +such planning grants, the Secretary shall give preference to those +States in which State law at the time of the application would not +prohibit the adoption of an alternative to current tort litigation. + ``(j) Definitions.--In this section: + +[[Page 124 STAT. 1014]] + + ``(1) Health care services.--The term `health care services' + means any services provided by a health care provider, or by any + individual working under the supervision of a health care + provider, that relate to-- + ``(A) the diagnosis, prevention, or treatment of any + human disease or impairment; or + ``(B) the assessment of the health of human beings. + ``(2) Health care organization.--The term `health care + organization' means any individual or entity which is obligated + to provide, pay for, or administer health benefits under any + health plan. + ``(3) Health care provider.--The term `health care provider' + means any individual or entity-- + ``(A) licensed, registered, or certified under + Federal or State laws or regulations to provide health + care services; or + ``(B) required to be so licensed, registered, or + certified but that is exempted by other statute or + regulation. + + ``(k) Authorization of Appropriations.--There are authorized to be +appropriated to carry out this section, $50,000,000 for the 5-fiscal +year period beginning with fiscal year 2011. + ``(l) Current State Efforts To Establish Alternative To Tort +Litigation.--Nothing in this section shall be construed to limit any +prior, current, or future efforts of any State to establish any +alternative to tort litigation. + ``(m) Rule of Construction.--Nothing in this section shall be +construed as limiting states' authority over or responsibility for their +state justice systems.''. + +SEC. 10608. EXTENSION OF MEDICAL MALPRACTICE COVERAGE TO FREE CLINICS. + + (a) In General.--Section 224(o)(1) of the Public Health Service Act +(42 U.S.C. 233(o)(1)) is amended by inserting after ``to an individual'' +the following: ``, or an officer, governing board member, employee, or +contractor of a free clinic shall in providing services for the free +clinic,''. + (b) <<NOTE: 42 USC 233 note.>> Effective Date.--The amendment made +by this section shall take effect on the date of enactment of this Act +and apply to any act or omission which occurs on or after that date. + +SEC. 10609. <<NOTE: Drugs and drug abuse.>> LABELING CHANGES. + + Section 505(j) of the Federal Food, Drug, and Cosmetic Act (21 +U.S.C. 355(j)) is amended by adding at the end the following: + ``(10)(A) <<NOTE: Deadlines.>> If the proposed labeling of a drug +that is the subject of an application under this subsection differs from +the listed drug due to a labeling revision described under clause (i), +the drug that is the subject of such application shall, notwithstanding +any other provision of this Act, be eligible for approval and shall not +be considered misbranded under section 502 if-- + ``(i) the application is otherwise eligible for approval + under this subsection but for expiration of patent, an + exclusivity period, or of a delay in approval described in + paragraph (5)(B)(iii), and a revision to the labeling of the + listed drug has been approved by the Secretary within 60 days of + such expiration; + ``(ii) the labeling revision described under clause (i) does + not include a change to the `Warnings' section of the labeling; + +[[Page 124 STAT. 1015]] + + ``(iii) the sponsor of the application under this subsection + agrees to submit revised labeling of the drug that is the + subject of such application not later than 60 days after the + notification of any changes to such labeling required by the + Secretary; and + ``(iv) such application otherwise meets the applicable + requirements for approval under this subsection. + + ``(B) <<NOTE: Determination.>> If, after a labeling revision +described in subparagraph (A)(i), the Secretary determines that the +continued presence in interstate commerce of the labeling of the listed +drug (as in effect before the revision described in subparagraph (A)(i)) +adversely impacts the safe use of the drug, no application under this +subsection shall be eligible for approval with such labeling.''. + + Subtitle G--Provisions Relating to Title VIII + +SEC. 10801. PROVISIONS RELATING TO TITLE VIII. + + (a) Title XXXII of the Public Health Service Act, as added by +section 8002(a)(1), is amended-- + (1) in section 3203 <<NOTE: 42 USC 300ll-2.>> -- + (A) in subsection (a)(1), by striking subparagraph + (E); + (B) in subsection (b)(1)(C)(i), by striking ``for + enrollment'' and inserting ``for reenrollment''; and + (C) in subsection (c)(1), by striking ``, as part of + their automatic enrollment in the CLASS program,''; and + (2) in section 3204 <<NOTE: 42 USC 300ll-3.>> -- + (A) in subsection (c)(2), by striking subparagraph + (A) and inserting the following: + ``(A) receives wages or income on which there is + imposed a tax under section 3101(a) or 3201(a) of the + Internal Revenue Code of 1986; or''; + (B) in subsection (d), by striking ``subparagraph + (B) or (C) of subsection (c)(1)'' and inserting + ``subparagraph (A) or (B) of subsection (c)(2)''; + (C) in subsection (e)(2)(A), by striking + ``subparagraph (A)'' and inserting ``paragraph (1)''; + and + (D) in subsection (g)(1), by striking ``has elected + to waive enrollment'' and inserting ``has not + enrolled''. + + (b) Section 8002 of this Act is amended in the heading for +subsection (d), by striking ``Information on Supplemental Coverage'' and +inserting ``CLASS Program Information''. + (c) Section 6021(d)(2)(A)(iv) of the Deficit Reduction Act of 2005, +as added by section 8002(d) of this Act, <<NOTE: 42 USC 1396p note.>> is +amended by striking ``and coverage available'' and all that follows +through ``that program,''. + + Subtitle H--Provisions Relating to Title IX + +SEC. 10901. MODIFICATIONS TO EXCISE TAX ON HIGH COST EMPLOYER-SPONSORED + HEALTH COVERAGE. + + (a) Longshore Workers Treated as Employees Engaged in High-risk +Professions.--Paragraph (3) of section 4980I(f) of the Internal Revenue +Code of 1986, as added by section 9001 of this Act, <<NOTE: 26 USC +4980I.>> is amended by inserting ``individuals whose primary + +[[Page 124 STAT. 1016]] + +work is longshore work (as defined in section 258(b) of the Immigration +and Nationality Act (8 U.S.C. 1288(b)), determined without regard to +paragraph (2) thereof),'' before ``and individuals engaged in the +construction, mining''. + + (b) Exemption From High-cost Insurance Tax Includes Certain +Additional Excepted Benefits.--Clause (i) of section 4980I(d)(1)(B) of +the Internal Revenue Code of 1986, as added by section 9001 of this Act, +is amended by striking ``section 9832(c)(1)(A)'' and inserting ``section +9832(c)(1) (other than subparagraph (G) thereof)''. + (c) <<NOTE: 26 USC 4980I note.>> Effective Date.--The amendments +made by this section shall apply to taxable years beginning after +December 31, 2012. + +SEC. 10902. INFLATION ADJUSTMENT OF LIMITATION ON HEALTH FLEXIBLE + SPENDING ARRANGEMENTS UNDER CAFETERIA PLANS. + + (a) In General.--Subsection (i) of section 125 of the Internal +Revenue Code of 1986, as added by section 9005 of this Act, <<NOTE: 26 +USC 125.>> is amended to read as follows: + + ``(i) Limitation on Health Flexible Spending Arrangements.-- + ``(1) In general.--For purposes of this section, if a + benefit is provided under a cafeteria plan through employer + contributions to a health flexible spending arrangement, such + benefit shall not be treated as a qualified benefit unless the + cafeteria plan provides that an employee may not elect for any + taxable year to have salary reduction contributions in excess of + $2,500 made to such arrangement. + ``(2) Adjustment for inflation.-- <<NOTE: Effective + date.>> In the case of any taxable year beginning after December + 31, 2011, the dollar amount in paragraph (1) shall be increased + by an amount equal to-- + ``(A) such amount, multiplied by + ``(B) the cost-of-living adjustment determined under + section 1(f)(3) for the calendar year in which such + taxable year begins by substituting `calendar year 2010' + for `calendar year 1992' in subparagraph (B) thereof. + If any increase determined under this paragraph is not a + multiple of $50, such increase shall be rounded to the next + lowest multiple of $50.''. + + (b) <<NOTE: 26 USC 125 note.>> Effective Date.--The amendment made +by this section shall apply to taxable years beginning after December +31, 2010. + +SEC. 10903. MODIFICATION OF LIMITATION ON CHARGES BY CHARITABLE + HOSPITALS. + + (a) In General.--Subparagraph (A) of section 501(r)(5) of the +Internal Revenue Code of 1986, as added by section 9007 of this +Act, <<NOTE: 26 USC 501.>> is amended by striking ``the lowest amounts +charged'' and inserting ``the amounts generally billed''. + + (b) <<NOTE: 26 USC 501 note.>> Effective Date.--The amendment made +by this section shall apply to taxable years beginning after the date of +the enactment of this Act. + +SEC. 10904. MODIFICATION OF ANNUAL FEE ON MEDICAL DEVICE MANUFACTURERS + AND IMPORTERS. + + (a) In General.--Section 9009 of this Act <<NOTE: 26 USC 4001 note +prec.>> is amended-- + (1) by striking ``2009'' in subsection (a)(1) and inserting + ``2010'', + +[[Page 124 STAT. 1017]] + + (2) by inserting ``($3,000,000,000 after 2017)'' after + ``$2,000,000,000'', and + (3) by striking ``2008'' in subsection (i) and inserting + ``2009''. + + (b) <<NOTE: 26 USC 4001 note prec.>> Effective Date.--The amendments +made by this section shall take effect as if included in the enactment +of section 9009. + +SEC. 10905. <<NOTE: 26 USC 4001 note prec.>> MODIFICATION OF ANNUAL FEE + ON HEALTH INSURANCE PROVIDERS. + + (a) Determination of Fee Amount.--Subsection (b) of section 9010 of +this Act is amended to read as follows: + ``(b) Determination of Fee Amount.-- + ``(1) In general.--With respect to each covered entity, the + fee under this section for any calendar year shall be equal to + an amount that bears the same ratio to the applicable amount + as-- + ``(A) the covered entity's net premiums written with + respect to health insurance for any United States health + risk that are taken into account during the preceding + calendar year, bears to + ``(B) the aggregate net premiums written with + respect to such health insurance of all covered entities + that are taken into account during such preceding + calendar year. + ``(2) Amounts taken into account.--For purposes of paragraph + (1), the net premiums written with respect to health insurance + for any United States health risk that are taken into account + during any calendar year with respect to any covered entity + shall be determined in accordance with the following table: + + + ``With respect to a covered entity's The percentage of net premiums + net premiums written during the written that are taken into + calendar year that are: account is: + + Not more than $25,000,000............ 0 percent + More than $25,000,000 but not more 50 percent + than $50,000,000. + More than $50,000,000................ 100 percent. + + + ``(3) Secretarial determination.--The Secretary shall + calculate the amount of each covered entity's fee for any + calendar year under paragraph (1). In calculating such amount, + the Secretary shall determine such covered entity's net premiums + written with respect to any United States health risk on the + basis of reports submitted by the covered entity under + subsection (g) and through the use of any other source of + information available to the Secretary.''. + + (b) Applicable Amount.--Subsection (e) of section 9010 of this Act +is amended to read as follows: + ``(e) Applicable Amount.--For purposes of subsection (b)(1), the +applicable amount shall be determined in accordance with the following +table: + +``Calendar year Applicable amount + 2011................................. $2,000,000,000 + 2012................................. $4,000,000,000 + +[[Page 124 STAT. 1018]] + + + 2013................................. $7,000,000,000 + 2014, 2015 and 2016.................. $9,000,000,000 + 2017 and thereafter.................. $10,000,000,000.''. + + + (c) Exemption From Annual Fee on Health Insurance for Certain +Nonprofit Entities.--Section 9010(c)(2) of this Act is amended by +striking ``or'' at the end of subparagraph (A), by striking the period +at the end of subparagraph (B) and inserting a comma, and by adding at +the end the following new subparagraphs: + ``(C) any entity-- + ``(i)(I) which is incorporated as, is a wholly + owned subsidiary of, or is a wholly owned + affiliate of, a nonprofit corporation under a + State law, or + ``(II) which is described in section 501(c)(4) + of the Internal Revenue Code of 1986 and the + activities of which consist of providing + commercial-type insurance (within the meaning of + section 501(m) of such Code), + ``(ii) the premium rate increases of which are + regulated by a State authority, + ``(iii) which, as of the date of the enactment + of this section, acts as the insurer of last + resort in the State and is subject to State + guarantee issue requirements, and + ``(iv) for which the medical loss ratio + (determined in a manner consistent with the + determination of such ratio under section + 2718(b)(1)(A) of the Public Health Service Act) + with respect to the individual insurance market + for such entity for the calendar year is not less + than 100 percent, + ``(D) any entity-- + ``(i)(I) which is incorporated as a nonprofit + corporation under a State law, or + ``(II) which is described in section 501(c)(4) + of the Internal Revenue Code of 1986 and the + activities of which consist of providing + commercial-type insurance (within the meaning of + section 501(m) of such Code), and + ``(ii) for which the medical loss ratio (as so + determined)-- + ``(I) with respect to each of the + individual, small group, and large group + insurance markets for such entity for + the calendar year is not less than 90 + percent, and + ``(II) with respect to all such + markets for such entity for the calendar + year is not less than 92 percent, or + ``(E) any entity-- + ``(i) which is a mutual insurance company, + ``(ii) which for the period reported on the + 2008 Accident and Health Policy Experience Exhibit + of the National Association of Insurance + Commissioners had-- + ``(I) a market share of the insured + population of a State of at least 40 but + not more than 60 percent, and + +[[Page 124 STAT. 1019]] + + ``(II) with respect to all markets + described in subparagraph (D)(ii)(I), a + medical loss ratio of not less than 90 + percent, and + ``(iii) with respect to annual payment dates + in calendar years after 2011, for which the + medical loss ratio (determined in a manner + consistent with the determination of such ratio + under section 2718(b)(1)(A) of the Public Health + Service Act) with respect to all such markets for + such entity for the preceding calendar year is not + less than 89 percent (except that with respect to + such annual payment date for 2012, the calculation + under 2718(b)(1)(B)(ii) of such Act is determined + by reference to the previous year, and with + respect to such annual payment date for 2013, such + calculation is determined by reference to the + average for the previous 2 years).''. + + (d) Certain Insurance Exempted From Fee.--Paragraph (3) of section +9010(h) of this Act is amended to read as follows: + ``(3) Health insurance.--The term `health insurance' shall + not include-- + ``(A) any insurance coverage described in paragraph + (1)(A) or (3) of section 9832(c) of the Internal Revenue + Code of 1986, + ``(B) any insurance for long-term care, or + ``(C) any medicare supplemental health insurance (as + defined in section 1882(g)(1) of the Social Security + Act).''. + + (e) Anti-avoidance Guidance.--Subsection (i) of section 9010 of this +Act is amended by inserting ``and shall prescribe such regulations as +are necessary or appropriate to prevent avoidance of the purposes of +this section, including inappropriate actions taken to qualify as an +exempt entity under subsection (c)(2)'' after ``section''. + (f) Conforming Amendments.-- + (1) Section 9010(a)(1) of this Act is amended by striking + ``2009'' and inserting ``2010''. + (2) Section 9010(c)(2)(B) of this Act is amended by striking + ``(except'' and all that follows through ``1323)''. + (3) Section 9010(c)(3) of this Act is amended by adding at + the end the following new sentence: ``If any entity described in + subparagraph (C)(i)(I), (D)(i)(I), or (E)(i) of paragraph (2) is + treated as a covered entity by reason of the application of the + preceding sentence, the net premiums written with respect to + health insurance for any United States health risk of such + entity shall not be taken into account for purposes of this + section.''. + (4) Section 9010(g)(1) of this Act is amended by striking + ``and third party administration agreement fees''. + (5) Section 9010(j) of this Act is amended-- + (A) by striking ``2008'' and inserting ``2009'', and + (B) by striking ``, and any third party + administration agreement fees received after such + date''. + + (g) Effective Date.--The amendments made by this section shall take +effect as if included in the enactment of section 9010. + +[[Page 124 STAT. 1020]] + +SEC. 10906. MODIFICATIONS TO ADDITIONAL HOSPITAL INSURANCE TAX ON HIGH- + INCOME TAXPAYERS. + + (a) FICA.--Section 3101(b)(2) of the Internal Revenue Code of 1986, +as added by section 9015(a)(1) of this Act, <<NOTE: 26 USC 3101.>> is +amended by striking ``0.5 percent'' and inserting ``0.9 percent''. + + (b) SECA.--Section 1401(b)(2)(A) of the Internal Revenue Code of +1986, as added by section 9015(b)(1) of this Act, <<NOTE: 26 USC +1401.>> is amended by striking ``0.5 percent'' and inserting ``0.9 +percent''. + + (c) <<NOTE: 26 USC 1401 note.>> Effective Date.--The amendments made +by this section shall apply with respect to remuneration received, and +taxable years beginning, after December 31, 2012. + +SEC. 10907. EXCISE TAX ON INDOOR TANNING SERVICES IN LIEU OF ELECTIVE + COSMETIC MEDICAL PROCEDURES. + + (a) <<NOTE: 26 USC 5000B and note.>> In General.--The provisions of, +and amendments made by, section 9017 of this Act are hereby deemed null, +void, and of no effect. + + (b) Excise Tax on Indoor Tanning Services.--Subtitle D of the +Internal Revenue Code of 1986, as amended by this Act, is amended by +adding at the end the following new chapter: + + ``CHAPTER 49--COSMETIC SERVICES + +``Sec. 5000B. Imposition of tax on indoor tanning services. + +``SEC. 5000B. <<NOTE: 26 USC 5000B.>> IMPOSITION OF TAX ON INDOOR + TANNING SERVICES. + + ``(a) In General.--There is hereby imposed on any indoor tanning +service a tax equal to 10 percent of the amount paid for such service +(determined without regard to this section), whether paid by insurance +or otherwise. + ``(b) Indoor Tanning Service.-- <<NOTE: Definitions.>> For purposes +of this section-- + ``(1) In general.--The term `indoor tanning service' means a + service employing any electronic product designed to incorporate + 1 or more ultraviolet lamps and intended for the irradiation of + an individual by ultraviolet radiation, with wavelengths in air + between 200 and 400 nanometers, to induce skin tanning. + ``(2) Exclusion of phototherapy services.--Such term does + not include any phototherapy service performed by a licensed + medical professional. + + ``(c) Payment of Tax.-- + ``(1) In general.--The tax imposed by this section shall be + paid by the individual on whom the service is performed. + ``(2) Collection.-- <<NOTE: Deadline.>> Every person + receiving a payment for services on which a tax is imposed under + subsection (a) shall collect the amount of the tax from the + individual on whom the service is performed and remit such tax + quarterly to the Secretary at such time and in such manner as + provided by the Secretary. + ``(3) Secondary liability.--Where any tax imposed by + subsection (a) is not paid at the time payments for indoor + tanning services are made, then to the extent that such tax is + not collected, such tax shall be paid by the person who performs + the service.''. + + (c) Clerical Amendment.--The table of chapter for subtitle D of the +Internal Revenue Code of 1986, as amended by this Act, is amended by +inserting after the item relating to chapter 48 the following new item: + +[[Page 124 STAT. 1021]] + + ``Chapter 49--Cosmetic Services''. + + (d) <<NOTE: 26 USC 5000B note.>> Effective Date.--The amendments +made by this section shall apply to services performed on or after July +1, 2010. + +SEC. 10908. EXCLUSION FOR ASSISTANCE PROVIDED TO PARTICIPANTS IN STATE + STUDENT LOAN REPAYMENT PROGRAMS FOR CERTAIN HEALTH + PROFESSIONALS. + + (a) In General.--Paragraph (4) of section 108(f) of the Internal +Revenue Code of 1986 <<NOTE: 26 USC 108.>> is amended to read as +follows: + ``(4) Payments under national health service corps loan + repayment program and certain state loan repayment programs.--In + the case of an individual, gross income shall not include any + amount received under section 338B(g) of the Public Health + Service Act, under a State program described in section 338I of + such Act, or under any other State loan repayment or loan + forgiveness program that is intended to provide for the + increased availability of health care services in underserved or + health professional shortage areas (as determined by such + State).''. + + (b) <<NOTE: 26 USC 108 note.>> Effective Date.--The amendment made +by this section shall apply to amounts received by an individual in +taxable years beginning after December 31, 2008. + +SEC. 10909. EXPANSION OF ADOPTION CREDIT AND ADOPTION ASSISTANCE + PROGRAMS. + + (a) Increase in Dollar Limitation.-- + (1) Adoption credit.-- + (A) In general.--Paragraph (1) of section 23(b) of + the Internal Revenue Code of 1986 <<NOTE: 26 USC + 23.>> (relating to dollar limitation) is amended by + striking ``$10,000'' and inserting ``$13,170''. + (B) Child with special needs.--Paragraph (3) of + section 23(a) of such Code (relating to $10,000 credit + for adoption of child with special needs regardless of + expenses) is amended-- + (i) in the text by striking ``$10,000'' and + inserting ``$13,170'', and + (ii) in the heading by striking ``$10,000'' + and inserting ``$13,170''. + (C) Conforming amendment to inflation adjustment.-- + Subsection (h) of section 23 of such Code (relating to + adjustments for inflation) is amended to read as + follows: + + ``(h) <<NOTE: Effective dates.>> Adjustments for Inflation.-- + ``(1) Dollar limitations.--In the case of a taxable year + beginning after December 31, 2010, each of the dollar amounts in + subsections (a)(3) and (b)(1) shall be increased by an amount + equal to-- + ``(A) such dollar amount, multiplied by + ``(B) the cost-of-living adjustment determined under + section 1(f)(3) for the calendar year in which the + taxable year begins, determined by substituting + `calendar year 2009' for `calendar year 1992' in + subparagraph (B) thereof. + If any amount as increased under the preceding sentence is not a + multiple of $10, such amount shall be rounded to the nearest + multiple of $10. + ``(2) Income limitation.--In the case of a taxable year + beginning after December 31, 2002, the dollar amount in + subsection (b)(2)(A)(i) shall be increased by an amount equal + to-- + +[[Page 124 STAT. 1022]] + + ``(A) such dollar amount, multiplied by + ``(B) the cost-of-living adjustment determined under + section 1(f)(3) for the calendar year in which the + taxable year begins, determined by substituting + `calendar year 2001' for `calendar year 1992' in + subparagraph (B) thereof. + If any amount as increased under the preceding sentence is not a + multiple of $10, such amount shall be rounded to the nearest + multiple of $10.''. + (2) Adoption assistance programs.-- + (A) In general.--Paragraph (1) of section 137(b) of + the Internal Revenue Code of 1986 <<NOTE: 26 USC + 137.>> (relating to dollar limitation) is amended by + striking ``$10,000'' and inserting ``$13,170''. + (B) Child with special needs.--Paragraph (2) of + section 137(a) of such Code (relating to $10,000 + exclusion for adoption of child with special needs + regardless of expenses) is amended-- + (i) in the text by striking ``$10,000'' and + inserting ``$13,170'', and + (ii) in the heading by striking ``$10,000'' + and inserting ``$13,170''. + (C) Conforming amendment to inflation adjustment.-- + Subsection (f) of section 137 of such Code (relating to + adjustments for inflation) is amended to read as + follows: + + ``(f) <<NOTE: Effective dates.>> Adjustments for Inflation.-- + ``(1) Dollar limitations.--In the case of a taxable year + beginning after December 31, 2010, each of the dollar amounts in + subsections (a)(2) and (b)(1) shall be increased by an amount + equal to-- + ``(A) such dollar amount, multiplied by + ``(B) the cost-of-living adjustment determined under + section 1(f)(3) for the calendar year in which the + taxable year begins, determined by substituting + `calendar year 2009' for `calendar year 1992' in + subparagraph (B) thereof. + If any amount as increased under the preceding sentence is not a + multiple of $10, such amount shall be rounded to the nearest + multiple of $10. + ``(2) Income limitation.--In the case of a taxable year + beginning after December 31, 2002, the dollar amount in + subsection (b)(2)(A) shall be increased by an amount equal to-- + ``(A) such dollar amount, multiplied by + ``(B) the cost-of-living adjustment determined under + section 1(f)(3) for the calendar year in which the + taxable year begins, determined by substituting + `calendar year 2001' for `calendar year 1992' in + subparagraph thereof. + If any amount as increased under the preceding sentence is not a + multiple of $10, such amount shall be rounded to the nearest + multiple of $10.''. + + (b) Credit Made Refundable.-- + (1) Credit moved to subpart relating to refundable + credits.--The Internal Revenue Code of 1986 is amended-- + (A) by redesignating section 23, <<NOTE: 26 USC + 36C.>> as amended by subsection (a), as section 36C, and + (B) by moving section 36C (as so redesignated) from + subpart A of part IV of subchapter A of chapter 1 to the + location immediately before section 37 in subpart C of + part IV of subchapter A of chapter 1. + +[[Page 124 STAT. 1023]] + + (2) Conforming amendments.-- + (A) Section 24(b)(3)(B) of such Code <<NOTE: 26 USC + 24.>> is amended by striking ``23,''. + (B) Section 25(e)(1)(C) of such Code <<NOTE: 26 USC + 25.>> is amended by striking ``23,'' both places it + appears. + (C) Section 25A(i)(5)(B) of such Code <<NOTE: 26 USC + 25A.>> is amended by striking ``23, 25D,'' and inserting + ``25D''. + (D) Section 25B(g)(2) of such Code <<NOTE: 26 USC + 25B.>> is amended by striking ``23,''. + (E) Section 26(a)(1) of such Code <<NOTE: 26 USC + 26.>> is amended by striking ``23,''. + (F) Section 30(c)(2)(B)(ii) of such Code <<NOTE: 26 + USC 30.>> is amended by striking ``23, 25D,'' and + inserting ``25D''. + (G) Section 30B(g)(2)(B)(ii) of such Code <<NOTE: 26 + USC 30B.>> is amended by striking ``23,''. + (H) Section 30D(c)(2)(B)(ii) of such Code <<NOTE: 26 + USC 30D.>> is amended by striking ``sections 23 and'' + and inserting ``section''. + (I) Section 36C of such Code, <<NOTE: 26 USC + 36C.>> as so redesignated, is amended-- + (i) by striking paragraph (4) of subsection + (b), and + (ii) by striking subsection (c). + (J) Section 137 of such Code <<NOTE: 26 USC + 137.>> is amended-- + (i) by striking ``section 23(d)'' in + subsection (d) and inserting ``section 36C(d)'', + and + (ii) by striking ``section 23'' in subsection + (e) and inserting ``section 36C''. + (K) Section 904(i) of such Code <<NOTE: 26 USC + 904.>> is amended by striking ``23,''. + (L) Section 1016(a)(26) <<NOTE: 26 USC 1016.>> is + amended by striking ``23(g)'' and inserting ``36C(g)''. + (M) Section 1400C(d) of such Code <<NOTE: 26 USC + 1400C.>> is amended by striking ``23,''. + (N) Section 6211(b)(4)(A) of such Code <<NOTE: 26 + USC 6211.>> is amended by inserting ``36C,'' before + ``53(e)''. + (O) The table of sections for subpart A of part IV + of subchapter A of chapter 1 of such Code of 1986 is + amended by striking the item relating to section 23. + (P) Paragraph (2) of section 1324(b) of title 31, + United States Code, as amended by this Act, is amended + by inserting ``36C,'' after ``36B,''. + (Q) The table of sections for subpart C of part IV + of subchapter A of chapter 1 of the Internal Revenue + Code of 1986, as amended by this Act, is amended by + inserting after the item relating to section 36B the + following new item: + +``Sec. 36C. Adoption expenses.''. + + (c) <<NOTE: 26 USC 1 note.>> Application and Extension of EGTRRA +Sunset.--Notwithstanding section 901 of the Economic Growth and Tax +Relief Reconciliation Act of 2001, such section shall apply to the +amendments made by this section and the amendments made by section 202 +of such Act by substituting ``December 31, 2011'' for ``December 31, +2010'' in subsection (a)(1) thereof. + +[[Page 124 STAT. 1024]] + + (d) Effective Date.--The amendments <<NOTE: 26 USC 1 note.>> made +by this section shall apply to taxable years beginning after December +31, 2009. + + Approved March 23, 2010. + +LEGISLATIVE HISTORY--H.R. 3590: +--------------------------------------------------------------------------- + +CONGRESSIONAL RECORD: + Vol. 155 (2009): + Oct. 7, 8, considered and passed + House. + Nov. 21, 30, Dec. 1-10, 13, 15, 16, + 19-24, considered and passed + Senate, amended. + Vol. 156 (2010): + Mar. 21, House concurred in Senate + amendments. +DAILY COMPILATION OF PRESIDENTIAL DOCUMENTS (2010): + Mar. 23, Presidential remarks. + + <all> |