Requires OMB to maintain and make publicly available a document containing a PAYGO ledger and, within seven days (excluding weekends and legal holidays) after the enactment of any PAYGO legislation, record on such ledger its estimate of the legislation's budgetary effects in each fiscal year, applying the look-back and averaging requirements of this Act.

Exempts from the requirements of this Act any PAYGO legislation designated as an emergency requirement by the President and enacted by Congress. (Requires OMB to display the budgetary effects of such legislation as an addendum in the document containing the PAYGO ledger but not record the budgetary effects in it.)

Requires OMB: (1) to make publicly available an annual PAYGO report and publish a notice of it in the Federal Register, including information on how it can be obtained; and (2) if such report shows a debit on the PAYGO ledger for the budget year, to prepare and the President to issue a sequestration order for submission to Congress.

Prescribes requirements for calculating a sequestration for certain nonexempt and Medicare mandatory programs.

Sets forth a special temporary rule to address the scoring of legislation affecting current policy for: (1) payments made under title XVIII (Medicare) of the Social Security Act for physician services; (2) the Estate and Gift Tax and the Alternative Minimum Tax (AMT) under the Internal Revenue Code; and (3) provisions of the Economic Growth and Tax Relief Reconciliation Act of 2001 or the Jobs and Growth Tax Relief and Reconciliation Act of 2003 that amended the Code extending middle-class tax cuts for individuals (or provisions in later statutes further amending such amendments).

Makes such rule effective through December 31, 2010, or, in specified circumstances, until December 31, 2011.

Amends the Balanced Budget and Emergency Deficit Control Act of 1985 (Gramm-Rudman-Hollings Act) to modify the assumptions used to calculate the baseline.

Requires: (1) temporary mandatory funding and tax provisions related to major natural or man-made disasters to be assumed to expire on schedule, and discretionary funding for them to not be projected; and (2) the baseline to include a disaster allowance that is not designated as mandatory or discretionary and is not allocated to any congressional committee.

Amends the Gramm-Rudman-Hollings Act to specify additional Social Security, veterans, Tier I Railroad Retirement benefits and other programs and activities exempt from a sequestration order as well as certain economic recovery programs.

Requires: (1) the Clerk of the House of Representatives or the Secretary of the Senate, as applicable, also to incorporate by reference such printed estimate into the enrollment of a PAYGO Act; and (2) budgetary effects that are not so included to be determined by the Office of Management and Budget (OMB) estimates.

Amends the CBA to require the chairs to request from the Director of the Congressional Budget Office (CBO) an estimate of the budgetary effects of a PAYGO Act before a vote in either chamber on it that, if determined in the affirmative, would clear it for enrollment.

Directs the chairs to post such estimate on their respective committee websites and cause it to be printed in the Congressional Record under "PAYGO ESTIMATE."

Requires CBO to make specified estimate adjustments when calculating budgetary effects of certain designated legislation affecting current policy, as detailed in Sec. 7 of this Act.

Requires OMB to maintain and make publicly available a continuously updated document containing two PAYGO scorecards (the first for a five-year period and the second for a 10-year period for the beginning of each respective budget year) displaying the budgetary effects of PAYGO legislation, applying certain look-back and averaging requirements. Requires OMB to display as a separate addendum the cost estimates of provisions designated in statute as emergency requirements.

(Sec. 5) Requires OMB to: (1) make an annual public PAYGO report, including a up-to-date document containing the PAYGO scorecards, within 14 business days after Congress adjourns to end a session; and (2) prepare for the President an offsetting sequestration order, which the President shall issue, if such report shows a debit on either PAYGO scorecard for the budget year.

(Sec. 6) Prescribes requirements for calculating a sequestration for nonexempt direct spending programs, including Medicare payments and certain nonexempt mandatory programs.

(Sec. 7) Prescribes requirements for CBO adjustments of estimates of budgetary effects of PAYGO legislation for legislation affecting current policy for: (1) payments made under title XVIII (Medicare) of the Social Security Act for physician services; (2) the Estate and Gift Tax under the Internal Revenue Code; and (3) the permanent extension of middle-class tax cuts and the Alternative Minimum Tax (AMT) relief under the Economic Growth and Tax Relief Reconciliation Act of 2001 or the Jobs and Growth Tax Relief and Reconciliation Act of 2003.

(Sec. 8) Applies to this Act certain sequestration order requirements of the Balanced Budget and Emergency Deficit Control Act of 1985 (Gramm-Rudman-Hollings Act), as amended by this Act, including the authority of Members of Congress and certain individuals to request an expedited judicial review of a sequestration order.

(Sec. 9) Makes technical and conforming amendments to the Gramm-Rudman-Hollings Act.

(Sec. 10) Exempts from sequestration: (1) low-income subsidies and catastrophic subsidies under Part D (Voluntary Prescription Drug Benefit Program) of the Social Security Act (SSA); and (2) qualified individual (QI) premiums for Medicare cost-sharing for certain dual eligible low-income Medicare beneficiaries under SSA title XIX (Medicaid).

(Sec. 11) Amends the Gramm-Rudman-Hollings Act to specify additional Social Security, veterans, Tier I Railroad Retirement benefits and other programs and activities exempt from a sequestration order as well as certain economic recovery programs.