[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3590 Enrolled Bill (ENR)]
H.R.3590
One Hundred Eleventh Congress
of the
United States of America
AT THE SECOND SESSION
Begun and held at the City of Washington on Tuesday,
the fifth day of January, two thousand and ten
An Act
Entitled The Patient Protection and Affordable Care Act.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short 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.
``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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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 as sections
2725 through 2728, respectively;
(3) by redesignating sections 2711 through 2713 as sections
2731 through 2733, respectively;
(4) by redesignating sections 2721 through 2723 as sections
2735 through 2737, respectively; and
(5) by inserting after section 2702, the following:
``Subpart II--Improving Coverage
``SEC. 2711. 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. 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. 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 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. 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. DEVELOPMENT AND UTILIZATION OF UNIFORM EXPLANATION OF
COVERAGE DOCUMENTS AND STANDARDIZED DEFINITIONS.
``(a) In 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:
``(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 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 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 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 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 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.
``(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. 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. 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.--
``(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 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 DOWN THE COST OF HEALTH CARE COVERAGE.
``(a) Clear Accounting for Costs.--A health insurance issuer
offering group or individual health insurance coverage shall, with
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 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. 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;
``(2) 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;
``(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. HEALTH INSURANCE CONSUMER INFORMATION.
``(a) In 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.
``(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. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOLLARS.
``(a) Initial Premium Review Process.--
``(1) In 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
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 with plan years beginning in
2014, the Secretary, in conjunction with the States 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. 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.
Subtitle B--Immediate Actions to Preserve and Expand Coverage
SEC. 1101. IMMEDIATE ACCESS TO INSURANCE FOR UNINSURED INDIVIDUALS WITH
A PREEXISTING CONDITION.
(a) In General.--Not 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);
(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 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
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 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. REINSURANCE FOR EARLY RETIREES.
(a) Administration.--
(1) In general.--Not 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, 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 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 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).
SEC. 1103. IMMEDIATE 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 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.--
(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:
``(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 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 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
``(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 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 plan certification.--
``(A) Eligibility for a health plan, health claim status,
electronic funds transfers, health care payment and remittance
advice.--Not 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 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 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 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.
``(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 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
``(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 later than August 1, 2014, and annually
thereafter, the Secretary of the Treasury shall 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 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 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)). 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 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;
(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. 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 transferring such section (as amended by subparagraph
(A)) so as to appear after the section 2703 added by paragraph (4);
(3)(A) in 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)--
(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 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 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) 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 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 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 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 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 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.
``(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 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 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--
``(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 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 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.
``SEC. 2707. COMPREHENSIVE 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 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 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).
(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 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. 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 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;
(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 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.
(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 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 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 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 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--
(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.
(B) Exceptions.--Such term does not include premiums,
balance billing amounts for non-network providers, or spending
for non-covered services.
(4) Premium 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.--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.
(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. 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
(ii) 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 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) 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 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.--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. 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 (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;
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.
PART II--CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH
BENEFIT EXCHANGES
SEC. 1311. AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS.
(a) Assistance to States to Establish American Health Benefit
Exchanges.--
(1) Planning and establishment grants.--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.--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 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 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 if the Exchange has
adequate resources to assist such individuals and employers.
(c) Responsibilities of the Secretary.--
(1) In general.--The 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.
(2) Rule of construction.--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) an initial open enrollment, as determined by the
Secretary (such determination to be made not later than July 1,
2012);
(B) 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) special monthly enrollment periods for Indians (as
defined in section 4 of the Indian Health Care Improvement
Act).
(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 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) 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) provide for the operation of a toll-free telephone
hotline to respond to requests for assistance;
(C) 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 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) 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) 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.--
(A) No federal funds for continued operations.--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.--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) 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. 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 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.--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;
(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.--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.--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) 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 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.--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.
SEC. 1312. 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 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.--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:
(A) In general.--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.--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.--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. FINANCIAL INTEGRITY.
(a) Accounting for Expenditures.--
(1) In general.--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.--An Exchange shall be subject to annual audits by
the Secretary.
(4) Pattern of abuse.--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.--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.--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.
PART III--STATE FLEXIBILITY RELATING TO EXCHANGES
SEC. 1321. STATE FLEXIBILITY IN OPERATION AND ENFORCEMENT OF EXCHANGES
AND RELATED REQUIREMENTS.
(a) Establishment of Standards.--
(1) In general.--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.--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) 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.
(2) Enforcement authority.--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.--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. 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
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) 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.--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.
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.--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) Advisory board.--
(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.--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.--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--
(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 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 (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.--Subparagraph (A) shall
apply to an organization only if--
``(i) 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) 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.''.
(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.--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. 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 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.--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.--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 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) 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.
(C) Consumer protections.--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.--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) 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 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) 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''.
(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) 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.--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.
(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.--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.
(h) Authorization of Appropriations.--There is authorized to be
appropriated such sums as may be necessary to carry out this section.
SEC. 1324. 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. 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 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.--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.
(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) 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 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) 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);
(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.--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. WAIVER FOR STATE INNOVATION.
(a) Application.--
(1) 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).
(2) Requirements.--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.--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.
(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) 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.--The Secretary shall make a
determination under subsection (a)(1) not later than 180 days after
the receipt of an application from a State under such subsection.
(2) Effect of determination.--
(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) 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. PROVISIONS RELATING TO OFFERING OF PLANS IN MORE THAN ONE
STATE.
(a) Health Care Choice Compacts.--
(1) In general.--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) 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) 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) 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;
(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) 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. TRANSITIONAL REINSURANCE PROGRAM FOR INDIVIDUAL AND SMALL
GROUP MARKETS IN EACH STATE.
(a) In General.--Each State shall, not later than January 1, 2014--
(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) 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) 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.--
(A) In general.--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) 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.
(c) Applicable Reinsurance Entity.--For purposes of this section--
(1) In general.--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. 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.
(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. 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 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. 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.--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
``(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 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--
``(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 respect to
the plan exceeds 9.8 percent of the applicable
taxpayer's household income.
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--
``(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.--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 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 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.''.
(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) Effective Date.--The amendments made by this section shall
apply to taxable years ending after December 31, 2013.
SEC. 1402. 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) 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).
(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
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 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) 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 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) 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 1412 and not the
taxable year for which the credit under section 36B of such Code is
allowed.
Subpart B--Eligibility Determinations
SEC. 1411. 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.
(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.
(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) 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) In general.--The Secretary, in consultation with the
Secretary of the Treasury, the Secretary of Homeland 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. 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) 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 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) 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) 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 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) 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--
(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.
(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. 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) 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--
(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) 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--
(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. 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;
(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.
(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.
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 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--
``(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 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 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. 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-related
credits) is amended by inserting after section 45Q the following:
``SEC. 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.
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) 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.
``(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) 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--
``(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) 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) 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 (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:
``(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) 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) 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. 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).
(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 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. 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.--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 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.--
``(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.--
``(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) 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) 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 was not
covered by minimum essential coverage for a continuous period
of less than 3 months.
``(B) 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) 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 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) Effective Date.--The amendments made by this section shall
apply to taxable years ending after December 31, 2013.
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. 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 (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 (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.--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:
``subpart d--information regarding health insurance coverage''.
(e) 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. 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. NOTICE TO EMPLOYEES.
``(a) In General.--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.
``(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. 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 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.
``(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.--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..--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.''.
(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). 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) 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. 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) 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,
``(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, 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 (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) 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 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) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2013.
Subtitle G--Miscellaneous Provisions
SEC. 1551. 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. TRANSPARENCY IN GOVERNMENT.
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).
SEC. 1553. 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) 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. 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.
SEC. 1555. 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) 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. 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). 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.
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. 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. 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. 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.
(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. HEALTH INFORMATION TECHNOLOGY ENROLLMENT STANDARDS AND
PROTOCOLS.
``(a) In General.--
``(1) Standards and protocols.--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.
``(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.
``(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 (42 U.S.C. 300gg), as so redesignated by
section 1201(2)--
(A) in subsection (c)--
(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 (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 (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)--
(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 (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 (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 (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'';
(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 (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'';
(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 (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)--
(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) 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) 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) 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) 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.
(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. 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. 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.
(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.--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) 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), 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) 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:
------------------------------------------------------------------------
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.--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.
``(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)), is amended by
inserting after paragraph (1) the following:
``(2) 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) 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''.
(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 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.--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.--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 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),'';
(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.--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) 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 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.--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) 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, 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. 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 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 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.--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.
``(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) 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.
(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) 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) 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'';
(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) 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) 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 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) 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) 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''.
Subtitle B--Enhanced Support for the Children's Health Insurance
Program
SEC. 2101. ADDITIONAL FEDERAL FINANCIAL PARTICIPATION FOR CHIP.
(a) In General.--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.--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.--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 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) 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) 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 implemented under title XIX or
XXI, or both, of the Social Security Act).
SEC. 2102. TECHNICAL CORRECTIONS.
(a) 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, 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 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)), 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 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).
(b) 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. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH STATE
HEALTH INSURANCE EXCHANGES.
``(a) Condition for Participation in Medicaid.--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.--A State shall establish procedures for--
``(A) 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 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).
``(4) Enrollment website requirements.--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) 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 of
presumptive eligibility made by a hospital that elects under
section 1902(a)(47)(B) to be a qualified entity for such purpose''.
(c) 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) 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) 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 matter
preceding clause (i) by striking ``and (21)'' and inserting ``, (21),
and (28)''.
(c) Effective Date.--
(1) In general.--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.--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:
``(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. (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 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) 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.--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.
``(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.--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''.
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.--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) 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,
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) 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 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) 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 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.
``(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) Oversight and Assessment of the Administration of Home and
Community-based Services.--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
(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.
``(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.--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), 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) 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''.
(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) Effective date.--The amendments made by this subsection
take effect 30 days after the date of enactment of this Act.
SEC. 2404. PROTECTION FOR RECIPIENTS OF HOME AND COMMUNITY-BASED
SERVICES AGAINST SPOUSAL IMPOVERISHMENT.
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 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.
``(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.--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.
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
(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) 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.''.
(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) 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).
(2) 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) 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:
``(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 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) 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)'';
(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.--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.--For purposes of subparagraph
(A), the fiscal year described in this subparagraph with
respect to a State is the first fiscal year that 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.--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) 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) 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.
``(B) 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. PROVIDING FEDERAL COVERAGE AND PAYMENT COORDINATION FOR DUAL
ELIGIBLE BENEFICIARIES.
(a) Establishment of Federal Coordinated Health Care Office.--
(1) In general.--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) 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.
(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 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. ADULT HEALTH QUALITY MEASURES.
``(a) Development of Core Set of Health Care Quality Measures for
Adults Eligible for Benefits Under Medicaid.--The 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.--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.--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 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.--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.--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. PAYMENT ADJUSTMENT FOR HEALTH CARE-ACQUIRED CONDITIONS.
(a) In General.--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.
(b) Health Care-Acquired Condition.--In this section. the term
``health care-acquired condition'' means a medical condition for which
an individual was diagnosed that could be identified 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) 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. State Option To Provide Coordinated Care Through a
Health Home for Individuals With Chronic Conditions.--
``(a) 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--
``(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) 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 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
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.--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) 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
(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. 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) 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 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. 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. The Secretary shall select not more than 5 States to participate
in the demonstration project.
(c) Eligible Safety Net Hospital System or Network.--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 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. 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) Minimum participation period.--A provider desiring to be
recognized as an accountable care organization under 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. 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)). 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 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 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)--
(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 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 ``,
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 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.''.
(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, 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) 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) 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.--The amendments made by this section shall
apply to items or services furnished on or after January 1, 2010.
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. 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.--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 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) 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 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.--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.--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).
``(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--
``(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.
``(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
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.--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) 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--
``(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.
``(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) 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 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.
``(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.''.
SEC. 2952. 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 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. 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 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.
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. 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 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 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) 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:
``(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 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)).
``(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) 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 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) 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;
``(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 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 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) 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.--
``(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 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.--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.
``(iii) Website.--Such information shall be posted on
the Hospital Compare Internet website in an easily
understandable format.
``(B) Aggregate information.--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--
(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) 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) 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) 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 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.
(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) Value-Based Purchasing Demonstration Programs.--
(1) Value-based purchasing demonstration program for inpatient
critical access hospitals.--
(A) Establishment.--
(i) In general.--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.
(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.--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--
(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.
``(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) 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.--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
(2) by adding at the end the following new subparagraph:
``(I) Informal appeals process.--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
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 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.
``(E) Public availability of data submitted.--The Secretary
shall establish procedures for making data submitted under
subparagraph (C) available to the public. Such 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. 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 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
fiscal year 2014.
``(E) Public availability of data submitted.--The Secretary
shall establish procedures for making data submitted under
subparagraph (C) available to the public. Such 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. 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).
``(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
fiscal year 2014.
``(E) Public availability of data submitted.--The Secretary
shall establish procedures for making data submitted under
subparagraph (C) available to the public. Such 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. 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 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.--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.--The Secretary
shall establish procedures for making data submitted under
paragraph (4) available to the public. 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. 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, 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
(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.--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 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) beginning on January 1, 2015, with respect to
specific physicians and groups of physicians the
Secretary determines appropriate; and
``(II) 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.--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.--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). 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.--
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.
``(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) 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) 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.--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.
``(3) 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.--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 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. 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
``(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--
``(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.--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. INTERAGENCY WORKING GROUP ON HEALTH CARE QUALITY.
(a) 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;
(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.--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) 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. QUALITY MEASURE DEVELOPMENT.
``(a) Quality Measure.--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.
``(b) Identification of Quality Measures.--
``(1) 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.--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
``(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) 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 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.--
``(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.--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. (a) Multi-stakeholder Group Input Into Selection of
Quality Measures.--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.
``(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.--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) 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
``(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. 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;
``(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.--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. PUBLIC REPORTING OF PERFORMANCE INFORMATION.
``(a) Development of Performance Websites.--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 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. (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.
``(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) 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.
``(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.
``(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) 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, 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.--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) 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) 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;
``(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). 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;
(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. (a) Establishment.--
``(1) In general.--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.
``(B) 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.--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 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.--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 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. 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);
``(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. (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
``(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 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.--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 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.--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.--
``(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.--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.''.
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. (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;
``(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.
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 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.--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 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 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.--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 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.--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.
``(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.--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 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.--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 respect to this title and
posted on the CMS Hospital Compare website.
``(B) Posting of hospital specific all patient readmission
rates.--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. QUALITY IMPROVEMENT PROGRAM FOR HOSPITALS WITH A HIGH
SEVERITY ADJUSTED READMISSION RATE.
``(a) Establishment.--
``(1) In general.--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.--As determined appropriate by the
Secretary, eligible hospitals and patient safety organizations 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. 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.--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 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.
(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) 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.''.
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 (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 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) 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 (Public Law 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) 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) 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 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) 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) Administration.--Notwithstanding any other provision of law,
the Secretary may implement the amendments made by subsection (a) by
program instruction or otherwise.
(c) 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) 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''.
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) 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''.
SEC. 3113. 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
(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: ``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. 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. 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 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
(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--
(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) 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--
(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) 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 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), is amended--
(1) in the section heading, by striking ``one-year'' and
inserting ``temporary''; and
(2) in subsection (a)--
(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) 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 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) 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. 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--
``(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) 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 (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.--
``(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.''.
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 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) 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 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.--
Section 1868(a) of the Social Security Act (42 U.S.C. 1395ee(a)) is
repealed.
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) 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 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.--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''.
(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) Effective Date.--
(1) 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), is amended by striking ``September 30, 2009''
and inserting ``September 30, 2010''.
(2) 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) Plan for Reforming the Medicare Hospital Wage Index System.--
(1) In general.--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;
(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.--
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:
``(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) 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. 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 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. 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
(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. 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--
``(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 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 (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.--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 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.--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) 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
``(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))--
(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) 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.--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;
``(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.--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.--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 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.--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.--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 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.--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. 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.--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.--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.--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.--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.--
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
``(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.--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.--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--
``(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.--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.
``(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.--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) 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.--For plan years beginning on or
after January 1, 2012, a rebate required under 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. 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) 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.--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).''.
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 (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.--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) 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 (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.''.
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.--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.--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) 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.--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) 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.--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 (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
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. TECHNICAL CORRECTION TO MA PRIVATE FEE-FOR-SERVICE PLANS.
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.
``(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.--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.--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) 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 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. 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. (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) the Secretary has made a determination that the
availability of the drug is essential to the health of
beneficiaries under this part; or
``(2) 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. (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. 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) 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.--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 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.--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. 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.--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.--Administering the
program, including--
``(i) 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, 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).
``(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.--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.--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--
``(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--
``(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 program under section 1860D-14A, regardless of whether
part of such costs were paid by a manufacturer under such
program.''.
(2) Effective date.--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) 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) Effective Date.--The amendment made by subsection (a) shall
apply to premiums for months beginning on or after January 1, 2011.
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.--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) 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.''.
(b) 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.--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.
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) 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).
``(iii) 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) 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-related
increase in the base beneficiary premium under this paragraph.
``(E) 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, 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) 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 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) Effective Date.--The amendment made by subsection (a) shall
apply to plan years beginning on or after January 1, 2012.
SEC. 3311. 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 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) Effective Date.--The amendment made by subsection (a) shall
apply to exceptions and appeals on or after January 1, 2012.
SEC. 3313. 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 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--
``(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) 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) 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) 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) 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) 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 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) 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--
``(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.
``(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) 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--
``(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, 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--
``(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) 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--
``(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--
``(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.''.
(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
(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) 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--
(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) 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. (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, 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 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.--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. The Board shall submit such draft
copy by not later than September 1 of the determination year.
``(E) Review and comment by the secretary.--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. 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.--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);
``(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)). 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.--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
``(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.--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.
``(d) Congressional Consideration.--
``(1) 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) 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.
``(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 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.--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.--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.
``(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.--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 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 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) 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.--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.--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 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.--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.
``(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) 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) 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.--The President shall establish a
system for public disclosure by appointed members 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.--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.--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.
``(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.--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 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.--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.--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.
``(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.--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) 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 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.--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:
``Subpart II--Health Care Quality Improvement Programs
``SEC. 933. 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;
``(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
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.--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;
``(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. 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.
``(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;
``(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.--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. 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) submit a plan for achieving long-term financial
sustainability within 3 years;
(3) 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
(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) 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 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) 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) provide a care plan to the care team for each patient
participant;
(2) 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.
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. 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. The Secretary shall commence the program under this
section not later than May 1, 2010.
``(b) 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;
``(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. 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;
``(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) 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. 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) 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.
``(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 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 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 section 1232--
(A) in subsection (a), by striking ``appropriated'' and all
that follows through the period at the end and inserting
``appropriated $24,000,000 for each of fiscal years 2010
through 2014.''; and
(B) by inserting after subsection (c) the following:
``(d) Authority.--For 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. 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.''.
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.
``(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 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).
``(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 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 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. 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. 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. 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--
``(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 following shall apply with
respect to grants provided in this part:
``(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. 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. 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.--
``(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 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)--
``(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 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 OF PRESCRIPTION DRUG BENEFIT AND RISK
INFORMATION.
(a) In General.--The 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 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 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 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 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.--
(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 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 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.--
``(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 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 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--
``(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 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:
``SEC. 925. 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 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;
``(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 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
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 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 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 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''.
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 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 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 PREVENTION, HEALTH PROMOTION AND PUBLIC HEALTH
COUNCIL.
(a) Establishment.--The 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 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;
(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 Group.--
(1) In general.--The 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
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 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 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 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 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 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 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.
``(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 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 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 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)) is redesignated as section 399S.
(B) Section 399R of such Act (as added by section 3 of the
Prenatally and Postnatally Diagnosed Conditions Awareness Act
(Public Law 110-374; 122 Stat. 4051)) is redesignated as
section 399T.
SEC. 4004. EDUCATION 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.
(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 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 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 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, 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 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 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 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. 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 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, 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, 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 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 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 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 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 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 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 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 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 components shall be
updated by the Secretary at least every 6 years. For 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.
(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).
``(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 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.
``(B) Not 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 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 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 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 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.--
(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
(2) in paragraph (7), by striking ``or (K)'' and inserting
``(K), or (P)''.
(e) Effective 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.
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 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:
``(n) Authority To Modify or Eliminate Coverage of Certain
Preventive Services.--Notwithstanding 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 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 assistance for such
services and vaccines and for items and services described in
subsection (a)(4)(D)''.
(c) Effective 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 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''.
(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 Date.--The amendments made by this section shall take
effect on October 1, 2010.
SEC. 4108. INCENTIVES 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 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 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 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.
(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;
(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 to the Secretary on processes that have been
developed and lessons learned from the program; and
(5) report on preventive services as part of reporting on
quality measures for Medicaid managed care programs.
(d) Evaluations and Reports.--
(1) Independent 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.
(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 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.--
(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;
(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 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;
(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 under this section shall
maintain records of screening results under this
subparagraph to establish the baseline data for monitoring
the targeted population
(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.
(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 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 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 OF STANDARDS FOR ACCESSIBLE MEDICAL
DIAGNOSTIC EQUIPMENT.
``(a) Standards.--Not 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.).''.
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 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;
``(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 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 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;
(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 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.--
``(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 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 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 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 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 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
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.
``(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 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. DATA COLLECTION, ANALYSIS, AND QUALITY.
``(a) Data Collection.--
``(1) In 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 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 national standards for the management of data
collected; and
``(B) develop interoperability and security systems for
data management.
``(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 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
``(B) all appropriate information security safeguards are
used in the collection, analysis, and sharing of data collected
pursuant to subsection (a).
``(2) Data 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:
``SEC. 1946. 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 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:
``PART U--EMPLOYER-BASED WELLNESS PROGRAM
``SEC. 399MM. 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. NATIONAL WORKSITE HEALTH POLICIES AND PROGRAMS STUDY.
``(a) In 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. 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. PROHIBITION OF FEDERAL WORKPLACE WELLNESS REQUIREMENTS.
``Notwithstanding any other provision of this part, any
recommendations, data, or assessments carried out under this part 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. 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 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'').
(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. 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 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.
``(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 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.
``(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 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.
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 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) 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. 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. 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
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 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].
``(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
``(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. 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 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 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 shall be filled in the
manner in which the original appointment was made.
(C) Initial appointments.--The 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
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 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);
(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.--
(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 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 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 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 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 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
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, 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.--
(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 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;
(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 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
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, 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 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).
``(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 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 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 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.''.
(2) Advisory committee on interdisciplinary, community-based
linkages.--Section 756(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.''.
(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.''.
(b) Student 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 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 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--
``(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 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).
``(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 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,
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 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 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 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 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''.
(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 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) 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 purpose of this section is to fund the
development and operation of nurse-managed health clinics.
(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. 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 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. 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''.
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 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 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.
``(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. 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 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;
``(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 OPPORTUNITIES FOR DIRECT CARE WORKERS.
``(a) In General.--The 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 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, 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. 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 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 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 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. DEMONSTRATION PROGRAM.
``(a) In General.--
``(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.--Beginning 1 year after
the enactment of this section, the Secretary may disperse to
any entity receiving a grant under this section 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) 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.--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 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. 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.
``(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.--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)) 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, 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) 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''.
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) striking section 757;
(2) redesignating section 756 (as amended by section 5103) as
section 757; and
(3) inserting after section 755 the following:
``SEC. 756. 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 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
``(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), 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,
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
(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. 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.
``(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 (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, by striking the
term ``this subpart'' each place it appears and inserting ``this
part'';
(3) in section 836(h), by striking the last sentence;
(4) in section 836, by redesignating subsection (l) as
subsection (k);
(5) in section 839, by striking ``839'' and all that follows
through ``(a)'' and inserting ``839. (a)'';
(6) in section 835(b), by striking ``841'' each place it
appears and inserting ``871'';
(7) by redesignating section 841 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 as section 851; and
(B) by redesignating part G as part F;
(9) in part H--
(A) by redesignating sections 851 and 852 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, 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 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. 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) 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.--
``(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. 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:
``SEC. 399V. 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 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.--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
``(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. 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:
``PART D--UNITED STATES PUBLIC HEALTH SCIENCES TRACK
``SEC. 271. 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. ADMINISTRATION.
``(a) In General.--The business of the Track shall be conducted by
the Surgeon General with funds appropriated for and provided 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) 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 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. 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 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
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) 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) 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.
``SEC. 274. FUNDING.
``Beginning 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) Formula for Allocations.--
``(1) 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 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.''.
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) 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 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.--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.
``(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;
``(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. 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.
``(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
and inserting the following:
``SEC. 752. CONTINUING EDUCATIONAL SUPPORT FOR HEALTH PROFESSIONALS
SERVING IN UNDERSERVED COMMUNITIES.
``(a) In General.--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.--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 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. 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 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) 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) 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--
``(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) 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
Secretary an application, at such time, in such manner, and
containing such information as the Secretary may require.
``(3) 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.--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.--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--
``(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) 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.--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 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.--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 (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.--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 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.--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.--
``(A) Reductions in limit based on unused positions.--
``(i) 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) 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).
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) 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:
``(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.--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) 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.''.
(c) Conforming Amendment.--Section 422(b)(2) of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003 (Public
Law 108-173) 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. 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) 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 ``(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.''.
(c) 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. 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) 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) 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
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) 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) 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 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.--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) 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) 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 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. 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.
``(C) Assurance of opportunities for indian populations.--
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) 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).
``(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.--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) 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
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.--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--
``(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) 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 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.--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. 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.
``(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).
``(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) 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. 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 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) 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 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) 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.
``(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) 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.--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 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. 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) 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.
(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) 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 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:
``(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. 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--
(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) 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) 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.
(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) Interim Final Effect.--The Secretary shall publish a rule under
this section in the Federal Register by not later than the target
publication date. 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. 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) 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, 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) 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. 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 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) 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 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) 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).
(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) 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.
(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. 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).'';
(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) 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) 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.--
``(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.
``(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) 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) 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 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) 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 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) 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) 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. 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).
``(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.
``(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.--
``(A) 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) 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, 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 (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 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.
``(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).''.
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.--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. 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
``(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. 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 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.--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) 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 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.--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 paragraph (2)
to the Secretary in a standardized format, and such other
regulations as are necessary to carry out this subsection. 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;
``(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.--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) 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. 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.--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) Development of regulations.--
``(A) In general.--Not later than the date that is 2 years
after such date of the enactment, the Secretary, 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. 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.--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 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.--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. 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. 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.--
``(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
``(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.--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) 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) 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:
``(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.
``(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.--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) 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) 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 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.--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) 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
``(ii) 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.--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.--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) 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) 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.
(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.--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) Standardized Complaint Form.--
``(1) Development by the secretary.--The Secretary shall
develop a standardized complaint form for use by a resident (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) 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, is amended by adding at the end the following new subsection:
``(g) Submission of Staffing Information Based on Payroll Data in a
Uniform Format.--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,
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.--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.--In the
case of a civil money penalty imposed under this
clause, the Secretary shall issue regulations that--
``(aa) subject 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) 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.--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.--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.--In the
case of a civil money penalty imposed under this
clause, the Secretary shall issue regulations that--
``(aa) subject 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) 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) Effective Date.--The amendments made by this section shall take
effect 1 year after the date of the enactment of this Act.
SEC. 6112. 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 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.--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.--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.--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) 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) 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) publish the results of such reviews, analyses, and
oversight.
(d) Implementation of Recommendations.--
(1) Receipt of finding by chain.--Not later than 10 days after
receipt of a finding of an independent monitor under subsection
(c)(4), 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.
(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. 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, 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--
``(A) 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) 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.--
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.--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)''.
(c) Effective Date.--The amendments made by this section shall take
effect 1 year after the date of the enactment of this Act.
SEC. 6114. 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.--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.--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
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) 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. 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.--
(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 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) 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 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.--
(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:
(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 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. (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
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) 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 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.
``(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, 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 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.--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 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). 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) 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.--The Institute shall, not later than 90
days after the conduct or receipt of research findings under
this part, make such research findings available 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) 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.
``(2) Nondelegable duties.--The activities described in
subsections (d)(1) and (d)(9) are nondelegable.
``(f) Board of Governors.--
``(1) 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) 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.--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 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 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.--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.--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.--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) Notice of public comment periods under paragraph (1),
including deadlines for public comments.
``(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.--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. DISSEMINATION AND BUILDING CAPACITY FOR RESEARCH.
``(a) In General.--
``(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. 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 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. (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--
``(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. (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.''.
(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. 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.
``(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.--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. HEALTH INSURANCE.
``(a) Imposition of Fee.--There is hereby imposed on each specified
health insurance policy for each policy year ending after 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.--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. 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.--For purposes of paragraph (1) the term
`plan sponsor' means--
``(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.--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.
``SEC. 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:
``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 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. FEDERAL COORDINATING COUNCIL FOR COMPARATIVE EFFECTIVENESS
RESEARCH.
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.--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.
``(B) Level of screening.--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.--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 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.--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.--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.
``(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.--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.--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 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.--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).
``(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.--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.--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) Disclosure of medicare terminated providers and suppliers
to states.--The Administrator of the Centers for 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. 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
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.--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, 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.--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.--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) 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)), 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.--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)) 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) 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.
``(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 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) 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;
``(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) 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 (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 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.--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) 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--
(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 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 (42 U.S.C. 1396u-7(e)) is amended--
(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:
``(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.--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.--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;'';
(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) establish procedures for the case where the health
care practitioner or entity disputes the accuracy of the
information reported.
``(2) Corrections.--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--
``(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) 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.). 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 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.--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.--
(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) 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.--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 (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) 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 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) 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) 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 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
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
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) 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) 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--
(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
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-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) 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. MEDICARE SELF-REFERRAL DISCLOSURE PROTOCOL.
(a) Development of Self-Referral Disclosure Protocol.--
(1) 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:
(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.--
(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) 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''.
(2) 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) 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.
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) 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 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) 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 (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) 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) 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.
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) 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) 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) 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. 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) 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 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. 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.''.
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. 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. 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:
``SEC. 521. 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:
``(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) 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--Elder Justice Act
SEC. 6701. SHORT TITLE OF SUBTITLE.
This subtitle may be cited as the ``Elder Justice Act of 2009''.
SEC. 6702. 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. 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.
``(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.
``(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)).
``(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. 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.
``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. 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) 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 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. 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) 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.
``(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) 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;
``(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. 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.
``SEC. 2024. 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. 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 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. 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) 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) Specific programs to improve management practices.--
``(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 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.--
``(A) 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. 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
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.--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;
``(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. 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. 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 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. 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--
``(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. 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) Effective date.--The amendment made by subparagraph (A)
shall take effect on January 1, 2011.
(b) Protecting Residents of Long-Term Care Facilities.--
(1) National training institute for surveyors.--
(A) In general.--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.
(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;
(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. (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--
``(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.
``(e) Procedure.--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).
(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, by striking ``title''
and inserting ``subtitle''; and
(B) in subtitle 1, 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)--
(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), by inserting ``subtitle 1 of'' before ``title XX''
each place it appears.
(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)--
(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), 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--Biologics Price Competition and Innovation
SEC. 7001. 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:
``(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) shall include publicly-available information
regarding the Secretary's previous determination that
the reference product is safe, pure, and potent; and
``(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) 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.--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 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).
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 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--
``(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.--
``(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 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.--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
``(B) may provide to the reference product sponsor
additional information requested by or on behalf of the
reference product sponsor.
``(3) 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 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.--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.--
``(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.--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) Immediate patent infringement action.--
``(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.--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) 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.--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 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:
``(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:
``(D) 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) 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:
``(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) 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) 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.--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.--Beginning not later than October 1, 2010,
the Secretary shall develop recommendations to 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. 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) publish such recommendations in the Federal
Register;
(iii) 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.--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) 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) Evaluation of costs of reviewing biosimilar biological
product applications.--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 Public Health Service Act (as added
by this Act) during such period.
(C) Audit.--
(i) 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 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 (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 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 (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;
``(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) 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. 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 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
``(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 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) 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:
``(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 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.
``(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) 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) 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) 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) 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 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 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) require that a manufacturer conduct an audit of
a covered entity pursuant to subsection (a)(5)(D) 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 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:
(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
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. 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. 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 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 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. 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 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 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) 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.
``(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 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. 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) 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;
``(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 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) 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. ENROLLMENT AND DISENROLLMENT REQUIREMENTS.
``(a) 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) 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 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 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, 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. 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 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 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) 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 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 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
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) 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 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 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--
``(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) 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--
``(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) 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) 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) 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.
``(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. 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) 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 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) 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) 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) be printed as a House document of the session of
the Congress to which the report is made.
``(C) 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. 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) 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) 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.--
``(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. SOLVENCY AND FISCAL INDEPENDENCE; REGULATIONS; ANNUAL
REPORT.
``(a) 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. 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) 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. 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.
``SEC. 3210. 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) 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) 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) 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) Personal Care Attendants Workforce Advisory Panel.--
(1) 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 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) Effective Date.--The amendments made by subsections (a), (b),
and (d) take effect on January 1, 2011.
(f) 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:
``SEC. 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) 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 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) 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) 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--
``(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) 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) 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 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.
``(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, 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) 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 (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
``(B) the amount of any salary reduction contributions to a
flexible spending arrangement (within the meaning of section
125).''.
(b) 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 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 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 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) 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) 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) 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
is amended--
(1) by redesignating subsections (i) and (j) as subsections (j)
and (k), respectively, and
(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) 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
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 (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) 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.--
``(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) 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
``(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) 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. 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) Mandatory Review of Tax Exemption for Hospitals.--The Secretary
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
(relating to certain organizations described in section 501(c)(3))
is amended by striking ``and'' at the end 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) 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) Effective Dates.--
(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. IMPOSITION OF ANNUAL FEE ON BRANDED PRESCRIPTION
PHARMACEUTICAL MANUFACTURERS AND IMPORTERS.
(a) 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) 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.
(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 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) 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) 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.
(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) 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.
The Centers 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) 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 is amended by inserting ``or section 9008(c) of the Patient
Protection and Affordable Care Act of 2009'' after ``this part''.
SEC. 9009. IMPOSITION OF ANNUAL FEE ON MEDICAL DEVICE MANUFACTURERS AND
IMPORTERS.
(a) 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 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) 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. 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) 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.
(g) Secretary.--For purposes of this section, the term
``Secretary'' means the Secretary of the Treasury or the Secretary's
delegate.
(h) 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 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. IMPOSITION OF ANNUAL FEE ON HEALTH INSURANCE PROVIDERS.
(a) 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) 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.
(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) 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) 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) 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.
(e) 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) 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) 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) Guidance.--The Secretary shall publish guidance necessary to
carry out the purposes of this section.
(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
is amended by striking the second sentence.
(b) 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 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) 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 is amended by striking ``by substituting `10
percent' for `7.5 percent''' and inserting ``without regard to
subsection (f) of such section''.
(d) 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 is amended by adding at the end the following new subparagraph:
``(6) Special rule for application to certain health insurance
providers.--
``(A) In general.--No deduction shall be allowed under this
chapter--
``(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 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) 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) 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)) 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 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 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) is amended by inserting
``(determined without regard to the rate imposed under
paragraph (2) of section 1401(b))'' after ``for such year''.
(c) 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 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) 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. 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 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) 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. 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) 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 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) 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) 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
(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
``(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 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) Effective Date.--The amendments made by this section shall
apply to years beginning after December 31, 2010.
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. 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,
``(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) 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,
``(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) 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 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 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
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) 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 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) 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) 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.
(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) 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 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) 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. 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 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, 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. 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. 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, 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
``(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. 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
``(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 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) 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, 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 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) Enforcement.--The Secretary shall promulgate regulations
for enforcing the provisions of this section and may provide for
appropriate penalties.
``(c) 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. 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 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. 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 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.
``(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 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, 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) 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) 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) 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.''.
SEC. 10102. AMENDMENTS TO SUBTITLE B.
(a) 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) 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, 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, 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. 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--
``(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) 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 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) 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.
``(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) 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) 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. 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--
``(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) 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 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) 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. SPECIAL RULES.
``(a) State Opt-out of Abortion Coverage.--
``(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--
``(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.--
``(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').''.
(d) Section 1304 of this Act is amended by adding at the end the
following:
``(e) 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) 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) 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. 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. 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 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. 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) 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) 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) 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) 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) 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 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) 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) 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) 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) Part III of subtitle D of title I of this Act is amended by
striking section 1323.
(n) 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) 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) 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. 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
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;
``(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 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) 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.
``(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) 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) 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, 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) 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) 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, is amended by striking ``2011'' and
inserting ``2010, 2011''.
(4) Section 1421(f) of this Act is amended by striking ``2010''
both places it appears and inserting ``2009''.
(5) 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. If the Secretary determines that an adjustment is feasible, the
study should include a methodology to make such an adjustment. 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) 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.
``(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 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, 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.''.
(3) Section 5000A(c)(3) of the Internal Revenue Code of 1986, as
added by section 1501(b) of this Act, 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, 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) 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 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) 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, 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 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) 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, 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) 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. 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. 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) 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 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) 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. 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) 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 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.''.
(2) 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, 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) 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 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) 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, 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, 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) 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, 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) 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
(B) by adding at the end the following new paragraph:
``(5) Consideration of standardization of activities and
items.--
``(A) 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) 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) 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 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) 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
assistance shall be made available to the individual through subclause
(IX) instead of through subclause (VIII)'' before the semicolon.
(3) 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) 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) 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--
``(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) 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) 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''.
(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) 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 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:
``(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 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, 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) 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) The Secretary shall annually report to Congress concerning
actions taken by the Secretary with respect to applications for
demonstration projects under this section.''.
(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. 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--
(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) 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.
(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.--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) ``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) 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.
(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.
(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 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) 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) 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) 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
(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) 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.--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.''.
(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) 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
(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) 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) 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 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 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 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. 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.
(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. 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. 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:
(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--
(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.--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.
(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) 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. 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. 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.--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.--
(1) Section 119 of the Indian Health Care Improvement Act (as
amended by section 111 of the bill referred to in subsection (a))
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 (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.--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) 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 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, 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), is amended by adding at the end the following
new subsection:
``(f) Development of Outcome Measures.--
``(1) In general.--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 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), is amended by adding at
the end the following new subsection:
``(f) Hospital Acquired Conditions.--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) is amended by adding at the end the following new paragraph:
``(4) Identification.--
``(A) In general.--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, 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, is amended to read as follows:
``(a) In General.--
``(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,
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
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) 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,
is amended by adding at the end the following new subsections:
``(i) Option To Use Other Payment Models.--
``(1) In general.--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 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) 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) 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) 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.--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, 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.--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) the Chief Actuary of the Centers for Medicare &
Medicaid Services certifies that such expansion would
reduce program spending under such title XVIII; and
``(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) 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 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, 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, 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, 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
(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), 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,
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) 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.
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 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, 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) 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 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.
``(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) 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, is amended--
(1) in clause (i)--
(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:
``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. 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) 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--
``(i) a reclassification of its wage index for purposes
of such section was extended pursuant to the amendment made
by paragraph (1); and
``(ii) 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), 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), 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:
``(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), 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), 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), 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, is amended--
(1) in subsection (c)--
(A) in paragraph (1)(B), by adding at the end the following
new sentence: ``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) 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.'';
(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'';
(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) 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 (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.--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.--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.--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) 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), is amended by adding at the end the following
new paragraph:
``(4) 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 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.--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. The Secretary shall report quality measures that
relate to services furnished in inpatient settings in
psychiatric hospitals and 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, 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. 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
``(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.
``(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--
``(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. 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.
``(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 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).''.
(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.--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 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. PILOT TESTING PAY-FOR-PERFORMANCE PROGRAMS FOR CERTAIN
MEDICARE PROVIDERS.
(a) In General.--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) 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--
(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) 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.--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 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 is amended by adding at
the end the following new paragraph:
``(3) Authority.--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)).''.
(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) 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.
``(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) 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.--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.
(c) Posting of Plan.--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. PUBLIC REPORTING OF PERFORMANCE INFORMATION.
(a) In General.--
(1) Development.--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.--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, 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.--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 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
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) 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 evidence in judicial or administrative
proceedings without consent of the applicable provider of
services or supplier.''.
(b) 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. 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.
``(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) 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. 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) 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 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.--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. 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. 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 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) 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) 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 sections 485E through 485H as
sections 464z-3 through 464z-6, respectively;
(ii) 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) 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, 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.''.
(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, 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 is amended by striking
``2010'' each place such appears and inserting ``2020''.
(b) Section 4002(c) of this Act is amended--
(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 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, 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), 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 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, 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)--
``(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. 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) 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 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.--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:
(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. 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. 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 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) 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.
``(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;
``(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.--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.
``(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.--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
``(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.--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.--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.
``(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. 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. 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.--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--
``(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 to provide mental
health, social, and human services to individuals with
depressive disorders.
``(6) National coordinating center.--
``(A) In general.--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
``(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 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.--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. 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:
``SEC. 399V-2. 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:
``SEC. 425. 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. 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:
``PART V--PROGRAMS RELATING TO BREAST HEALTH AND CANCER
``SEC. 399NN. 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.--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.--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.--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 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.--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.
``(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 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:
``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.--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, 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]''.
(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. 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;
``(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, 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, 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, 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:
``SEC. 399V-3. 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 are repealed.
(i)(1) The provisions of, and amendments made by, section 5502 of
this Act 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) 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.
``(B) Collection of data and evaluation.--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 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 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. 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:
``Subpart II--Training in Underserved Communities
``SEC. 749B. 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.
``(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.--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.--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.
``(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
``(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) 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.--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
(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. 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.--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. DEMONSTRATION PROJECT TO PROVIDE ACCESS TO AFFORDABLE CARE.
(a) In General.--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.
The Secretary shall evaluate the feasibility of expanding the project
to additional States.
(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), 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) 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)
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.''.
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), 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
(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) 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--
(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.
(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. 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 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. 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;
``(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.--
``(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.--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 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.--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 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:
``(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) 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. 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) 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;
``(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) 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--
(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--
(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, 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, is amended by
inserting ``individuals whose primary 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) 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, 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.--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) 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, is
amended by striking ``the lowest amounts charged'' and inserting ``the
amounts generally billed''.
(b) 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 is amended--
(1) by striking ``2009'' in subsection (a)(1) and inserting
``2010'',
(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) Effective Date.--The amendments made by this section shall take
effect as if included in the enactment of section 9009.
SEC. 10905. 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
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
``(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.
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, 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, is amended by
striking ``0.5 percent'' and inserting ``0.9 percent''.
(c) 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) 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. 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.--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.--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:
``Chapter 49--Cosmetic Services''.
(d) 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 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) 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 (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) 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--
``(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 (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) 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, 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.
(2) Conforming amendments.--
(A) Section 24(b)(3)(B) of such Code is amended by striking
``23,''.
(B) Section 25(e)(1)(C) of such Code is amended by striking
``23,'' both places it appears.
(C) Section 25A(i)(5)(B) of such Code is amended by
striking ``23, 25D,'' and inserting ``25D''.
(D) Section 25B(g)(2) of such Code is amended by striking
``23,''.
(E) Section 26(a)(1) of such Code is amended by striking
``23,''.
(F) Section 30(c)(2)(B)(ii) of such Code is amended by
striking ``23, 25D,'' and inserting ``25D''.
(G) Section 30B(g)(2)(B)(ii) of such Code is amended by
striking ``23,''.
(H) Section 30D(c)(2)(B)(ii) of such Code is amended by
striking ``sections 23 and'' and inserting ``section''.
(I) Section 36C of such Code, 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 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 is amended by striking
``23,''.
(L) Section 1016(a)(26) is amended by striking ``23(g)''
and inserting ``36C(g)''.
(M) Section 1400C(d) of such Code is amended by striking
``23,''.
(N) Section 6211(b)(4)(A) of such Code 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) 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.
(d) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2009.
Speaker of the House of Representatives.
Vice President of the United States and
President of the Senate.