[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3962 Introduced in House (IH)]
111th CONGRESS
1st Session
H. R. 3962
To provide affordable, quality health care for all Americans and reduce
the growth in health care spending, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
October 29, 2009
Mr. Dingell (for himself, Mr. Rangel, Mr. Waxman, Mr. George Miller of
California, Mr. Stark, Mr. Pallone, and Mr. Andrews) introduced the
following bill; which was referred to the Committee on Energy and
Commerce, and in addition to the Committees on Education and Labor,
Ways and Means, Oversight and Government Reform, the Budget, Rules,
Natural Resources, and the Judiciary, for a period to be subsequently
determined by the Speaker, in each case for consideration of such
provisions as fall within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To provide affordable, quality health care for all Americans and reduce
the growth in health care spending, and for other purposes.
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 DIVISIONS, TITLES, AND SUBTITLES.
(a) Short Title.--This Act may be cited as the ``Affordable Health
Care for America Act''.
(b) Table of Divisions, Titles, and Subtitles.--This Act is divided
into divisions, titles, and subtitles as follows:
DIVISION A--AFFORDABLE HEALTH CARE CHOICES
TITLE I--IMMEDIATE REFORMS
TITLE II--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS
Subtitle A--General Standards
Subtitle B--Standards Guaranteeing Access to Affordable Coverage
Subtitle C--Standards Guaranteeing Access to Essential Benefits
Subtitle D--Additional Consumer Protections
Subtitle E--Governance
Subtitle F--Relation to Other Requirements; Miscellaneous
TITLE III--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS
Subtitle A--Health Insurance Exchange
Subtitle B--Public Health Insurance Option
Subtitle C--Individual Affordability Credits
TITLE IV--SHARED RESPONSIBILITY
Subtitle A--Individual Responsibility
Subtitle B--Employer Responsibility
TITLE V--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986
Subtitle A--Shared Responsibility
Subtitle B--Credit for Small Business Employee Health Coverage Expenses
Subtitle C--Disclosures To Carry Out Health Insurance Exchange
Subsidies
Subtitle D--Other Revenue Provisions
DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS
TITLE I--IMPROVING HEALTH CARE VALUE
Subtitle A--Provisions related to Medicare part A
Subtitle B--Provisions Related to Part B
Subtitle C--Provisions Related to Medicare Parts A and B
Subtitle D--Medicare Advantage Reforms
Subtitle E--Improvements to Medicare Part D
Subtitle F--Medicare Rural Access Protections
TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A--Improving and Simplifying Financial Assistance for Low
Income Medicare Beneficiaries
Subtitle B--Reducing Health Disparities
Subtitle C--Miscellaneous Improvements
TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND
COORDINATED CARE
TITLE IV--QUALITY
Subtitle A--Comparative Effectiveness Research
Subtitle B--Nursing Home Transparency
Subtitle C--Quality Measurements
Subtitle D--Physician Payments Sunshine Provision
Subtitle E--Public Reporting on Health Care-Associated Infections
TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION
TITLE VI--PROGRAM INTEGRITY
Subtitle A--Increased funding to fight waste, fraud, and abuse
Subtitle B--Enhanced penalties for fraud and abuse
Subtitle C--Enhanced Program and Provider Protections
Subtitle D--Access to Information Needed to Prevent Fraud, Waste, and
Abuse
TITLE VII--MEDICAID AND CHIP
Subtitle A--Medicaid and Health Reform
Subtitle B--Prevention
Subtitle C--Access
Subtitle D--Coverage
Subtitle E--Financing
Subtitle F--Waste, Fraud, and Abuse
Subtitle G--Puerto Rico and the Territories
Subtitle H--Miscellaneous
TITLE VIII--REVENUE-RELATED PROVISIONS
TITLE IX--MISCELLANEOUS PROVISIONS
DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT
TITLE I--COMMUNITY HEALTH CENTERS
TITLE II--WORKFORCE
Subtitle A--Primary Care Workforce
Subtitle B--Nursing Workforce
Subtitle C--Public Health Workforce
Subtitle D--Adapting Workforce to Evolving Health System Needs
TITLE III--PREVENTION AND WELLNESS
TITLE IV--QUALITY AND SURVEILLANCE
TITLE V--OTHER PROVISIONS
Subtitle A--Drug Discount for Rural and Other Hospitals; 340B Program
Integrity
Subtitle B--Programs
Subtitle C--Food and Drug Administration
Subtitle D--Community Living Assistance Services and Supports
Subtitle E--Miscellaneous
DIVISION D--INDIAN HEALTH CARE IMPROVEMENT
TITLE I--AMENDMENTS TO INDIAN LAWS
TITLE II--IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER THE SOCIAL
SECURITY ACT
DIVISION A--AFFORDABLE HEALTH CARE CHOICES
SEC. 100. PURPOSE; TABLE OF CONTENTS OF DIVISION; GENERAL DEFINITIONS.
(a) Purpose.--
(1) In general.--The purpose of this division is to provide
affordable, quality health care for all Americans and reduce
the growth in health care spending.
(2) Building on current system.--This division achieves
this purpose by building on what works in today's health care
system, while repairing the aspects that are broken.
(3) Insurance reforms.--This division--
(A) enacts strong insurance market reforms;
(B) creates a new Health Insurance Exchange, with a
public health insurance option alongside private plans;
(C) includes sliding scale affordability credits;
and
(D) initiates shared responsibility among workers,
employers, and the Government;
so that all Americans have coverage of essential health
benefits.
(4) Health delivery reform.--This division institutes
health delivery system reforms both to increase quality and to
reduce growth in health spending so that health care becomes
more affordable for businesses, families, and Government.
(b) Table of Contents of Division.--The table of contents of this
division is as follows:
Sec. 100. Purpose; table of contents of division; general definitions.
TITLE I--IMMEDIATE REFORMS
Sec. 101. National high-risk pool program.
Sec. 102. Ensuring value and lower premiums.
Sec. 103. Ending health insurance rescission abuse.
Sec. 104. Sunshine on price gouging by health insurance issuers.
Sec. 105. Requiring the option of extension of dependent coverage for
uninsured young adults.
Sec. 106. Limitations on preexisting condition exclusions in group
health plans in advance of applicability of
new prohibition of preexisting condition
exclusions.
Sec. 107. Prohibiting acts of domestic violence from being treated as
preexisting conditions.
Sec. 108. Ending health insurance denials and delays of necessary
treatment for children with deformities.
Sec. 109. Elimination of lifetime limits.
Sec. 110. Prohibition against postretirement reductions of retiree
health benefits by group health plans.
Sec. 111. Reinsurance program for retirees.
Sec. 112. Wellness program grants.
Sec. 113. Extension of COBRA continuation coverage.
Sec. 114. State Health Access Program grants.
Sec. 115. Administrative simplification.
TITLE II--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS
Subtitle A--General Standards
Sec. 201. Requirements reforming health insurance marketplace.
Sec. 202. Protecting the choice to keep current coverage.
Subtitle B--Standards Guaranteeing Access to Affordable Coverage
Sec. 211. Prohibiting preexisting condition exclusions.
Sec. 212. Guaranteed issue and renewal for insured plans and
prohibiting rescissions.
Sec. 213. Insurance rating rules.
Sec. 214. Nondiscrimination in benefits; parity in mental health and
substance abuse disorder benefits.
Sec. 215. Ensuring adequacy of provider networks.
Sec. 216. Requiring the option of extension of dependent coverage for
uninsured young adults.
Sec. 217. Consistency of costs and coverage under qualified health
benefits plans during plan year.
Subtitle C--Standards Guaranteeing Access to Essential Benefits
Sec. 221. Coverage of essential benefits package.
Sec. 222. Essential benefits package defined.
Sec. 223. Health Benefits Advisory Committee.
Sec. 224. Process for adoption of recommendations; adoption of benefit
standards.
Subtitle D--Additional Consumer Protections
Sec. 231. Requiring fair marketing practices by health insurers.
Sec. 232. Requiring fair grievance and appeals mechanisms.
Sec. 233. Requiring information transparency and plan disclosure.
Sec. 234. Application to qualified health benefits plans not offered
through the Health Insurance Exchange.
Sec. 235. Timely payment of claims.
Sec. 236. Standardized rules for coordination and subrogation of
benefits.
Sec. 237. Application of administrative simplification.
Sec. 238. State prohibitions on discrimination against health care
providers.
Sec. 239. Protection of physician prescriber information.
Sec. 240. Dissemination of advance care planning information.
Subtitle E--Governance
Sec. 241. Health Choices Administration; Health Choices Commissioner.
Sec. 242. Duties and authority of Commissioner.
Sec. 243. Consultation and coordination.
Sec. 244. Health Insurance Ombudsman.
Subtitle F--Relation to Other Requirements; Miscellaneous
Sec. 251. Relation to other requirements.
Sec. 252. Prohibiting discrimination in health care.
Sec. 253. Whistleblower protection.
Sec. 254. Construction regarding collective bargaining.
Sec. 255. Severability.
Sec. 256. Treatment of Hawaii Prepaid Health Care Act.
Sec. 257. Actions by State attorneys general.
Sec. 258. Application of State and Federal laws regarding abortion.
Sec. 259. Nondiscrimination on abortion and respect for rights of
conscience.
Sec. 260. Authority of Federal Trade Commission.
Sec. 261. Construction regarding standard of care.
Sec. 262. Restoring application of antitrust laws to health sector
insurers.
Sec. 263. Study and report on methods to increase EHR use by small
health care providers.
TITLE III--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS
Subtitle A--Health Insurance Exchange
Sec. 301. Establishment of Health Insurance Exchange; outline of
duties; definitions.
Sec. 302. Exchange-eligible individuals and employers.
Sec. 303. Benefits package levels.
Sec. 304. Contracts for the offering of Exchange-participating health
benefits plans.
Sec. 305. Outreach and enrollment of Exchange-eligible individuals and
employers in Exchange-participating health
benefits plan.
Sec. 306. Other functions.
Sec. 307. Health Insurance Exchange Trust Fund.
Sec. 308. Optional operation of State-based health insurance exchanges.
Sec. 309. Interstate health insurance compacts.
Sec. 310. Health insurance cooperatives.
Sec. 311. Retention of DOD and VA authority.
Subtitle B--Public Health Insurance Option
Sec. 321. Establishment and administration of a public health insurance
option as an Exchange-qualified health
benefits plan.
Sec. 322. Premiums and financing.
Sec. 323. Payment rates for items and services.
Sec. 324. Modernized payment initiatives and delivery system reform.
Sec. 325. Provider participation.
Sec. 326. Application of fraud and abuse provisions.
Sec. 327. Application of HIPAA insurance requirements.
Sec. 328. Application of health information privacy, security, and
electronic transaction requirements.
Sec. 329. Enrollment in public health insurance option is voluntary.
Sec. 330. Enrollment in public health insurance option by Members of
Congress.
Sec. 331. Reimbursement of Secretary of Veterans Affairs.
Subtitle C--Individual Affordability Credits
Sec. 341. Availability through Health Insurance Exchange.
Sec. 342. Affordable credit eligible individual.
Sec. 343. Affordability premium credit.
Sec. 344. Affordability cost-sharing credit.
Sec. 345. Income determinations.
Sec. 346. Special rules for application to territories.
Sec. 347. No Federal payment for undocumented aliens.
TITLE IV--SHARED RESPONSIBILITY
Subtitle A--Individual Responsibility
Sec. 401. Individual responsibility.
Subtitle B--Employer Responsibility
Part 1--Health Coverage Participation Requirements
Sec. 411. Health coverage participation requirements.
Sec. 412. Employer responsibility to contribute toward employee and
dependent coverage.
Sec. 413. Employer contributions in lieu of coverage.
Sec. 414. Authority related to improper steering.
Sec. 415. Impact study on employer responsibility requirements.
Sec. 416. Study on employer hardship exemption.
Part 2--Satisfaction of Health Coverage Participation Requirements
Sec. 421. Satisfaction of health coverage participation requirements
under the Employee Retirement Income
Security Act of 1974.
Sec. 422. Satisfaction of health coverage participation requirements
under the Internal Revenue Code of 1986.
Sec. 423. Satisfaction of health coverage participation requirements
under the Public Health Service Act.
Sec. 424. Additional rules relating to health coverage participation
requirements.
TITLE V--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986
Subtitle A--Provisions Relating to Health Care Reform
Part 1--Shared Responsibility
subpart a--individual responsibility
Sec. 501. Tax on individuals without acceptable health care coverage.
subpart b--employer responsibility
Sec. 511. Election to satisfy health coverage participation
requirements.
Sec. 512. Health care contributions of nonelecting employers.
Part 2--Credit for Small Business Employee Health Coverage Expenses
Sec. 521. Credit for small business employee health coverage expenses.
Part 3--Limitations on Health Care Related Expenditures
Sec. 531. Distributions for medicine qualified only if for prescribed
drug or insulin.
Sec. 532. Limitation on health flexible spending arrangements under
cafeteria plans.
Sec. 533. Increase in penalty for nonqualified distributions from
health savings accounts.
Sec. 534. Denial of deduction for federal subsidies for prescription
drug plans which have been excluded from
gross income.
Part 4--Other Provisions to Carry Out Health Insurance Reform
Sec. 541. Disclosures to carry out health insurance exchange subsidies.
Sec. 542. Offering of exchange-participating health benefits plans
through cafeteria plans.
Sec. 543. Exclusion from gross income of payments made under
reinsurance program for retirees.
Sec. 544. CLASS program treated in same manner as long-term care
insurance.
Sec. 545. Exclusion from gross income for medical care provided for
Indians.
Subtitle B--Other Revenue Provisions
Part 1--General Provisions
Sec. 551. Surcharge on high income individuals.
Sec. 552. Excise tax on medical devices.
Sec. 553. Expansion of information reporting requirements.
Sec. 554. Delay in application of worldwide allocation of interest.
Part 2--Prevention of Tax Avoidance
Sec. 561. Limitation on treaty benefits for certain deductible
payments.
Sec. 562. Codification of economic substance doctrine; penalties.
Sec. 563. Certain large or publicly traded persons made subject to a
more likely than not standard for avoiding
penalties on underpayments.
Part 3--Parity in Health Benefits
Sec. 571. Certain health related benefits applicable to spouses and
dependents extended to eligible
beneficiaries.
(c) General Definitions.--Except as otherwise provided, in this
division:
(1) Acceptable coverage.--The term ``acceptable coverage''
has the meaning given such term in section 302(d)(2).
(2) Basic plan.--The term ``basic plan'' has the meaning
given such term in section 303(c).
(3) Commissioner.--The term ``Commissioner'' means the
Health Choices Commissioner established under section 241.
(4) Cost-sharing.--The term ``cost-sharing'' includes
deductibles, coinsurance, copayments, and similar charges, but
does not include premiums, balance billing amounts for non-
network providers, or spending for non-covered services.
(5) Dependent.--The term ``dependent'' has the meaning
given such term by the Commissioner and includes a spouse.
(6) Employment-based health plan.--The term ``employment-
based health plan''--
(A) means a group health plan (as defined in
section 733(a)(1) of the Employee Retirement Income
Security Act of 1974);
(B) includes such a plan that is the following:
(i) Federal, state, and tribal governmental
plans.--A governmental plan (as defined in
section 3(32) of the Employee Retirement Income
Security Act of 1974), including a health
benefits plan offered under chapter 89 of title
5, United States Code.
(ii) Church plans.--A church plan (as
defined in section 3(33) of the Employee
Retirement Income Security Act of 1974); and
(C) excludes coverage described in section
302(d)(2)(E) (relating to TRICARE).
(7) Enhanced plan.--The term ``enhanced plan'' has the
meaning given such term in section 303(c).
(8) Essential benefits package.--The term ``essential
benefits package'' is defined in section 222(a).
(9) Exchange-participating health benefits plan.--The term
``Exchange-participating health benefits plan'' means a
qualified health benefits plan that is offered through the
Health Insurance Exchange and may be purchased directly from
the entity offering the plan or through enrollment agents and
brokers.
(10) Family.--The term ``family'' means an individual and
includes the individual's dependents.
(11) Federal poverty level; fpl.--The terms ``Federal
poverty level'' and ``FPL'' have the meaning given the term
``poverty line'' in section 673(2) of the Community Services
Block Grant Act (42 U.S.C. 9902(2)), including any revision
required by such section.
(12) Health benefits plan.--The term ``health benefits
plan'' means health insurance coverage and an employment-based
health plan and includes the public health insurance option.
(13) Health insurance coverage.--The term ``health
insurance coverage'' has the meaning given such term in section
2791 of the Public Health Service Act, but does not include
coverage in relation to its provision of excepted benefits--
(A) described in paragraph (1) of subsection (c) of
such section; 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.
(14) Health insurance issuer.--The term ``health insurance
issuer'' has the meaning given such term in section 2791(b)(2)
of the Public Health Service Act.
(15) Health insurance exchange.--The term ``Health
Insurance Exchange'' means the Health Insurance Exchange
established under section 301.
(16) Indian.--The term ``Indian'' has the meaning given
such term in section 4 of the Indian Health Care Improvement
Act (24 U.S.C. 1603).
(17) Indian health care provider.--The term ``Indian health
care provider'' means a health care program operated by the
Indian Health Service, an Indian tribe, tribal organization, or
urban Indian organization as such terms are defined in section
4 of the Indian Health Care Improvement Act (25 U.S.C. 1603).
(18) Medicaid.--The term ``Medicaid'' means a State plan
under title XIX of the Social Security Act (whether or not the
plan is operating under a waiver under section 1115 of such
Act).
(19) Medicaid eligible individual.--The term ``Medicaid
eligible individual'' means an individual who is eligible for
medical assistance under Medicaid.
(20) Medicare.--The term ``Medicare'' means the health
insurance programs under title XVIII of the Social Security
Act.
(21) 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.
(22) Plan year.--The term ``plan year'' means--
(A) with respect to an employment-based health
plan, a plan year as specified under such plan; or
(B) with respect to a health benefits plan other
than an employment-based health plan, a 12-month period
as specified by the Commissioner.
(23) Premium plan; premium-plus plan.--The terms ``premium
plan'' and ``premium-plus plan'' have the meanings given such
terms in section 303(c).
(24) QHBP offering entity.--The terms ``QHBP offering
entity'' means, with respect to a health benefits plan that
is--
(A) a group health plan (as defined, subject to
subsection (d), in section 733(a)(1) of the Employee
Retirement Income Security Act of 1974), the plan
sponsor in relation to such group health plan, except
that, in the case of a plan maintained jointly by 1 or
more employers and 1 or more employee organizations and
with respect to which an employer is the primary source
of financing, such term means such employer;
(B) health insurance coverage, the health insurance
issuer offering the coverage;
(C) the public health insurance option, the
Secretary of Health and Human Services;
(D) a non-Federal governmental plan (as defined in
section 2791(d) of the Public Health Service Act), the
State or political subdivision of a State (or agency or
instrumentality of such State or subdivision) which
establishes or maintains such plan; or
(E) a Federal governmental plan (as defined in
section 2791(d) of the Public Health Service Act), the
appropriate Federal official.
(25) Qualified health benefits plan.--The term ``qualified
health benefits plan'' means a health benefits plan that--
(A) meets the requirements for such a plan under
title II and includes the public health insurance
option; and
(B) is offered by a QHBP offering entity that meets
the applicable requirements of such title with respect
to such plan.
(26) Public health insurance option.--The term ``public
health insurance option'' means the public health insurance
option as provided under subtitle B of title III.
(27) Service area; premium rating area.--The terms
``service area'' and ``premium rating area'' mean with respect
to health insurance coverage--
(A) offered other than through the Health Insurance
Exchange, such an area as established by the QHBP
offering entity of such coverage in accordance with
applicable State law; and
(B) offered through the Health Insurance Exchange,
such an area as established by such entity in
accordance with applicable State law and applicable
rules of the Commissioner for Exchange-participating
health benefits plans.
(28) State.--The term ``State'' means the 50 States and the
District of Columbia and includes--
(A) for purposes of title I, Puerto Rico, the
Virgin Islands, Guam, American Samoa, and the Northern
Mariana Islands; and
(B) for purposes of titles II and III, as elected
under and subject to section 346, Puerto Rico, the
Virgin Islands, Guam, American Samoa, and the Northern
Mariana Islands.
(29) State medicaid agency.--The term ``State Medicaid
agency'' means, with respect to a Medicaid plan, the single
State agency responsible for administering such plan under
title XIX of the Social Security Act.
(30) Y1, y2, etc.--The terms ``Y1'', ``Y2'', ``Y3'',
``Y4'', ``Y5'', and similar subsequently numbered terms, mean
2013 and subsequent years, respectively.
TITLE I--IMMEDIATE REFORMS
SEC. 101. NATIONAL HIGH-RISK POOL PROGRAM.
(a) In General.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary'') shall establish a
temporary national high-risk pool program (in this section referred to
as the ``program'') to provide health benefits to eligible individuals
during the period beginning on January 1, 2010, and, subject to
subsection (h)(3)(B), ending on the date on which the Health Insurance
Exchange is established.
(b) Administration.--The Secretary may carry out this section
directly or, pursuant to agreements, grants, or contracts with States,
through State high-risk pool programs provided that the requirements of
this section are met.
(c) Eligibility.--For purposes of this section, the term ``eligible
individual'' means an individual--
(1) who--
(A) is not eligible for--
(i) benefits under title XVIII, XIX, or XXI
of the Social Security Act; or
(ii) coverage under an employment-based
health plan (not including coverage under a
COBRA continuation provision, as defined in
section 107(d)(1)); and
(B) who--
(i) is an eligible individual under section
2741(b) of the Public Health Service Act; or
(ii) is medically eligible for the program
by virtue of being an individual described in
subsection (d) at any time during the 6-month
period ending on the date the individual
applies for high-risk pool coverage under this
section;
(2) who is the spouse or dependent of an individual who is
described in paragraph (1); or
(3) who has not had health insurance coverage or coverage
under an employment-based health plan for at least the 6-month
period immediately preceding the date of the individual's
application for high-risk pool coverage under this section.
For purposes of paragraph (1)(A)(ii), a person who is in a waiting
period as defined in section 2701(b)(4) of the Public Health Service
Act shall not be considered to be eligible for coverage under an
employment-based health plan.
(d) Medically Eligible Requirements.--For purposes of subsection
(c)(1)(B)(ii), an individual described in this subsection is an
individual--
(1) who, during the 6-month period ending on the date the
individual applies for high-risk pool coverage under this
section applied for individual health insurance coverage and--
(A) was denied such coverage because of a
preexisting condition or health status; or
(B) was offered such coverage--
(i) under terms that limit the coverage for
such a preexisting condition; or
(ii) at a premium rate that is above the
premium rate for high risk pool coverage under
this section; or
(2) who has an eligible medical condition as defined by the
Secretary.
In making a determination under paragraph (1) of whether an individual
was offered individual coverage at a premium rate above the premium
rate for high risk pool coverage, the Secretary shall make adjustments
to offset differences in premium rating that are attributable solely to
differences in age rating.
(e) Enrollment.--To enroll in coverage in the program, an
individual shall--
(1) submit 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) attest that the individual is an eligible individual
and is a resident of one of the 50 States or the District of
Columbia; and
(3) if the individual had other prior health insurance
coverage or coverage under an employment-based health plan
during the previous 6 months, provide information as to the
nature and source of such coverage and reasons for its
discontinuance.
(f) Protection Against Dumping Risks 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 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 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.
(g) Covered Benefits, Cost-sharing, Premiums, and Consumer
Protections.--
(1) Premium.--The monthly premium charged to eligible
individuals for coverage under the program--
(A) may vary by age so long as the ratio of the
highest such premium to the lowest such premium does
not exceed the ratio of 2 to 1;
(B) shall be set at a level that does not exceed
125 percent of the prevailing standard rate for
comparable coverage in the individual market; and
(C) shall be adjusted for geographic variation in
costs.
Health insurance issuers shall provide such information as the
Secretary may require to determine prevailing standard rates
under this paragraph. The Secretary shall establish standard
rates in consultation with the National Association of
Insurance Commissioners.
(2) Covered benefits.--Covered benefits under the program
shall be determined by the Secretary and shall be consistent
with the basic categories in the essential benefits package
described in section 222. Under such benefits package--
(A) the annual deductible for such benefits may not
be higher than $1,500 for an individual or such higher
amount for a family as determined by the Secretary;
(B) there may not be annual or lifetime limits; and
(C) the maximum cost-sharing with respect to an
individual (or family) for a year shall not exceed
$5,000 for an individual (or $10,000 for a family).
(3) No preexisting condition exclusion periods.--No
preexisting condition exclusion period shall be imposed on
coverage under the program.
(4) Appeals.--The Secretary shall establish an appeals
process for individuals to appeal a determination of the
Secretary--
(A) with respect to claims submitted under this
section; and
(B) with respect to eligibility determinations made
by the Secretary under this section.
(5) State contribution, maintenance of effort.--As a
condition of providing health benefits under this section to
eligible individual residing in a State--
(A) in the case of a State in which a qualified
high-risk pool (as defined under section 2744(c)(2) of
the Public Health Service Act) was in effect as of July
1, 2009, the Secretary shall require the State make a
maintenance of effort payment each year that the high-
risk pool is in effect equal to an amount not less than
the amount of all sources of funding for high-risk pool
coverage made by that State in the year ending July 1,
2009; and
(B) in the case of a State which required health
insurance issuers to contribute to a State high-risk
pool or similar arrangement for the assessment against
such issuers for pool losses, the State shall maintain
such a contribution arrangement among such issuers.
(6) Limiting program expenditures.--The Secretary shall,
with respect to the program--
(A) establish procedures to protect against fraud,
waste, and abuse under the program; and
(B) provide for other program integrity methods.
(7) Treatment as creditable coverage.--Coverage under the
program shall be treated, for purposes of applying the
definition of ``creditable coverage'' under the provisions of
title XXVII of the Public Health Service Act, part 6 of
subtitle B of title I of Employee Retirement Income Security
Act of 1974, and chapter 100 of the Internal Revenue Code of
1986 (and any other provision of law that references such
provisions) in the same manner as if it were coverage under a
State health benefits risk pool described in section
2701(c)(1)(G) of the Public Health Service Act.
(h) 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 administrative costs
of) the high-risk pool under this section in excess of the
premiums collected with respect to 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 payment of
expenses of the high-risk pool will be less than the amount of
the expenses, the Secretary shall make such adjustments as are
necessary to eliminate such deficit, including reducing
benefits, increasing premiums, or establishing waiting lists.
(3) Termination of authority.--
(A) In general.--Except as provided in subparagraph
(B), coverage of eligible individuals under a high-risk
pool shall terminate as of the date on which the Health
Insurance Exchange is established.
(B) Transition to exchange.--The Secretary shall
develop procedures to provide for the transition of
eligible individuals who are enrolled in health
insurance coverage offered through a high-risk pool
established under this section to be enrolled in
acceptable coverage. Such procedures shall ensure that
there is no lapse in coverage with respect to the
individual and may extend coverage offered through such
a high-risk pool beyond 2012 if the Secretary
determines necessary to avoid such a lapse.
SEC. 102. ENSURING VALUE AND LOWER PREMIUMS.
(a) Group Health Insurance Coverage.--Title XXVII of the Public
Health Service Act is amended by inserting after section 2713 the
following new section:
``SEC. 2714. ENSURING VALUE AND LOWER PREMIUMS.
``(a) In General.--Each health insurance issuer that offers health
insurance coverage in the small or large group market shall provide
that for any plan year in which the coverage has a medical loss ratio
below a level specified by the Secretary (but not less than 85
percent), the issuer shall provide in a manner specified by the
Secretary for rebates to enrollees of the amount by which the issuer's
medical loss ratio is less than the level so specified.
``(b) Implementation.--The Secretary shall establish a uniform
definition of medical loss ratio and methodology for determining how to
calculate it based on the average medical loss ratio in a health
insurance issuer's book of business for the small and large group
market. Such methodology shall be designed to take into account the
special circumstances of smaller plans, different types of plans, and
newer plans. In determining the medical loss ratio, the Secretary shall
exclude State taxes and licensing or regulatory fees. Such methodology
shall be designed and exceptions shall be established to ensure
adequate participation by health insurance issuers, competition in the
health insurance market, and value for consumers so that their premiums
are used for services.
``(c) Sunset.--Subsections (a) and (b) shall not apply to health
insurance coverage on and after the first date that health insurance
coverage is offered through the Health Insurance Exchange.''.
(b) Individual Health Insurance Coverage.--Such title is further
amended by inserting after section 2753 the following new section:
``SEC. 2754. ENSURING VALUE AND LOWER PREMIUMS.
``The provisions of section 2714 shall apply to health insurance
coverage offered in the individual market in the same manner as such
provisions apply to health insurance coverage offered in the small or
large group market except to the extent the Secretary determines that
the application of such section may destabilize the existing individual
market.''.
(c) Immediate Implementation.--The amendments made by this section
shall apply in the group and individual market for plan years beginning
on or after January 1, 2010, or as soon as practicable after such date.
SEC. 103. ENDING HEALTH INSURANCE RESCISSION ABUSE.
(a) Clarification Regarding Application of Guaranteed Renewability
of Individual and Group Health Insurance Coverage.--Sections 2712 and
2742 of the Public Health Service Act (42 U.S.C. 300gg-12, 300gg-42)
are each amended--
(1) in its heading, by inserting ``and continuation in
force, including prohibition of rescission,'' after
``guaranteed renewability''; and
(2) in subsection (a), by inserting ``, including without
rescission,'' after ``continue in force''.
(b) Secretarial Guidance Regarding Rescissions.--
(1) Group health insurance market.--Section 2712 of such
Act (42 U.S.C. 300gg-12) is amended by adding at the end the
following:
``(f) Rescission.--A health insurance issuer may rescind group
health insurance coverage only upon clear and convincing evidence of
fraud described in subsection (b)(2), under procedures that provide for
independent, external third-party review.''.
(2) Individual health market.--Section 2742 of such Act (42
U.S.C. 300gg-42) is amended by adding at the end the following:
``(f) Rescission.--A health insurance issuer may rescind individual
health insurance coverage only upon clear and convincing evidence of
fraud described in subsection (b)(2), under procedures that provide for
independent, external third-party review.''.
(3) Guidance.--The Secretary of Health and Human Services,
no later than 90 days after the date of the enactment of this
Act, shall issue guidance implementing the amendments made by
paragraphs (1) and (2), including procedures for independent,
external third-party review.
(c) Opportunity for Independent, External Third-party Review in
Certain Cases.--
(1) Individual market.--Subpart 1 of part B of title XXVII
of such Act (42 U.S.C. 300gg-41 et seq.) is amended by adding
at the end the following:
``SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD-PARTY REVIEW
IN CASES OF RESCISSION.
``(a) Notice and Review Right.--If a health insurance issuer
determines to rescind health insurance coverage for an individual in
the individual market, before such rescission may take effect the
issuer shall provide the individual with notice of such proposed
rescission and an opportunity for a review of such determination by an
independent, external third-party under procedures specified by the
Secretary under section 2742(f).
``(b) Independent Determination.--If the individual requests such
review by an independent, external third-party of a rescission of
health insurance coverage, the coverage shall remain in effect until
such third party determines that the coverage may be rescinded under
the guidance issued by the Secretary under section 2742(f).''.
(2) Application to group health insurance.--Such title is
further amended by adding after section 2702 the following new
section:
``SEC. 2703. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD-PARTY REVIEW
IN CASES OF RESCISSION.
``The provisions of section 2746 shall apply to group health
insurance coverage in the same manner as such provisions apply to
individual health insurance coverage, except that any reference to
section 2742(f) is deemed a reference to section 2712(f).''.
(d) Effective Date.--The amendments made by this section shall take
effect on the date of the enactment of this Act and shall apply to
rescissions occurring on and after July 1, 2010, with respect to health
insurance coverage issued before, on, or after such date.
SEC. 104. SUNSHINE ON PRICE GOUGING BY HEALTH INSURANCE ISSUERS.
The Secretary of Health and Human Services, in conjunction with
States, shall establish a process for the annual review of increases in
premiums for health insurance coverage. Such process shall require
health insurance issuers to submit a justification for any premium
increases prior to implementation of the increase.
SEC. 105. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE FOR
UNINSURED YOUNG ADULTS.
(a) Under Group Health Plans.--
(1) PHSA.--Title XXVII of the Public Health Service Act is
amended by inserting after section 2702 the following new
section:
``SEC. 2703. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE
FOR UNINSURED YOUNG ADULTS.
``(a) In General.--A group health plan and a health insurance
issuer offering health insurance coverage in connection with a group
health plan that provides coverage for dependent children shall make
available such coverage, at the option of the participant involved, for
one or more qualified children (as defined in subsection (b)) of the
participant.
``(b) Qualified Child Defined.--In this section, the term
`qualified child' means, with respect to a participant in a group
health plan or group health insurance coverage, an individual who (but
for age) would be treated as a dependent child of the participant under
such plan or coverage and who--
``(1) is under 27 years of age; and
``(2) is not enrolled as a participant, beneficiary, or
enrollee (other than under this section, section 2746, or
section 704 of the Employee Retirement Income Security Act of
1974) under any health insurance coverage or group health plan.
``(c) Premiums.--Nothing in this section shall be construed as
preventing a group health plan or health insurance issuer with respect
to group health insurance coverage from increasing the premiums
otherwise required for coverage provided under this section consistent
with standards established by the Secretary based upon family size.''.
(2) Employee retirement income security act of 1974.--
(A) In general.--Part 7 of subtitle B of title I of
the Employee Retirement Income Security Act of 1974 is
amended by inserting after section 703 the following
new section:
``SEC. 704. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE FOR
UNINSURED YOUNG ADULTS.
``(a) In General.--A group health plan and a health insurance
issuer offering health insurance coverage in connection with a group
health plan that provides coverage for dependent children shall make
available such coverage, at the option of the participant involved, for
one or more qualified children (as defined in subsection (b)) of the
participant.
``(b) Qualified Child Defined.--In this section, the term
`qualified child' means, with respect to a participant in a group
health plan or group health insurance coverage, an individual who (but
for age) would be treated as a dependent child of the participant under
such plan or coverage and who--
``(1) is under 27 years of age; and
``(2) is not enrolled as a participant, beneficiary, or
enrollee (other than under this section) under any health
insurance coverage or group health plan.
``(c) Premiums.--Nothing in this section shall be construed as
preventing a group health plan or health insurance issuer with respect
to group health insurance coverage from increasing the premiums
otherwise required for coverage provided under this section consistent
with standards established by the Secretary based upon family size.''.
(B) Clerical amendment.--The table of contents of
such Act is amended by inserting after the item
relating to section 703 the following new item:
``Sec. 704. Requiring the option of extension of dependent coverage for
uninsured young adults.''.
(3) IRC.--
(A) In general.--Subchapter A of chapter 100 of the
Internal Revenue Code of 1986 is amended by adding at
the end the following new section:
``SEC. 9804. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE
FOR UNINSURED YOUNG ADULTS.
``(a) In General.--A group health plan that provides coverage for
dependent children shall make available such coverage, at the option of
the participant involved, for one or more qualified children (as
defined in subsection (b)) of the participant.
``(b) Qualified Child Defined.--In this section, the term
`qualified child' means, with respect to a participant in a group
health plan, an individual who (but for age) would be treated as a
dependent child of the participant under such plan and who--
``(1) is under 27 years of age; and
``(2) is not enrolled as a participant, beneficiary, or
enrollee (other than under this section, section 704 of the
Employee Retirement Income Security Act of 1974, or section
2704 or 2746 of the Public Health Service Act) under any health
insurance coverage or group health plan.
``(c) Premiums.--Nothing in this section shall be construed as
preventing a group health plan from increasing the premiums otherwise
required for coverage provided under this section consistent with
standards established by the Secretary based upon family size.''.
(B) Clerical amendment.--The table of sections of
such chapter is amended by inserting after the item
relating to section 9803 the following:
``Sec. 9804. Requiring the option of extension of dependent coverage
for uninsured young adults.''.
(b) Individual Health Insurance Coverage.--Title XXVII of the
Public Health Service Act is amended by inserting after section 2745
the following new section:
``SEC. 2746. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE
FOR UNINSURED YOUNG ADULTS.
``The provisions of section 2703 shall apply to health insurance
coverage offered by a health insurance issuer in the individual market
in the same manner as they apply to health insurance coverage offered
by a health insurance issuer in connection with a group health plan in
the small or large group market.''.
(c) Effective Dates.--
(1) Group health plans.--The amendments made by subsection
(a) shall apply to group health plans for plan years beginning
on or after January 1, 2010.
(2) Individual health insurance coverage.--Section 2746 of
the Public Health Service Act, as inserted by subsection (b),
shall apply with respect to health insurance coverage offered,
sold, issued, renewed, in effect, or operated in the individual
market on or after January 1, 2010.
SEC. 106. LIMITATIONS ON PREEXISTING CONDITION EXCLUSIONS IN GROUP
HEALTH PLANS IN ADVANCE OF APPLICABILITY OF NEW
PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS.
(a) Amendments to the Employee Retirement Income Security Act of
1974.--
(1) Reduction in look-back period.--Section 701(a)(1) of
the Employee Retirement Income Security Act of 1974 (29 U.S.C.
1181(a)(1)) is amended by striking ``6-month period'' and
inserting ``30-day period''.
(2) Reduction in permitted preexisting condition limitation
period.--Section 701(a)(2) of such Act (29 U.S.C. 1181(a)(2))
is amended by striking ``12 months'' and inserting ``3
months'', and by striking ``18 months'' and inserting ``9
months''.
(3) Sunset of interim limitation.--Section 701 of such Act
(29 U.S.C. 1181) is amended by adding at the end the following
new subsection:
``(h) Termination.--This section shall cease to apply to any group
health plan as of the date that such plan becomes subject to the
requirements of section 211 of the (relating to prohibiting preexisting
condition exclusions).''.
(b) Amendments to the Internal Revenue Code of 1986.--
(1) Reduction in look-back period.--Section 9801(a)(1) of
the Internal Revenue Code of 1986 is amended by striking ``6-
month period'' and inserting ``30-day period''.
(2) Reduction in permitted preexisting condition limitation
period.--Section 9801(a)(2) of such Code is amended by striking
``12 months'' and inserting ``3 months'', and by striking ``18
months'' and inserting ``9 months''.
(3) Sunset of interim limitation.--Section 9801 of such
Code is amended by adding at the end the following new
subsection:
``(g) Termination.--This section shall cease to apply to any group
health plan as of the date that such plan becomes subject to the
requirements of section 211 of the (relating to prohibiting preexisting
condition exclusions).''.
(c) Amendments to Public Health Service Act.--
(1) Reduction in look-back period.--Section 2701(a)(1) of
the Public Health Service Act (42 U.S.C. 300gg(a)(1)) is
amended by striking ``6-month period'' and inserting ``30-day
period''.
(2) Reduction in permitted preexisting condition limitation
period.--Section 2701(a)(2) of such Act (42 U.S.C. 300gg(a)(2))
is amended by striking ``12 months'' and inserting ``3
months'', and by striking ``18 months'' and inserting ``9
months''.
(3) Sunset of interim limitation.--Section 2701 of such Act
(42 U.S.C. 300gg) is amended by adding at the end the following
new subsection:
``(h) Termination.--This section shall cease to apply to any group
health plan as of the date that such plan becomes subject to the
requirements of section 211 of the (relating to prohibiting preexisting
condition exclusions).''.
(4) Miscellaneous technical amendment.--Section 2702(a)(2)
of such Act (42 U.S.C. 300gg-1) is amended by striking ``701''
and inserting ``2701''.
(d) Effective Date.--
(1) In general.--Except as provided in paragraph (2), the
amendments made by this section shall apply with respect to
group health plans for plan years beginning on or after January
1, 2010.
(2) Special rule for collective bargaining agreements.--In
the case of a group health plan maintained pursuant to 1 or
more collective bargaining agreements between employee
representatives and 1 or more employers ratified before the
date of the enactment of this Act, the amendments made by this
section shall not apply to plan years beginning before the
earlier of--
(A) the date on which the last of the collective
bargaining agreements relating to the plan terminates
(determined without regard to any extension thereof
agreed to after the date of the enactment of this Act);
(B) 3 years after the date of the enactment of this
Act.
SEC. 107. PROHIBITING ACTS OF DOMESTIC VIOLENCE FROM BEING TREATED AS
PREEXISTING CONDITIONS.
(a) ERISA.--Section 701(d)(3) of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. ) is amended--
(1) in the heading, by inserting ``or domestic violence''
after ``pregnancy''; and
(2) by inserting ``or domestic violence'' after ``relating
to pregnancy''.
(b) PHSA.--
(1) Group market.--Section 2701(d)(3) of the Public Health
Service Act (42 U.S.C. 300gg(d)(3)) is amended--
(A) in the heading, by inserting ``or domestic
violence'' after ``pregnancy''; and
(B) by inserting ``or domestic violence'' after
``relating to pregnancy''.
(2) Individual market.--Title XXVII of such Act is amended
by inserting after section 2753 the following new section:
``SEC. 2754. PROHIBITION ON DOMESTIC VIOLENCE AS PREEXISTING CONDITION.
``A health insurance issuer offering health insurance coverage in
the individual market may not, on the basis of domestic violence,
impose any preexisting condition exclusion (as defined in section
2701(b)(1)(A)) with respect to such coverage.''.
(c) IRC.--Section 9801(d)(3) of the Internal Revenue Code of 1986
is amended--
(1) in the heading, by inserting ``or domestic violence''
after ``pregnancy''; and
(2) by inserting ``or domestic violence'' after ``relating
to pregnancy''.
(d) Effective Dates.--
(1) Except as otherwise provided in this subsection, the
amendments made by this section shall apply with respect to
group health plans (and health insurance issuers offering group
health insurance coverage) for plan years beginning on or after
January 1, 2010.
(2) The amendment made by subsection (b)(2) shall apply
with respect to health insurance coverage offered, sold,
issued, renewed, in effect, or operated in the individual
market on or after such date.
SEC. 108. ENDING HEALTH INSURANCE DENIALS AND DELAYS OF NECESSARY
TREATMENT FOR CHILDREN WITH DEFORMITIES.
(a) Amendments to the Employee Retirement Income Security Act of
1974.--
(1) In general.--Subpart B of part 7 of subtitle B of title
I of the Employee Retirement Income Security Act of 1974 is
amended by adding at the end the following new section:
``SEC. 715. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S CONGENITAL
OR DEVELOPMENTAL DEFORMITY OR DISORDER.
``(a) Requirements for Treatment for Children With Deformities.--
``(1) In general.--A group health plan, and a health
insurance issuer offering group health insurance coverage, that
provides coverage for surgical benefits shall provide coverage
for outpatient and inpatient diagnosis and treatment of a minor
child's congenital or developmental deformity, disease, or
injury. A minor child shall include any individual who is 21
years of age or younger.
``(2) Treatment defined.--
``(A) In general.--In this section, the term
`treatment' includes reconstructive surgical procedures
(procedures that are generally performed to improve
function, but may also be performed to approximate a
normal appearance) that are performed on abnormal
structures of the body caused by congenital defects,
developmental abnormalities, trauma, infection, tumors,
or disease, including--
``(i) procedures that do not materially
affect the function of the body part being
treated; and
``(ii) procedures for secondary conditions
and follow-up treatment.
``(B) Exception.--Such term does not include
cosmetic surgery performed to reshape normal structures
of the body to improve appearance or self-esteem.
``(b) Notice.--A group health plan under this part shall comply
with the notice requirement under section 713(b) (other than paragraph
(3)) with respect to the requirements of this section.''.
(2) Conforming amendment.--
(A) Subsection (c) of section 731 of such Act is
amended by striking ``section 711'' and inserting
``sections 711 and 715''.
(B) The table of contents in section 1 of such Act
is amended by inserting after the item relating to
section 714 the following new item:
``Sec. 715. Standards relating to benefits for minor child's congenital
or developmental deformity or disorder.''.
(b) Amendments to the Internal Revenue Code of 1986.--
(1) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new section:
``SEC. 9814. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S
CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.
``(a) Requirements for Treatment for Children With Deformities.--A
group health plan that provides coverage for surgical benefits shall
provide coverage for outpatient and inpatient diagnosis and treatment
of a minor child's congenital or developmental deformity, disease, or
injury. A minor child shall include any individual who is 21 years of
age or younger.
``(b) Treatment Defined.--
``(1) In general.--In this section, the term `treatment'
includes reconstructive surgical procedures (procedures that
are generally performed to improve function, but may also be
performed to approximate a normal appearance) that are
performed on abnormal structures of the body caused by
congenital defects, developmental abnormalities, trauma,
infection, tumors, or disease, including--
``(A) procedures that do not materially affect the
function of the body part being treated, and
``(B) procedures for secondary conditions and
follow-up treatment.
``(2) Exception.--Such term does not include cosmetic
surgery performed to reshape normal structures of the body to
improve appearance or self-esteem.''.
(2) Clerical amendment.--The table of sections for
subchapter B of chapter 100 of such Code is amended by adding
at the end the following new item:
``Sec. 9814. Standards relating to benefits for minor child's
congenital or developmental deformity or
disorder.''.
(c) Amendments to the Public Health Service Act.--
(1) In general.--Subpart 2 of part A of title XXVII of the
Public Health Service Act is amended by adding at the end the
following new section:
``SEC. 2708. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S
CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.
``(a) Requirements for Treatment for Children With Deformities.--
``(1) In general.--A group health plan, and a health
insurance issuer offering group health insurance coverage, that
provides coverage for surgical benefits shall provide coverage
for outpatient and inpatient diagnosis and treatment of a minor
child's congenital or developmental deformity, disease, or
injury. A minor child shall include any individual who is 21
years of age or younger.
``(2) Treatment defined.--
``(A) In general.--In this section, the term
`treatment' includes reconstructive surgical procedures
(procedures that are generally performed to improve
function, but may also be performed to approximate a
normal appearance) that are performed on abnormal
structures of the body caused by congenital defects,
developmental abnormalities, trauma, infection, tumors,
or disease, including--
``(i) procedures that do not materially
affect the function of the body part being
treated; and
``(ii) procedures for secondary conditions
and follow-up treatment.
``(B) Exception.--Such term does not include
cosmetic surgery performed to reshape normal structures
of the body to improve appearance or self-esteem.
``(b) Notice.--A group health plan under this part shall comply
with the notice requirement under section 715(b) of the Employee
Retirement Income Security Act of 1974 with respect to the requirements
of this section as if such section applied to such plan.''.
(2) Individual health insurance.--Subpart 2 of part B of
title XXVII of the Public Health Service Act, as amended by
section 161(b), is further amended by adding at the end the
following new section:
``SEC. 2755. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S
CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.
``The provisions of section 2708 shall apply to health insurance
coverage offered by a health insurance issuer in the individual market
in the same manner as such provisions apply to health insurance
coverage offered by a health insurance issuer in connection with a
group health plan in the small or large group market.''.
(3) Conforming amendments.--
(A) Section 2723(c) of such Act (42 U.S.C. 300gg-
23(c)) is amended by striking ``section 2704'' and
inserting ``sections 2704 and 2708''.
(B) Section 2762(b)(2) of such Act (42 U.S.C.
300gg-62(b)(2)) is amended by striking ``section 2751''
and inserting ``sections 2751 and 2755''.
(d) Effective Dates.--
(1) The amendments made by this section shall apply with
respect to group health plans (and health insurance issuers
offering group health insurance coverage) for plan years
beginning on or after January 1, 2010.
(2) The amendment made by subsection (c)(2) shall apply
with respect to health insurance coverage offered, sold,
issued, renewed, in effect, or operated in the individual
market on or after such date.
(e) Coordination.--Section 104(1) of the Health Insurance
Portability and Accountability Act of 1996 is amended by striking
``(and the amendments made by this subtitle and section 401)'' and
inserting ``, part 7 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974, parts A and C of title XXVII of
the Public Health Service Act, and chapter 100 of the Internal Revenue
Code of 1986''.
SEC. 109. ELIMINATION OF LIFETIME LIMITS.
(a) Amendments to the Employee Retirement Income Security Act of
1974.--
(1) In general.--Subpart B of part 7 of subtitle B of title
I of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185 et seq.), as amended by section 108, is amended by
adding at the end the following:
``SEC. 716. ELIMINATION OF LIFETIME AGGREGATE LIMITS.
``(a) In General.--A group health plan and a health insurance
issuer providing health insurance coverage in connection with a group
health plan, may not impose an aggregate dollar lifetime limit with
respect to benefits payable under the plan or coverage.
``(b) Definition.--In this section, the term `aggregate dollar
lifetime limit' means, with respect to benefits under a group health
plan or health insurance coverage offered in connection with a group
health plan, a dollar limitation on the total amount that may be paid
with respect to such benefits under the plan or health insurance
coverage with respect to an individual or other coverage unit on a
lifetime basis.''.
(2) Clerical amendment.--The table of contents in section 1
of such Act, is amended by inserting after the item relating to
section 715 the following new item:
``Sec. 716. Elimination of lifetime aggregate limits.''.
(b) Amendments to the Internal Revenue Code of 1986.--
(1) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986, as amended by section 108(b), is
amended by adding at the end the following new section:
``SEC. 9815. ELIMINATION OF LIFETIME AGGREGATE LIMITS.
``(a) In General.--A group health plan may not impose an aggregate
dollar lifetime limit with respect to benefits payable under the plan.
``(b) Definition.--In this section, the term `aggregate dollar
lifetime limit' means, with respect to benefits under a group health
plan a dollar limitation on the total amount that may be paid with
respect to such benefits under the plan with respect to an individual
or other coverage unit on a lifetime basis.''.
(2) Clerical amendment.--The table of sections for
subchapter B of chapter 100 of such Code, as amended by section
108(b), is amended by adding at the end the following new item:
``Sec. 9854. Standards relating to benefits for minor child's
congenital or developmental deformity or
disorder.''.
(c) Amendment to the Public Health Service Act Relating to the
Group Market.--
(1) In general.--Subpart 2 of part A of title XXVII of the
Public Health Service Act (42 U.S.C. 300gg-4 et seq.) as
amended by section 108(c)(1), is amended by adding at the end
the following:
``SEC. 2709. ELIMINATION OF LIFETIME AGGREGATE LIMITS.
``(a) In General.--A group health plan and a health insurance
issuer providing health insurance coverage in connection with a group
health plan, may not impose an aggregate dollar lifetime limit with
respect to benefits payable under the plan or coverage.
``(b) Definition.--In this section, the term `aggregate dollar
lifetime limit' means, with respect to benefits under a group health
plan or health insurance coverage, a dollar limitation on the total
amount that may be paid with respect to such benefits under the plan or
health insurance coverage with respect to an individual or other
coverage unit on a lifetime basis.''.
(2) Individual market.--Subpart 2 of part B of title XXVII
of the Public Health Service Act (42 U.S.C. 300gg-51 et seq.),
as amended by section 108(c)(2), is amended by adding at the
end the following:
``SEC. 2756. ELIMINATION OF ANNUAL OR LIFETIME AGGREGATE LIMITS.
``The provisions of section 2709 shall apply to health insurance
coverage offered by a health insurance issuer in the individual market
in the same manner as they apply to health insurance coverage offered
by a health insurance issuer in connection with a group health plan in
the small or large group market.''.
(d) Effective Dates.--
(1) The amendments made by this section shall apply with
respect to group health plans (and health insurance issuers
offering group health insurance coverage) for plan years
beginning on or after January 1, 2010.
(2) The amendment made by subsection (c)(2) shall apply
with respect to health insurance coverage offered, sold,
issued, renewed, in effect, or operated in the individual
market on or after such date.
SEC. 110. PROHIBITION AGAINST POSTRETIREMENT REDUCTIONS OF RETIREE
HEALTH BENEFITS BY GROUP HEALTH PLANS.
(a) In General.--Part 7 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974, as amended by sections 108 and
109, is amended by inserting after section 716 the following new
section:
``SEC. 717. PROTECTION AGAINST POSTRETIREMENT REDUCTION OF RETIREE
HEALTH BENEFITS.
``(a) In General.--Every group health plan shall contain a
provision which expressly bars the plan, or any fiduciary of the plan,
from reducing the benefits provided under the plan to a retired
participant, or beneficiary of such participant, if such reduction
affects the benefits provided to the participant or beneficiary as of
the date the participant retired for purposes of the plan and such
reduction occurs after the participant's retirement unless such
reduction is also made with respect to active participants. Nothing in
this section shall prohibit a plan from enforcing a total aggregate cap
on amounts paid for retiree health coverage that is part of the plan at
the time of retirement.
``(b) No Reduction.--Notwithstanding that a group health plan may
contain a provision reserving the general power to amend or terminate
the plan or a provision specifically authorizing the plan to make post-
retirement reductions in retiree health benefits, it shall be
prohibited for any group health plan, whether through amendment or
otherwise, to reduce the benefits provided to a retired participant or
the participant's beneficiary under the terms of the plan if such
reduction of benefits occurs after the date the participant retired for
purposes of the plan and reduces benefits that were provided to the
participant, or the participant's beneficiary, as of the date the
participant retired unless such reduction is also made with respect to
active participants.
``(c) Reduction Described.-- For purposes of this section, a
reduction in benefits--
``(1) with respect to premiums occurs under a group health
plan when a participant's (or beneficiary's) share of the total
premium (or, in the case of a self-insured plan, the costs of
coverage) of the plan substantially increases; or
``(2) with respect to other cost-sharing and benefits under
a group health plan occurs when there is a substantial decrease
in the actuarial value of the benefit package under the plan.
For purposes of this section, the term `substantial' means an increase
in the total premium share or a decrease in the actuarial value of the
benefit package that is greater than 5 percent.''
(b) Conforming Amendment.--The table of contents in section 1 of
such Act, as amended by sections 108 and 109, is amended by inserting
after the item relating to section 716 the following new item:
``Sec. 717. Protection against postretirement reduction of retiree
health benefits.''.
(c) Waiver.--An employer may, in a form and manner which shall be
prescribed by the Secretary of Labor, apply for a waiver from this
provision if the employer can reasonably demonstrate that meeting the
requirements of this section would impose an undue hardship on the
employer.
(d) Effective Date.--The amendments made by this section shall take
effect on the date of the enactment of this Act.
SEC. 111. REINSURANCE PROGRAM FOR RETIREES.
(a) Establishment.--
(1) In general.--Not later than 90 days after the date of
the enactment of this Act, the Secretary of Health and Human
Services shall establish a temporary reinsurance program (in
this section referred to as the ``reinsurance program'') to
provide reimbursement to assist participating employment-based
plans with the cost of providing health benefits to retirees
and to eligible spouses, surviving spouses and dependents of
such retirees.
(2) Definitions.--For purposes of this section:
(A) The term ``eligible employment-based plan''
means a group health plan or employment-based health
plan that--
(i) is --
(I) maintained by one or more
employers (including without limitation
any State or political subdivision
thereof, or any agency or
instrumentality of any of the
foregoing), former employers or
employee organizations or associations,
or 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 retirees.
(B) 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.
(C) The term ``participating employment-based
plan'' means an eligible employment-based plan that is
participating in the reinsurance program.
(D) The term ``retiree'' means, with respect to a
participating employment-benefit plan, an individual
who--
(i) is 55 years of age or older;
(ii) is not eligible for coverage under
title XVIII of the Social Security Act; and
(iii) is not an active employee of an
employer maintaining the plan or of any
employer that makes or has made substantial
contributions to fund such plan.
(E) The term ``Secretary'' means Secretary of
Health and Human Services.
(b) Participation.--To be eligible to participate in the
reinsurance program, an eligible employment-based plan shall submit 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.
(c) Payment.--
(1) Submission of claims.--
(A) In general.--Under the reinsurance program, 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.--Each claim 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 appropriate
employment based health benefits provided to a retiree
or to the spouse, surviving spouse, or dependent of a
retiree. In determining the amount of any 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 benefits. For purposes of calculating the
amount of any claim, the costs paid by the retiree or
by the spouse, surviving spouse, or dependent of the
retiree in the form of deductibles, copayments, and
coinsurance shall be included along with the amounts
paid by the participating employment-based plan.
(2) Program payments and limit.--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 exceeds $15,000, but is
less than $90,000. Such amounts shall be adjusted each year
based on the percentage increase in the medical care component
of the Consumer Price Index (rounded to the nearest multiple of
$1,000) for the year involved.
(3) Use of payments.--Amounts paid to a participating
employment-based plan under this subsection shall only be used
to reduce the costs of health care provided by the plan by
reducing premium costs for the employer or employee association
maintaining the plan, and reducing premium contributions,
deductibles, copayments, coinsurance, or other out-of-pocket
costs for plan participants and beneficiaries. Where the
benefits are provided by an employer to members of a
represented bargaining unit, the allocation of payments among
these purposes shall be subject to collective bargaining.
Amounts paid to the plan under this subsection shall not be
used as general revenues by the employer or employee
association maintaining the plan or for any other purposes. The
Secretary shall develop a mechanism to monitor the appropriate
use of such payments by such plans.
(4) Appeals and program protections.--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.
(5) Audits.--The Secretary shall conduct annual audits of
claims data submitted by participating employment-based plans
under this section to ensure that they are in compliance with
the requirements of this section.
(d) Retiree Reserve Trust Fund.--
(1) Establishment.--
(A) In general.--There is established in the
Treasury of the United States a trust fund to be known
as the ``Retiree Reserve Trust Fund'' (referred to in
this section as the ``Trust Fund''), that shall consist
of such amounts as may be appropriated or credited to
the Trust Fund as provided for in this subsection to
enable the Secretary to carry out the reinsurance
program. Such amounts shall remain available until
expended.
(B) Funding.--There are hereby appropriated to the
Trust Fund, out of any moneys in the Treasury not
otherwise appropriated, an amount requested by the
Secretary as necessary to carry out this section,
except that the total of all such amounts requested
shall not exceed $10,000,000,000.
(C) Appropriations from the trust fund.--
(i) In general.--Amounts in the Trust Fund
are appropriated to provide funding to carry
out the reinsurance program and shall be used
to carry out such program.
(ii) Limitation to available funds.--The
Secretary has the authority to stop taking
applications for participation in the program
or take such other steps in reducing
expenditures under the reinsurance program in
order to ensure that expenditures under the
reinsurance program do not exceed the funds
available under this subsection.
SEC. 112. WELLNESS PROGRAM GRANTS.
(a) Allowance of Grant.--
(1) In general.--For purposes of this section, the
Secretaries of Health and Human Services and Labor shall
jointly award wellness grants as determined under this section.
Wellness program grants shall be awarded to small employers (as
defined by the Secretary) for any plan year in an amount equal
to 50 percent of the costs paid or incurred by such employers
in connection with a qualified wellness program during the plan
year. For purposes of the preceding sentence, in the case of
any qualified wellness program offered as part of an
employment-based health plan, only costs attributable to the
qualified wellness program and not to the health plan, or
health insurance coverage offered in connection with such a
plan, may be taken into account.
(2) Limitations.--
(A) Period.--A wellness grant awarded to an
employer under this section shall be for up to 3 years.
(B) Amount.--The amount of the grant under
paragraph (1) for an employer shall not exceed--
(i) the product of $150 and the number of
employees of the employer for any plan year;
and
(ii) $50,000 for the entire period of the
grant.
(b) Qualified Wellness Program.--For purposes of this section:
(1) Qualified wellness program.--The term ``qualified
wellness program'' means a program that --
(A) includes any 3 wellness components described in
subsection (c); and
(B) is to be certified jointly by the Secretary of
Health and Human Services and the Secretary of Labor,
in coordination with the Director of the Centers for
Disease Control and Prevention, as a qualified wellness
program under this section.
(2) Programs must be consistent with research and best
practices.--
(A) In general.--The Secretary of Health and Human
Services and the Secretary of Labor shall not certify a
program as a qualified wellness program unless the
program--
(i) is consistent with evidence-based
research and best practices, as identified by
persons with expertise in employer health
promotion and wellness programs;
(ii) includes multiple, evidence-based
strategies which are based on the existing and
emerging research and careful scientific
reviews, including the Guide to Community
Preventative Services, the Guide to Clinical
Preventative Services, and the National
Registry for Effective Programs, and
(iii) includes strategies which focus on
prevention and support for employee populations
at risk of poor health outcomes.
(B) Periodic updating and review.--The Secretaries
of Health and Human Services and Labor, in consultation
with other appropriate agencies shall jointly establish
procedures for periodic review, evaluation, and update
of the programs under this subsection.
(3) Health literacy and accessibility.--The Secretaries of
Health and Human Services and Labor shall jointly, as part of
the certification process--
(A) ensure that employers make the programs
culturally competent, physically and programmatically
accessible (including for individuals with
disabilities), and appropriate to the health literacy
needs of the employees covered by the programs;
(B) require a health literacy component to provide
special assistance and materials to employees with low
literacy skills, limited English and from underserved
populations; and
(C) require the Secretaries to compile and
disseminate to employer health plans information on
model health literacy curricula, instructional
programs, and effective intervention strategies.
(c) Wellness Program Components.--For purposes of this section, the
wellness program components described in this subsection are the
following:
(1) Health awareness component.--A health awareness
component which provides for the following:
(A) Health education.--The dissemination of health
information which addresses the specific needs and
health risks of employees.
(B) Health screenings.--The opportunity for
periodic screenings for health problems and referrals
for appropriate follow-up measures.
(2) Employee engagement component.--An employee engagement
component which provides for the active engagement of employees
in worksite wellness programs through worksite assessments and
program planning, onsite delivery, evaluation, and improvement
efforts.
(3) Behavioral change component.--A behavioral change
component which encourages healthy living through counseling,
seminars, on-line programs, self-help materials, or other
programs which provide technical assistance and problem solving
skills. Such component may include programs relating to--
(A) tobacco use;
(B) obesity;
(C) stress management;
(D) physical fitness;
(E) nutrition;
(F) substance abuse;
(G) depression; and
(H) mental health promotion.
(4) Supportive environment component.--A supportive
environment component which includes the following:
(A) On-site policies.--Policies and services at the
worksite which promote a healthy lifestyle, including
policies relating to--
(i) tobacco use at the worksite;
(ii) the nutrition of food available at the
worksite through cafeterias and vending
options;
(iii) minimizing stress and promoting
positive mental health in the workplace; and
(iv) the encouragement of physical activity
before, during, and after work hours.
(d) Participation Requirement.--No grant shall be allowed under
subsection (a) unless the Secretaries of Health and Human Services and
Labor, in consultation with other appropriate agencies, jointly
certify, as a part of any certification described in subsection (b),
that each wellness program component of the qualified wellness
program--
(1) shall be available to all employees of the employer;
(2) shall not mandate participation by employees; and
(3) may provide a financial reward for participation of an
individual in such program so long as such reward is not tied
to the premium or cost-sharing of the individual under the
health benefits plan.
(e) Privacy Protections.--Data gathered for purposes of the
employer wellness program may be used solely for the purposes of
administering the program. The Secretaries of Health and Human Services
and Labor shall develop standards to ensure such data remain
confidential and are not used for purposes beyond those for
administering the program.
(f) Certain Costs Not Included.--For purposes of this section,
costs paid or incurred by an employer for food or health insurance
shall not be taken into account under subsection (a).
(g) Outreach.--The Secretaries of Health and Human Services and
Labor, in conjunction with other appropriate agencies and members of
the business community, shall jointly institute an outreach program to
inform businesses about the availability of the wellness program grant
as well as to educate businesses on how to develop programs according
to recognized and promising practices and on how to measure the success
of implemented programs.
(h) Effective Date.--This section shall take effect on July 1,
2010.
(i) Authorization of Appropriations.--There are authorized to be
appropriated such sums as are necessary to carry out this section.
SEC. 113. EXTENSION OF COBRA CONTINUATION COVERAGE.
(a) Extension of Current Periods of Continuation Coverage.--
(1) In general.--In the case of any individual who is,
under a COBRA continuation coverage provision, covered under
COBRA continuation coverage on or after the date of the
enactment of this Act, the required period of any such coverage
which has not subsequently terminated under the terms of such
provision for any reason other than the expiration of a period
of a specified number of months shall, notwithstanding such
provision and subject to subsection (b), extend to the earlier
of the date on which such individual becomes eligible for
acceptable coverage or the date on which such individual
becomes eligible for health insurance coverage through the
Health Insurance Exchange (or a State-based Health Insurance
Exchange operating in a State or group of States).
(2) Notice.--As soon as practicable after the date of the
enactment of this Act, the Secretary of Labor, in consultation
with the Secretary of the Treasury and the Secretary of Health
and Human Services, shall, in consultation with administrators
of the group health plans (or other entities) that provide or
administer the COBRA continuation coverage involved, provide
rules setting forth the form and manner in which prompt notice
to individuals of the continued availability of COBRA
continuation coverage to such individuals under paragraph (1).
(b) Continued Effect of Other Terminating Events.--Notwithstanding
subsection (a), any required period of COBRA continuation coverage
which is extended under such subsection shall terminate upon the
occurrence, prior to the date of termination otherwise provided in such
subsection, of any terminating event specified in the applicable
continuation coverage provision other than the expiration of a period
of a specified number of months.
(c) Access to State Health Benefits Risk Pools.--This section shall
supersede any provision of the law of a State or political subdivision
thereof to the extent that such provision has the effect of limiting or
precluding access by a qualified beneficiary whose COBRA continuation
coverage has been extended under this section to a State health
benefits risk pool recognized by the Commissioner for purposes of this
section solely by reason of the extension of such coverage beyond the
date on which such coverage otherwise would have expired.
(d) Definitions.--For purposes of this section--
(1) COBRA continuation coverage.--The term ``COBRA
continuation coverage'' means continuation coverage provided
pursuant to part 6 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (other than under
section 609), title XXII of the Public Health Service Act,
section 4980B of the Internal Revenue Code of 1986 (other than
subsection (f)(1) of such section insofar as it relates to
pediatric vaccines), or section 905a of title 5, United States
Code, or under a State program that provides comparable
continuation coverage. Such term does not include coverage
under a health flexible spending arrangement under a cafeteria
plan within the meaning of section 125 of the Internal Revenue
Code of 1986.
(2) COBRA continuation provision.--The term ``COBRA
continuation provision'' means the provisions of law described
in paragraph (1).
SEC. 114. STATE HEALTH ACCESS PROGRAM GRANTS.
(a) In General.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary'') shall provide grants to
States (as defined for purposes of title XIX of the Social Security
Act) to establish programs to expand access to affordable health care
coverage for the uninsured populations in that State in a manner
consistent with reforms to take effect under this division in Y1.
(b) Types of Programs.--The types of programs for which grants are
available under subsection (a) include the following:
(1) State insurance exchanges.--State insurance exchanges
that develop new, less expensive, portable benefit packages for
small employers and part-time and seasonal workers.
(2) Community coverage program.--Community coverage with
shared responsibility between employers, governmental or
nonprofit entity, and the individual.
(3) Reinsurance plan program.--Reinsurance plans that
subsidize a certain share of carrier losses within a certain
risk corridor health insurance premium assistance.
(4) Transparent marketplace program.--Transparent
marketplace that provides an organized structure for the sale
of insurance products such as a Web exchange or portal.
(5) Automated enrollment program.--Statewide or automated
enrollment systems for public assistance programs.
(6) Innovative strategies.--Innovative strategies to insure
low-income childless adults.
(7) Purchasing collaboratives.--Business/consumer
collaborative that provides direct contract health care service
purchasing options for group plan sponsors.
(c) Eligibility and Administration.--
(1) Implementation of key statutory or regulatory
changes.--In order to be awarded a grant under this section for
a program, a State shall demonstrate that--
(A) it has achieved the key State and local
statutory or regulatory changes required to begin
implementing the new program within 1 year after the
initiation of funding under the grant; and
(B) it will be able to sustain the program without
Federal funding after the end of the period of the
grant.
(2) Ineligibility.--A State that has already developed a
comprehensive health insurance access program is not eligible
for a grant under this section.
(3) Application required.--No State shall receive a grant
under this section unless the State has approved by the
Secretary such an application, in such form and manner as the
Secretary specifies.
(4) Administration based on current program.--The program
under this section is intended to build on the State Health
Access Program funded under the Omnibus Appropriations Act,
2009 (Public Law 111-8).
(d) Funding Limitations.--
(1) In general.--A grant under this section shall--
(A) only be available for expenditures before Y1;
and
(B) only be used to supplement, and not supplant,
funds otherwise provided.
(2) Matching fund requirement.--
(A) In general.--Subject to subparagraph (B), no
grant may be awarded to a State unless the State
demonstrates the seriousness of its effort by matching
at least 20 percent of the grant amount through non-
Federal resources, which may be a combination of State,
local, private dollars from insurers, providers, and
other private organizations.
(B) Waiver.--The Secretary may waive the
requirement of subparagraph (A) if the State
demonstrates to the Secretary financial hardship in
complying with such requirement.
(e) Study.--The Secretary shall review, study, and benchmark the
progress and results of the programs funded under this section.
(f) Report.--Each State receiving a grant under this section shall
submit to the Secretary a report on best practices and lessons learned
through the grant to inform the health reform coverage expansions under
this division beginning in Y1.
(g) Funding.--There are authorized to be appropriated such sums as
may be necessary to carry out this section.
SEC. 115. ADMINISTRATIVE SIMPLIFICATION.
(a) Standardizing Electronic Administrative Transactions.--
(1) In general.--Part C of title XI of the Social Security
Act (42 U.S.C. 1320d et seq.) is amended by inserting after
section 1173 the following new sections:
``SEC. 1173A. STANDARDIZE ELECTRONIC ADMINISTRATIVE TRANSACTIONS.
``(a) Standards for Financial and Administrative Transactions.--
``(1) In general.--The Secretary shall adopt and regularly
update standards consistent with the goals described in
paragraph (2).
``(2) Goals for financial and administrative
transactions.--The goals for standards under paragraph (1) are
that such standards shall, to the extent practicable--
``(A) be unique with no conflicting or redundant
standards;
``(B) be authoritative, permitting no additions or
constraints for electronic transactions, including
companion guides;
``(C) be comprehensive, efficient and robust,
requiring minimal augmentation by paper transactions or
clarification by further communications;
``(D) enable the real-time (or near real-time)
determination of an individual's financial
responsibility at the point of service and, to the
extent possible, prior to service, including whether
the individual is eligible for a specific service with
a specific physician at a specific facility, on a
specific date or range of dates, include utilization of
a machine-readable health plan beneficiary
identification card or similar mechanism;
``(E) enable, where feasible, near real-time
adjudication of claims;
``(F) provide for timely acknowledgment, response,
and status reporting applicable to any electronic
transaction deemed appropriate by the Secretary;
``(G) describe all data elements (such as reason
and remark codes) in unambiguous terms, not permit
optional fields, require that data elements be either
required or conditioned upon set values in other
fields, and prohibit additional conditions except where
required by (or to implement) State or Federal law or
to protect against fraud and abuse; and
``(H) harmonize all common data elements across
administrative and clinical transaction standards.
``(3) Time for adoption.--Not later than 2 years after the
date of the enactment of this section, the Secretary shall
adopt standards under this section by interim, final rule.
``(4) Requirements for specific standards.--The standards
under this section shall be developed, adopted, and enforced so
as to--
``(A) clarify, refine, complete, and expand, as
needed, the standards required under section 1173;
``(B) require paper versions of standardized
transactions to comply with the same standards as to
data content such that a fully compliant, equivalent
electronic transaction can be populated from the data
from a paper version;
``(C) enable electronic funds transfers, in order
to allow automated reconciliation with the related
health care payment and remittance advice;
``(D) require timely and transparent claim and
denial management processes, including uniform claim
edits, uniform reason and remark denial codes,
tracking, adjudication, and appeal processing;
``(E) require the use of a standard electronic
transaction with which health care providers may
quickly and efficiently enroll with a health plan to
conduct the other electronic transactions provided for
in this part; and
``(F) provide for other requirements relating to
administrative simplification as identified by the
Secretary, in consultation with stakeholders.
``(5) Building on existing standards.--In adopting the
standards under this section, the Secretary shall consider
existing and planned standards.
``(6) Implementation and enforcement.--Not later than 6
months after the date of the enactment of this section, the
Secretary shall submit to the appropriate committees of
Congress a plan for the implementation and enforcement, by not
later than 5 years after such date of enactment, of the
standards under this section. Such plan shall include--
``(A) a process and timeframe with milestones for
developing the complete set of standards;
``(B) a proposal for accommodating necessary
changes between version changes and a process for
upgrading standards as often as annually by interim,
final rulemaking;
``(C) programs to provide incentives for, and ease
the burden of, implementation for certain health care
providers, with special consideration given to such
providers serving rural or underserved areas and ensure
coordination with standards, implementation
specifications, and certification criteria being
adopted under the HITECH Act;
``(D) programs to provide incentives for, and ease
the burden of, health care providers who volunteer to
participate in the process of setting standards for
electronic transactions;
``(E) an estimate of total funds needed to ensure
timely completion of the implementation plan; and
``(F) an enforcement process that includes timely
investigation of complaints, random audits to ensure
compliance, civil monetary and programmatic penalties
for noncompliance consistent with existing laws and
regulations, and a fair and reasonable appeals process
building off of enforcement provisions under this part,
and concurrent State enforcement jurisdiction.
The Secretary may promulgate an annual audit and certification
process to ensure that all health plans and clearinghouses are
both syntactically and functionally compliant with all the
standard transactions mandated pursuant to the administrative
simplification provisions of this part and the Health Insurance
Portability and Accountability Act of 1996.
``(b) 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 violate State or Federal law.
``(c) Protection of Data.--The Secretary shall ensure (through the
promulgation of regulations or otherwise) that all data collected
pursuant to subsection (a) are used and disclosed in a manner that
meets the HIPAA privacy and security law (as defined in section
3009(a)(2) of the Public Health Service Act), including any privacy or
security standard adopted under section 3004 of such Act.
``SEC. 1173B. INTERIM COMPANION GUIDES, INCLUDING OPERATING RULES.
``(a) In General.--The Secretary shall adopt a single, binding,
comprehensive companion guide, that includes operating rules for each
X12 Version 5010 transaction described in section 1173(a)(2), to be
effective until the new version of these transactions which comply with
section 1173A are adopted and implemented.
``(b) Companion Guide and Operating Rules Development.--In adopting
such interim companion guide and rules, the Secretary shall comply with
section 1172, except that a nonprofit entity that meets the following
criteria shall also be consulted:
``(1) The entity focuses its mission on administrative
simplification.
``(2) The entity uses a multistakeholder process that
creates consensus-based companion guides, including operating
rules using a voting process that ensures balanced
representation by the critical stakeholders (including health
plans and health care providers) so that no one group dominates
the entity and shall include others such as standards
development organizations, and relevant Federal or State
agencies.
``(3) The entity has in place a public set of guiding
principles that ensure the companion guide and operating rules
and process are open and transparent.
``(4) The entity coordinates its activities with the HIT
Policy Committee, and the HIT Standards Committee (established
under title XXX of the Public Health Service Act) and
complements the efforts of the Office of the National
Healthcare Coordinator and its related health information
exchange goals.
``(5) The entity incorporates the standards issued under
Health Insurance Portability and Accountability Act of 1996 and
this part, and in developing the companion guide and operating
rules does not change the definition, data condition or use of
a data element or segment in a standard, add any elements or
segments to the maximum defined data set, use any codes or data
elements that are either marked `not used' in the standard's
implementation specifications or are not in the standard's
implementation specifications, or change the meaning or intent
of the standard's implementation specifications.
``(6) The entity uses existing market research and proven
best practices.
``(7) The entity has a set of measures that allow for the
evaluation of their market impact and public reporting of
aggregate stakeholder impact.
``(8) The entity supports nondiscrimination and conflict of
interest policies that demonstrate a commitment to open, fair,
and nondiscriminatory practices.
``(9) The entity allows for public reviews and comment on
updates of the companion guide, including the operating rules.
``(c) Implementation.--The Secretary shall adopt a single, binding
companion guide, including operating rules under this section, for each
transaction, to become effective with the X12 Version 5010 transaction
implementation, or as soon thereafter as feasible. The companion guide,
including operating rules for the transactions for eligibility for
health plan and health claims status under this section shall be
adopted not later than October 1, 2011, in a manner such that such set
of rules is effective beginning not later than January 1, 2013. The
companion guide, including operating rules for the remainder of the
transactions described in section 1173(a)(2) shall be adopted not later
than October 1, 2012, in a manner such that such set of rules is
effective beginning not later than January 1, 2014.''.
(2) Definitions.--Section 1171 of such Act (42 U.S.C.
1320d) is amended--
(A) in paragraph (1), by inserting ``, and
associated operational guidelines and instructions, as
determined appropriate by the Secretary'' after
``medical procedure codes''; and
(B) by adding at the end the following new
paragraph:
``(10) Operating rules.--The term `operating rules' means
business rules for using and processing transactions, such as
service level requirements, which do not impact the
implementation specifications or other data content
requirements.''.
(3) Conforming amendment.--Section 1179(a) of such Act (42
U.S.C. 1320d-8(a)) is amended, in the matter before paragraph
(1)--
(A) by inserting ``on behalf of an individual''
after ``1978)''; and
(B) by inserting ``on behalf of an individual''
after ``for a financial institution'' and
(b) Standards for Claims Attachments and Coordination of
Benefits.--
(1) Standard for health claims attachments.--Not later than
1 year after the date of the enactment of this Act, the
Secretary of Health and Human Services shall promulgate an
interim, final rule to establish a standard for health claims
attachment transaction described in section 1173(a)(2)(B) of
the Social Security Act (42 U.S.C. 1320d-2(a)(2)(B)) and
coordination of benefits.
(2) Revision in processing payment transactions by
financial institutions.--
(A) In general.--Section 1179 of the Social
Security Act (42 U.S.C. 1320d-8) is amended, in the
matter before paragraph (1)--
(i) by striking ``or is engaged'' and
inserting ``and is engaged''; and
(ii) by inserting ``(other than as a
business associate for a covered entity)''
after ``for a financial institution''.
(B) Compliance date.--The amendments made by
subparagraph (A) shall apply to transactions occurring
on or after such date (not later than January 1, 2014)
as the Secretary of Health and Human Services shall
specify.
(c) Standards for First Report of Injury.--Not later than January
1, 2014, the Secretary of Health and Human Services shall promulgate an
interim final rule to establish a standard for the first report of
injury transaction described in section 1173(a)(2)(G) of the Social
Security Act (42 U.S.C. 1320d-2(a)(2)(G)).
(d) Unique Health Plan Identifier.--Not later October 1, 2012, the
Secretary of Health and Human Services shall promulgate an interim
final rule to establish a unique health plan identifier 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 of Vital and Health Statistics
and consultation with health plans, health care providers, and other
interested parties.
(e) 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 ``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) subject to subsection (h), not later than January 1,
2015, for which the payment is other than by electronic funds
transfer (EFT) so long as the Secretary has adopted and
implemented a standard for electronic funds transfer under
section 1173A.''.
(f) Expansion of Penalties.--Section 1176 of such Act (42 U.S.C.
1320d-5) is amended by adding at the end the following new subsection:
``(c) Expansion of Penalty Authority.--The Secretary may, in
addition to the penalties provided under subsections (a) and (b),
provide for the imposition of penalties for violations of this part
that are comparable--
``(1) in the case of health plans, to the sanctions the
Secretary is authorized to impose under part C or D of title
XVIII in the case of a plan that violates a provision of such
part; or
``(2) in the case of a health care provider, to the
sanctions the Secretary is authorized to impose under part A,
B, or D of title XVIII in the case of a health care provider
that violations a provision of such part with respect to that
provider.''.
TITLE II--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS
Subtitle A--General Standards
SEC. 201. REQUIREMENTS REFORMING HEALTH INSURANCE MARKETPLACE.
(a) Purpose.--The purpose of this title is to establish standards
to ensure that new health insurance coverage and employment-based
health plans that are offered meet standards guaranteeing access to
affordable coverage, essential benefits, and other consumer
protections.
(b) Requirements for Qualified Health Benefits Plans.--On or after
the first day of Y1, a health benefits plan shall not be a qualified
health benefits plan under this division unless the plan meets the
applicable requirements of the following subtitles for the type of plan
and plan year involved:
(1) Subtitle B (relating to affordable coverage).
(2) Subtitle C (relating to essential benefits).
(3) Subtitle D (relating to consumer protection).
(c) Terminology.--In this division:
(1) Enrollment in employment-based health plans.--An
individual shall be treated as being ``enrolled'' in an
employment-based health plan if the individual is a participant
or beneficiary (as such terms are defined in section 3(7) and
3(8), respectively, of the Employee Retirement Income Security
Act of 1974) in such plan.
(2) Individual and group health insurance coverage.--The
terms ``individual health insurance coverage'' and ``group
health insurance coverage'' mean health insurance coverage
offered in the individual market or large or small group
market, respectively, as defined in section 2791 of the Public
Health Service Act.
SEC. 202. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE.
(a) Grandfathered Health Insurance Coverage Defined.--Subject to
the succeeding provisions of this section, for purposes of establishing
acceptable coverage under this division, the term ``grandfathered
health insurance coverage'' means individual health insurance coverage
that is offered and in force and effect before the first day of Y1 if
the following conditions are met:
(1) Limitation on new enrollment.--
(A) In general.--Except as provided in this
paragraph, the individual health insurance issuer
offering such coverage does not enroll any individual
in such coverage if the first effective date of
coverage is on or after the first day of Y1.
(B) Dependent coverage permitted.--Subparagraph (A)
shall not affect the subsequent enrollment of a
dependent of an individual who is covered as of such
first day.
(2) Limitation on changes in terms or conditions.--Subject
to paragraph (3) and except as required by law, the issuer does
not change any of its terms or conditions, including benefits
and cost-sharing, from those in effect as of the day before the
first day of Y1.
(3) Restrictions on premium increases.--The issuer cannot
vary the percentage increase in the premium for a risk group of
enrollees in specific grandfathered health insurance coverage
without changing the premium for all enrollees in the same risk
group at the same rate, as specified by the Commissioner.
(b) Grace Period for Current Employment-Based Health Plans.--
(1) Grace period.--
(A) In general.--The Commissioner shall establish a
grace period whereby, for plan years beginning after
the end of the 5-year period beginning with Y1, an
employment-based health plan in operation as of the day
before the first day of Y1 must meet the same
requirements as apply to a qualified health benefits
plan under section 201, including the essential benefit
package requirement under section 221.
(B) Exception for limited benefits plans.--
Subparagraph (A) shall not apply to an employment-based
health plan in which the coverage consists only of one
or more of the following:
(i) Any coverage described in section
3001(a)(1)(B)(ii)(IV) of division B of the
American Recovery and Reinvestment Act of 2009
(Public Law 111-5).
(ii) Excepted benefits (as defined in
section 733(c) of the Employee Retirement
Income Security Act of 1974), including
coverage under a specified disease or illness
policy described in paragraph (3)(A) of such
section.
(iii) Such other limited benefits as the
Commissioner may specify.
In no case shall an employment-based health plan in
which the coverage consists only of one or more of the
coverage or benefits described in clauses (i) through
(iii) be treated as acceptable coverage under this
division.
(2) Transitional treatment as acceptable coverage.--During
the grace period specified in paragraph (1)(A), an employment-
based health plan (which may be a high deducible health plan,
as defined in section 223(c)(2) of the Internal Revenue Code of
1986) that is described in such paragraph shall be treated as
acceptable coverage under this division.
(c) Limitation on Individual Health Insurance Coverage.--
(1) In general.--Individual health insurance coverage that
is not grandfathered health insurance coverage under subsection
(a) may only be offered on or after the first day of Y1 as an
Exchange-participating health benefits plan.
(2) Separate, excepted coverage permitted.--Nothing in--
(A) paragraph (1) shall prevent the offering of
excepted benefits described in section 2791(c) of the
Public Health Service Act so long as such benefits are
offered outside the Health Insurance Exchange and are
priced separately from health insurance coverage; and
(B) this division shall be construed--
(i) to prevent the offering of a stand-
alone plan that offers coverage of excepted
benefits described in section 2791(c)(2)(A) of
the Public Health Service Act (relating to
limited scope dental or vision benefits) for
individuals and families from a State-licensed
dental and vision carrier; or
(ii) as applying requirements for a
qualified health benefits plan to such a stand-
alone plan that is offered and priced
separately from a qualified health benefits
plan.
Subtitle B--Standards Guaranteeing Access to Affordable Coverage
SEC. 211. PROHIBITING PREEXISTING CONDITION EXCLUSIONS.
A qualified health benefits plan may not impose any preexisting
condition exclusion (as defined in section 2701(b)(1)(A) of the Public
Health Service Act) or otherwise impose any limit or condition on the
coverage under the plan with respect to an individual or dependent
based on any of the following: health status, medical condition, claims
experience, receipt of health care, medical history, genetic
information, evidence of insurability, disability, or source of injury
(including conditions arising out of acts of domestic violence) or any
similar factors.
SEC. 212. GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS AND
PROHIBITING RESCISSIONS.
The requirements of sections 2711 (other than subsections (e) and
(f)) and 2712 (other than paragraphs (3), and (6) of subsection (b) and
subsection (e)) of the Public Health Service Act, relating to
guaranteed availability and renewability of health insurance coverage,
shall apply to individuals and employers in all individual and group
health insurance coverage, whether offered to individuals or employers
through the Health Insurance Exchange, through any employment-based
health plan, or otherwise, in the same manner as such sections apply to
employers and health insurance coverage offered in the small group
market, except that such section 2712(b)(1) shall apply only if, before
nonrenewal or discontinuation of coverage, the issuer has provided the
enrollee with notice of nonpayment of premiums and there is a grace
period during which the enrollee has an opportunity to correct such
nonpayment. Rescissions of such coverage shall be prohibited except in
cases of fraud as defined in section 2712(b)(2) of such Act.
SEC. 213. INSURANCE RATING RULES.
(a) In General.--The premium rate charged for a qualified health
benefits plan that is health insurance coverage may not vary except as
follows:
(1) Limited age variation permitted.--By age (within such
age categories as the Commissioner shall specify) so long as
the ratio of the highest such premium to the lowest such
premium does not exceed the ratio of 2 to 1.
(2) By area.--By premium rating area (as permitted by State
insurance regulators or, in the case of Exchange-participating
health benefits plans, as specified by the Commissioner in
consultation with such regulators).
(3) By family enrollment.--By family enrollment (such as
variations within categories and compositions of families) so
long as the ratio of the premium for family enrollment (or
enrollments) to the premium for individual enrollment is
uniform, as specified under State law and consistent with rules
of the Commissioner.
(b) Actuarial Value of Optional Service Coverage.--
(1) In general.--The Commissioner shall estimate the basic
per enrollee, per month cost, determined on an average
actuarial basis, for including coverage under a basic plan of
the services described in section 222(d)(4)(A).
(2) Considerations.--In making such estimate the
Commissioner--
(A) 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;
(B) shall estimate such costs as if such coverage
were included for the entire population covered; and
(C) may not estimate such a cost at less than $1
per enrollee, per month.
(c) Study and Reports.--
(1) Study.--The Commissioner, in coordination with the
Secretary of Health and Human Services and the Secretary of
Labor, shall conduct a study of the large-group-insured and
self-insured employer health care markets. Such study shall
examine the following:
(A) The types of employers by key characteristics,
including size, that purchase insured products versus
those that self-insure.
(B) The similarities and differences between
typical insured and self-insured health plans.
(C) The financial solvency and capital reserve
levels of employers that self-insure by employer size.
(D) The risk of self-insured employers not being
able to pay obligations or otherwise becoming
financially insolvent.
(E) The extent to which rating rules are likely to
cause adverse selection in the large group market or to
encourage small and midsize employers to self-insure.
(2) Reports.--Not later than 18 months after the date of
the enactment of this Act, the Commissioner shall submit to
Congress and the applicable agencies a report on the study
conducted under paragraph (1). Such report shall include any
recommendations the Commissioner deems appropriate to ensure
that the law does not provide incentives for small and midsize
employers to self-insure or create adverse selection in the
risk pools of large group insurers and self-insured employers.
Not later than 18 months after the first day of Y1, the
Commissioner shall submit to Congress and the applicable
agencies an updated report on such study, including updates on
such recommendations.
SEC. 214. NONDISCRIMINATION IN BENEFITS; PARITY IN MENTAL HEALTH AND
SUBSTANCE ABUSE DISORDER BENEFITS.
(a) Nondiscrimination in Benefits.--A qualified health benefits
plan shall comply with standards established by the Commissioner to
prohibit discrimination in health benefits or benefit structures for
qualifying health benefits plans, building from section 702 of the
Employee Retirement Income Security Act of 1974, section 2702 of the
Public Health Service Act, and section 9802 of the Internal Revenue
Code of 1986.
(b) Parity in Mental Health and Substance Abuse Disorder
Benefits.--To the extent such provisions are not superceded by or
inconsistent with subtitle C, the provisions of section 2705 (other
than subsections (a)(1), (a)(2), and (c)) of the Public Health Service
Act shall apply to a qualified health benefits plan, regardless of
whether it is offered in the individual or group market, in the same
manner as such provisions apply to health insurance coverage offered in
the large group market.
SEC. 215. ENSURING ADEQUACY OF PROVIDER NETWORKS.
(a) In General.--A qualified health benefits plan that uses a
provider network for items and services shall meet such standards
respecting provider networks as the Commissioner may establish to
assure the adequacy of such networks in ensuring enrollee access to
such items and services and transparency in the cost-sharing
differentials among providers participating in the network and policies
for accessing out-of-network providers.
(b) Internet Access to Information.--A qualified health benefits
plan that uses a provider network shall provide a current listing of
all providers in its network on its Website and such data shall be
available on the Health Insurance Exchange Website as a part of the
basic information on that plan. The Commissioner shall also establish
an on-line system whereby an individual may select by name any medical
provider (as defined by the Commissioner) and be informed of the plan
or plans with which that provider is contracting.
(c) Provider Network Defined.--In this division, the term
``provider network'' means the providers with respect to which covered
benefits, treatments, and services are available under a health
benefits plan.
SEC. 216. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE FOR
UNINSURED YOUNG ADULTS.
(a) In General.--A qualified health benefits plan shall make
available, at the option of the principal enrollee under the plan,
coverage for one or more qualified children (as defined in subsection
(b)) of the enrollee.
(b) Qualified Child Defined.--In this section, the term ``qualified
child'' means, with respect to a principal enrollee in a qualified
health benefits plan, an individual who (but for age) would be treated
as a dependent child of the enrollee under such plan and who--
(1) is under 27 years of age; and
(2) is not enrolled in a health benefits plan other than
under this section.
(c) Premiums.--Nothing in this section shall be construed as
preventing a qualified health benefits plan from increasing the
premiums otherwise required for coverage provided under this section
consistent with standards established by the Commissioner based upon
family size under section 213(a)(3).
SEC. 217. CONSISTENCY OF COSTS AND COVERAGE UNDER QUALIFIED HEALTH
BENEFITS PLANS DURING PLAN YEAR.
In the case of health insurance coverage offered under a qualified
health benefits plan, if the coverage decreases or the cost-sharing
increases, the issuer of the coverage shall notify enrollees of the
change at least 90 days before the change takes effect (or such shorter
period of time in cases where the change is necessary to ensure the
health and safety of enrollees).
Subtitle C--Standards Guaranteeing Access to Essential Benefits
SEC. 221. COVERAGE OF ESSENTIAL BENEFITS PACKAGE.
(a) In General.--A qualified health benefits plan shall provide
coverage that at least meets the benefit standards adopted under
section 224 for the essential benefits package described in section 222
for the plan year involved.
(b) Choice of Coverage.--
(1) Non-exchange-participating health benefits plans.--In
the case of a qualified health benefits plan that is not an
Exchange-participating health benefits plan, such plan may
offer such coverage in addition to the essential benefits
package as the QHBP offering entity may specify.
(2) Exchange-participating health benefits plans.--In the
case of an Exchange-participating health benefits plan, such
plan is required under section 203 to provide specified levels
of benefits and, in the case of a plan offering a premium-plus
level of benefits, provide additional benefits.
(3) Continuation of offering of separate excepted benefits
coverage.--Nothing in this division shall be construed as
affecting the offering outside of the Health Insurance Exchange
and under State law of health benefits in the form of excepted
benefits (described in section 202(b)(1)(B)(ii)) if such
benefits are offered under a separate policy, contract, or
certificate of insurance.
(c) Clinical Appropriateness.--Nothing in this Act shall be
construed to prohibit a group health plan or health insurance issuer
from using medical management practices so long as such management
practices are based on valid medical evidence and are relevant to the
patient whose medical treatment is under review.
(d) Provision of Benefits.--Nothing in this division shall be
construed as prohibiting a qualified health benefits plan from
subcontracting with stand-alone health insurance issuers or insurers
for the provision of dental, vision, mental health, and other benefits
and services.
SEC. 222. ESSENTIAL BENEFITS PACKAGE DEFINED.
(a) In General.--In this division, the term ``essential benefits
package'' means health benefits coverage, consistent with standards
adopted under section 224, to ensure the provision of quality health
care and financial security, that--
(1) provides payment for the items and services described
in subsection (b) in accordance with generally accepted
standards of medical or other appropriate clinical or
professional practice;
(2) limits cost-sharing for such covered health care items
and services in accordance with such benefit standards,
consistent with subsection (c);
(3) does not impose any annual or lifetime limit on the
coverage of covered health care items and services;
(4) complies with section 215(a) (relating to network
adequacy); and
(5) is equivalent in its scope of benefits, as certified by
Office of the Actuary of the Centers for Medicare & Medicaid
Services, to the average prevailing employer-sponsored coverage
in Y1.
In order to carry out paragraph (5), 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 Health Benefits Advisory
Committee and to the Secretary of Health and Human Services.
(b) Minimum Services To Be Covered.--Subject to subsection (d), the
items and services described in this subsection are the following:
(1) Hospitalization.
(2) Outpatient hospital and outpatient clinic services,
including emergency department services.
(3) Professional services of physicians and other health
professionals.
(4) Such services, equipment, and supplies incident to the
services of a physician's or a health professional's delivery
of care in institutional settings, physician offices, patients'
homes or place of residence, or other settings, as appropriate.
(5) Prescription drugs.
(6) Rehabilitative and habilitative services.
(7) Mental health and substance use disorder services,
including behavioral health treatments.
(8) Preventive services, including those services
recommended with a grade of A or B by the Task Force on
Clinical Preventive Services and those vaccines recommended for
use by the Director of the Centers for Disease Control and
Prevention.
(9) Maternity care.
(10) Well-baby and well-child care and oral health, vision,
and hearing services, equipment, and supplies for children
under 21 years of age.
(11) Durable medical equipment, prosthetics, orthotics and
related supplies.
(c) Requirements Relating to Cost-Sharing and Minimum Actuarial
Value.--
(1) No cost-sharing for preventive services.--There shall
be no cost-sharing under the essential benefits package for--
(A) preventive items and services recommended with
a grade of A or B by the Task Force on Clinical
Preventive Services and those vaccines recommended for
use by the Director of the Centers for Disease Control
and Prevention; or
(B) well-baby and well-child care.
(2) Annual limitation.--
(A) Annual limitation.--The cost-sharing incurred
under the essential benefits package with respect to an
individual (or family) for a year does not exceed the
applicable level specified in subparagraph (B).
(B) Applicable level.--The applicable level
specified in this subparagraph for Y1 is not to exceed
$5,000 for an individual and not to exceed $10,000 for
a family. Such levels shall be increased (rounded to
the nearest $100) for each subsequent year by the
annual percentage increase in the enrollment-weighted
average of premium increases for basic plans applicable
to such year, except that Secretary shall adjust such
increase to ensure that the applicable level specified
in this subparagraph meets the minimum actuarial value
required under paragraph (3).
(C) Use of copayments.--In establishing cost-
sharing levels for basic, enhanced, and premium plans
under this subsection, the Secretary shall, to the
maximum extent possible, use only copayments and not
coinsurance.
(3) Minimum actuarial value.--
(A) In general.--The cost-sharing under the
essential benefits package shall be designed to provide
a level of coverage that is designed to provide
benefits that are actuarially equivalent to
approximately 70 percent of the full actuarial value of
the benefits provided under the reference benefits
package described in subparagraph (B).
(B) Reference benefits package described.--The
reference benefits package described in this
subparagraph is the essential benefits package if there
were no cost-sharing imposed.
(d) Assessment and Counseling for Domestic Violence.--The Secretary
shall support the need for an assessment and brief counseling for
domestic violence as part of a behavioral health assessment or primary
care visit and determine the appropriate coverage for such assessment
and counseling.
(e) Abortion Coverage Prohibited as Part of Minimum Benefits
Package.--
(1) Prohibition of required coverage.--The Health Benefits
Advisory Committee may not recommend under section 223(b), and
the Secretary may not adopt in standards under section 224(b),
the services described in paragraph (4)(A) or (4)(B) as part of
the essential benefits package and the Commissioner may not
require such services for qualified health benefits plans to
participate in the Health Insurance Exchange.
(2) Voluntary choice of coverage by plan.--In the case of a
qualified health benefits plan, the plan is not required (or
prohibited) under this Act from providing coverage of services
described in paragraph (4)(A) or (4)(B) and the QHBP offering
entity shall determine whether such coverage is provided.
(3) Coverage under public health insurance option.--The
public health insurance option shall provide coverage for
services described in paragraph (4)(B). Nothing in this Act
shall be construed as preventing the public health insurance
option from providing for or prohibiting coverage of services
described in paragraph (4)(A).
(4) Abortion services.--
(A) Abortions for which public funding is
prohibited.--The services described in this
subparagraph 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.
(B) Abortions for which public funding is
allowed.--The services described in this subparagraph
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.
(f) Report Regarding Inclusion of Oral Health Care in Essential
Benefits Package.--Not later than 1 year after the date of the
enactment of this Act, the Secretary of Health and Human Services shall
submit to Congress a report containing the results of a study
determining the need and cost of providing accessible and affordable
oral health care to adults as part of the essential benefits package.
SEC. 223. HEALTH BENEFITS ADVISORY COMMITTEE.
(a) Establishment.--
(1) In general.--There is established a private-public
advisory committee which shall be a panel of medical and other
experts to be known as the Health Benefits Advisory Committee
to recommend covered benefits and essential, enhanced, and
premium plans.
(2) Chair.--The Surgeon General shall be a member and the
chair of the Health Benefits Advisory Committee.
(3) Membership.--The Health Benefits Advisory Committee
shall be composed of the following members, in addition to the
Surgeon General:
(A) Nine members who are not Federal employees or
officers and who are appointed by the President.
(B) Nine members who are not Federal employees or
officers and who are appointed by the Comptroller
General of the United States in a manner similar to the
manner in which the Comptroller General appoints
members to the Medicare Payment Advisory Commission
under section 1805(c) of the Social Security Act.
(C) Such even number of members (not to exceed 8)
who are Federal employees and officers, as the
President may appoint.
Such initial appointments shall be made not later than 60 days
after the date of the enactment of this Act.
(4) Terms.--Each member of the Health Benefits Advisory
Committee shall serve a 3-year term on the Committee, except
that the terms of the initial members shall be adjusted in
order to provide for a staggered term of appointment for all
such members.
(5) Participation.--The membership of the Health Benefits
Advisory Committee shall at least reflect providers, patient
representatives, employers (including small employers), labor,
health insurance issuers, experts in health care financing and
delivery, experts in oral health care, experts in racial and
ethnic disparities, experts on health care needs and
disparities of individuals with disabilities, representatives
of relevant governmental agencies, and at least one practicing
physician or other health professional and an expert in child
and adolescent health and shall represent a balance among
various sectors of the health care system so that no single
sector unduly influences the recommendations of such Committee.
(b) Duties.--
(1) Recommendations on benefit standards.--The Health
Benefits Advisory Committee shall recommend to the Secretary of
Health and Human Services (in this subtitle referred to as the
``Secretary'') benefit standards (as defined in paragraph (5)),
and periodic updates to such standards. In developing such
recommendations, the Committee shall take into account
innovation in health care and consider how such standards could
reduce health disparities.
(2) Deadline.--The Health Benefits Advisory Committee shall
recommend initial benefit standards to the Secretary not later
than 1 year after the date of the enactment of this Act.
(3) State input.--The Health Benefits Advisory Committee
shall examine the health coverage laws and benefits of each
State in developing recommendations under this subsection and
may incorporate such coverage and benefits as the Committee
determines to be appropriate and consistent with this Act. The
Health Benefits Advisory Committee shall also seek input from
the States and consider recommendations on how to ensure
quality of health coverage in all States.
(4) Public input.--The Health Benefits Advisory Committee
shall allow for public input as a part of developing
recommendations under this subsection.
(5) Benefit standards defined.--In this subtitle, the term
``benefit standards'' means standards respecting--
(A) the essential benefits package described in
section 222, including categories of covered
treatments, items and services within benefit classes,
and cost-sharing consistent with subsection (d) of such
section; and
(B) the cost-sharing levels for enhanced plans and
premium plans (as provided under section 303(c))
consistent with paragraph (5).
(6) Levels of cost-sharing for enhanced and premium
plans.--
(A) Enhanced plan.--The level of cost-sharing for
enhanced plans shall be designed so that such plans
have benefits that are actuarially equivalent to
approximately 85 percent of the actuarial value of the
benefits provided under the reference benefits package
described in section 222(c)(3)(B).
(B) Premium plan.--The level of cost-sharing for
premium plans shall be designed so that such plans have
benefits that are actuarially equivalent to
approximately 95 percent of the actuarial value of the
benefits provided under the reference benefits package
described in section 222(c)(3)(B).
(c) Operations.--
(1) Per diem pay.--Each member of the Health Benefits
Advisory Committee shall receive travel expenses, including per
diem in accordance with applicable provisions under subchapter
I of chapter 57 of title 5, United States Code, and shall
otherwise serve without additional pay.
(2) Members not treated as federal employees.--Members of
the Health Benefits Advisory Committee shall not be considered
employees of the Federal Government solely by reason of any
service on the Committee, except such members shall be
considered to be within the meaning of section 202(a) of title
18, United States Code, for the purposes of disclosure and
management of conflicts of interest.
(3) Application of faca.--The Federal Advisory Committee
Act (5 U.S.C. App.), other than section 14, shall apply to the
Health Benefits Advisory Committee.
(d) Publication.--The Secretary shall provide for publication in
the Federal Register and the posting on the Internet Website of the
Department of Health and Human Services of all recommendations made by
the Health Benefits Advisory Committee under this section.
SEC. 224. PROCESS FOR ADOPTION OF RECOMMENDATIONS; ADOPTION OF BENEFIT
STANDARDS.
(a) Process for Adoption of Recommendations.--
(1) Review of recommended standards.--Not later than 45
days after the date of receipt of benefit standards recommended
under section 223 (including such standards as modified under
paragraph (2)(B)), the Secretary shall review such standards
and shall determine whether to propose adoption of such
standards as a package.
(2) Determination to adopt standards.--If the Secretary
determines--
(A) to propose adoption of benefit standards so
recommended as a package, the Secretary shall, by
regulation under section 553 of title 5, United States
Code, propose adoption of such standards; or
(B) not to propose adoption of such standards as a
package, the Secretary shall notify the Health Benefits
Advisory Committee in writing of such determination and
the reasons for not proposing the adoption of such
recommendation and provide the Committee with a further
opportunity to modify its previous recommendations and
submit new recommendations to the Secretary on a timely
basis.
(3) Contingency.--If, because of the application of
paragraph (2)(B), the Secretary would otherwise be unable to
propose initial adoption of such recommended standards by the
deadline specified in subsection (b)(1), the Secretary shall,
by regulation under section 553 of title 5, United States Code,
propose adoption of initial benefit standards by such deadline.
(4) Publication.--The Secretary shall provide for
publication in the Federal Register of all determinations made
by the Secretary under this subsection.
(b) Adoption of Standards.--
(1) Initial standards.--Not later than 18 months after the
date of the enactment of this Act, the Secretary shall, through
the rulemaking process consistent with subsection (a), adopt an
initial set of benefit standards.
(2) Periodic updating standards.--Under subsection (a), the
Secretary shall provide for the periodic updating of the
benefit standards previously adopted under this section.
(3) Requirement.--The Secretary may not adopt any benefit
standards for an essential benefits package or for level of
cost-sharing that are inconsistent with the requirements for
such a package or level under sections 222 (including
subsection (d)) and 223(b)(5).
Subtitle D--Additional Consumer Protections
SEC. 231. REQUIRING FAIR MARKETING PRACTICES BY HEALTH INSURERS.
The Commissioner shall establish uniform marketing standards that
all QHBP offering entities shall meet with respect to qualified health
benefits plans that are health insurance coverage.
SEC. 232. REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS.
(a) In General.--A QHBP offering entity shall provide for timely
grievance and appeals mechanisms with respect to qualified health
benefits plans that the Commissioner shall establish consistent with
this section. The Commissioner shall establish time limits for each of
such mechanisms and implement them in a manner that is protective to
the needs of patients.
(b) Internal Claims and Appeals Process.--Under a qualified health
benefits plan the QHBP offering entity 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. 70246) and shall update such process in accordance
with any standards that the Commissioner may establish.
(c) External Review Process.--
(1) In general.--The Commissioner shall establish an
external review process (including procedures for expedited
reviews of urgent claims) that provides for an impartial,
independent, and de novo review of denied claims under this
division.
(2) Requiring fair grievance and appeals mechanisms.--A
determination made, with respect to a qualified health benefits
plan offered by a QHBP offering entity, under the external
review process established under this subsection shall be
binding on the plan and the entity.
(d) Time Limits.--The Commissioner shall establish time limits for
each of these processes and implement them in a manner that is
protective to the patient.
(e) Construction.--Nothing in this section shall be construed as
affecting the availability of judicial review under State law for
adverse decisions under subsection (b) or (c), subject to section 251.
SEC. 233. REQUIRING INFORMATION TRANSPARENCY AND PLAN DISCLOSURE.
(a) Accurate and Timely Disclosure.--
(1) For exchange-participating health benefits plans.--A
QHBP offering entity offering an Exchange-participating health
benefits plan shall comply with standards established by the
Commissioner for the accurate and timely disclosure to the
Commissioner and the public of plan documents, plan terms and
conditions, claims payment policies and practices, periodic
financial disclosure, data on enrollment, data on
disenrollment, data on the number of claims denials, data on
rating practices, information on cost-sharing and payments with
respect to any out-of-network coverage, and other information
as determined appropriate by the Commissioner.
(2) Employment-based 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 Commissioner under paragraph (1).
(3) Use of plain language.--
(A) In general.--The disclosures under paragraphs
(1) and (2) shall be provided in plain language.
(B) Definition.--In this paragraph, 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.
(C) Guidance.--The Commissioner and the Secretary
of Labor shall jointly develop and issue guidance on
best practices of plain language writing.
(4) Information on rights.--The information disclosed under
this subsection shall include information on enrollee and
participant rights under this division.
(5) Cost-sharing transparency.--A qualified health benefits
plan shall allow 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 request. At a minimum, this information
shall be made available to such individual via an Internet
Website and other means for individuals without access to the
Internet.
(b) Contracting Reimbursement.--A qualified health benefits plan
shall comply with standards established by the Commissioner to ensure
transparency to each health care provider relating to reimbursement
arrangements between such plan and such provider.
(c) Pharmacy Benefit Managers Transparency Requirements.--
(1) In general.--If a QHBP offering entity contracts with a
pharmacy benefit manager or other entity (in this subsection
referred to as a ``PBM'') to manage prescription drug coverage
or otherwise control prescription drug costs under a qualified
health benefits plan, the PBM shall provide at least annually
to the Commissioner and to the QHBP offering entity offering
such plan the following information, in a form and manner to be
determined by the Commissioner:
(A) Information on the number and total cost of
prescriptions under the contract that are filled via
mail order and at retail pharmacies.
(B) An estimate of aggregate average payments under
the contract, per prescription (weighted by
prescription volume), made to mail order and retail
pharmacies, and the average amount, per prescription,
that the PBM was paid by the plan for prescriptions
filled at mail order and retail pharmacists.
(C) An estimate of the aggregate average payment
per prescription (weighted by prescription volume)
under the contract received from pharmaceutical
manufacturers, including all rebates, discounts, prices
concessions, or administrative, and other payments from
pharmaceutical manufacturers, and a description of the
types of payments, and the amount of these payments
that were shared with the plan, and a description of
the percentage of prescriptions for which the PBM
received such payments.
(D) Information on the overall percentage of
generic drugs dispensed under the contract at retail
and mail order pharmacies, and the percentage of cases
in which a generic drug is dispensed when available.
(E) Information on the percentage and number of
cases under the contract in which individuals were
switched because of PBM policies or at the direct or
indirect control of the PBM from a prescribed drug that
had a lower cost for the QHBP offering entity to a drug
that had a higher cost for the QHBP offering entity,
the rationale for these switches, and a description of
the PBM policies governing such switches.
(2) Confidentiality of information.--Information disclosed
by a PBM to the Commissioner or a QHBP offering entity under
this subsection is confidential and shall not be disclosed by
the Commissioner or the QHBP offering entity in a form which
discloses the identity of a specific PBM or prices charged by
such PBM or a specific retailer, manufacturer, or wholesaler,
except only by the Commissioner--
(A) to permit State or Federal law enforcement
authorities to use the information provided for program
compliance purposes and for the purpose of combating
waste, fraud, and abuse;
(B) to permit the Comptroller General, the Medicare
Payment Advisory Commission, or the Secretary of Health
and Human Services to review the information provided;
and
(C) to permit the Director of the Congressional
Budget Office to review the information provided.
(3) Annual public report.--On an annual basis, the
Commissioner shall prepare a public report providing
industrywide aggregate or average information to be used in
assessing the overall impact of PBMs on prescription drug
prices and spending. Such report shall not disclose the
identity of a specific PBM, or prices charged by such PBM, or a
specific retailer, manufacturer, or wholesaler, or any other
confidential or trade secret information.
(4) Penalties.--The provisions of subsection (b)(3)(C) of
section 1927 shall apply to a PBM that fails to provide
information required under subsection (a) or that knowingly
provides false information in the same manner as such
provisions apply to a manufacturer with an agreement under such
section that fails to provide information under subsection
(b)(3)(A) of such section or knowingly provides false
information under such section, respectively.
SEC. 234. APPLICATION TO QUALIFIED HEALTH BENEFITS PLANS NOT OFFERED
THROUGH THE HEALTH INSURANCE EXCHANGE.
The requirements of the previous provisions of this subtitle shall
apply to qualified health benefits plans that are not being offered
through the Health Insurance Exchange only to the extent specified by
the Commissioner.
SEC. 235. TIMELY PAYMENT OF CLAIMS.
A QHBP offering entity shall comply with the requirements of
section 1857(f) of the Social Security Act with respect to a qualified
health benefits plan it offers in the same manner as a Medicare
Advantage organization is required to comply with such requirements
with respect to a Medicare Advantage plan it offers under part C of
Medicare.
SEC. 236. STANDARDIZED RULES FOR COORDINATION AND SUBROGATION OF
BENEFITS.
The Commissioner shall establish standards for the coordination and
subrogation of benefits and reimbursement of payments in cases of
qualified health benefits plans involving individuals and multiple plan
coverage.
SEC. 237. APPLICATION OF ADMINISTRATIVE SIMPLIFICATION.
A QHBP offering entity is required to comply with administrative
simplification provisions under part C of title XI of the Social
Security Act with respect to qualified health benefits plans it offers.
SEC. 238. STATE PROHIBITIONS ON DISCRIMINATION AGAINST HEALTH CARE
PROVIDERS.
This Act (and the amendments made by this Act) shall not be
construed as superseding laws, as they now or hereinafter exist, of any
State or jurisdiction designed to prohibit a qualified health benefits
plan from discriminating with respect to participation, reimbursement,
covered services, indemnification, or related requirements under such
plan against a health care provider that is acting within the scope of
that provider's license or certification under applicable State law.
SEC. 239. PROTECTION OF PHYSICIAN PRESCRIBER INFORMATION.
(a) Study.--The Secretary of Health and Human Services shall
conduct a study on the use of physician prescriber information in sales
and marketing practices of pharmaceutical manufacturers.
(b) Report.--Based on the study conducted under subsection (a), the
Secretary shall submit to Congress a report on actions needed to be
taken by the Congress or the Secretary to protect providers from biased
marketing and sales practices.
SEC. 240. DISSEMINATION OF ADVANCE CARE PLANNING INFORMATION.
(a) In General.--The QHBP offering entity --
(1) shall provide for the dissemination of information
related to end-of-life planning to individuals seeking
enrollment in Exchange-participating health benefits plans
offered through the Exchange;
(2) shall present such individuals with--
(A) the option to establish advanced directives and
physician's orders for life sustaining treatment
according to the laws of the State in which the
individual resides; and
(B) information related to other planning tools;
and
(3) shall not promote suicide, assisted suicide,
euthanasia, or mercy killing.
The information presented under paragraph (2) shall not presume the
withdrawal of treatment and shall include end-of-life planning
information that includes options to maintain all or most medical
interventions.
(b) Construction.-- Nothing in this section shall be construed--
(1) to require an individual to complete an advanced
directive or a physician's order for life sustaining treatment
or other end-of-life planning document;
(2) to require an individual to consent to restrictions on
the amount, duration, or scope of medical benefits otherwise
covered under a qualified health benefits plan; or
(3) to promote suicide, assisted suicide, euthanasia, or
mercy killing.
(c) Advanced Directive Defined.--In this section, the term
``advanced directive'' includes a living will, a comfort care order, or
a durable power of attorney for health care.
(d) Prohibition on the Promotion of Assisted Suicide.--
(1) In general.--Subject to paragraph (3), information
provided to meet the requirements of subsection (a)(2) shall
not include advanced directives or other planning tools that
list or describe as an option suicide, assisted suicide,
euthanasia, or mercy killing, regardless of legality.
(2) Construction.--Nothing in paragraph (1) shall be
construed to apply to or affect any option to--
(A) withhold or withdraw of medical treatment or
medical care;
(B) withhold or withdraw of nutrition or hydration;
and
(C) provide palliative or hospice care or use 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.
(3) No preemption of state law.--Nothing in this section
shall be construed to preempt or otherwise have any effect on
State laws regarding advance care planning, palliative care, or
end-of-life decision-making.
Subtitle E--Governance
SEC. 241. HEALTH CHOICES ADMINISTRATION; HEALTH CHOICES COMMISSIONER.
(a) In General.--There is hereby established, as an independent
agency in the executive branch of the Government, a Health Choices
Administration (in this division referred to as the
``Administration'').
(b) Commissioner.--
(1) In general.--The Administration shall be headed by a
Health Choices Commissioner (in this division referred to as
the ``Commissioner'') who shall be appointed by the President,
by and with the advice and consent of the Senate.
(2) Compensation; etc.--The provisions of paragraphs (2),
(5), and (7) of subsection (a) (relating to compensation,
terms, general powers, rulemaking, and delegation) of section
702 of the Social Security Act (42 U.S.C. 902) shall apply to
the Commissioner and the Administration in the same manner as
such provisions apply to the Commissioner of Social Security
and the Social Security Administration.
(c) Inspector General.--For provision establishing an Office of the
Inspector General for the Health Choices Administration, see section
1647.
SEC. 242. DUTIES AND AUTHORITY OF COMMISSIONER.
(a) Duties.--The Commissioner is responsible for carrying out the
following functions under this division:
(1) Qualified plan standards.--The establishment of
qualified health benefits plan standards under this title,
including the enforcement of such standards in coordination
with State insurance regulators and the Secretaries of Labor
and the Treasury.
(2) Health insurance exchange.--The establishment and
operation of a Health Insurance Exchange under subtitle A of
title III.
(3) Individual affordability credits.--The administration
of individual affordability credits under subtitle C of title
III, including determination of eligibility for such credits.
(4) Additional functions.--Such additional functions as may
be specified in this division.
(b) Promoting Accountability.--
(1) In general.--The Commissioner shall undertake
activities in accordance with this subtitle to promote
accountability of QHBP offering entities in meeting Federal
health insurance requirements, regardless of whether such
accountability is with respect to qualified health benefits
plans offered through the Health Insurance Exchange or outside
of such Exchange.
(2) Compliance examination and audits.--
(A) In general.--The Commissioner shall, in
coordination with States, conduct audits of qualified
health benefits plan compliance with Federal
requirements. Such audits may include random
compliance audits and targeted audits in response to
complaints or other suspected noncompliance.
(B) Recoupment of costs in connection with
examination and audits.--The Commissioner is authorized
to recoup from qualified health benefits plans
reimbursement for the costs of such examinations and
audit of such QHBP offering entities.
(c) Data Collection.--The Commissioner shall collect data for
purposes of carrying out the Commissioner's duties, including for
purposes of promoting quality and value, protecting consumers, and
addressing disparities in health and health care and may share such
data with the Secretary of Health and Human Services.
(d) Sanctions Authority.--
(1) In general.--In the case that the Commissioner
determines that a QHBP offering entity violates a requirement
of this title, the Commissioner may, in coordination with State
insurance regulators and the Secretary of Labor, provide, in
addition to any other remedies authorized by law, for any of
the remedies described in paragraph (2).
(2) Remedies.--The remedies described in this paragraph,
with respect to a qualified health benefits plan offered by a
QHBP offering entity, are--
(A) civil money penalties of not more than the
amount that would be applicable under similar
circumstances for similar violations under section
1857(g) of the Social Security Act;
(B) suspension of enrollment of individuals under
such plan after the date the Commissioner notifies the
entity of a determination under paragraph (1) and until
the Commissioner is satisfied that the basis for such
determination has been corrected and is not likely to
recur;
(C) in the case of an Exchange-participating health
benefits plan, suspension of payment to the entity
under the Health Insurance Exchange for individuals
enrolled in such plan after the date the Commissioner
notifies the entity of a determination under paragraph
(1) and until the Secretary is satisfied that the basis
for such determination has been corrected and is not
likely to recur; or
(D) working with State insurance regulators to
terminate plans for repeated failure by the offering
entity to meet the requirements of this title.
(e) Standard Definitions of Insurance and Medical Terms.--The
Commissioner shall provide for the development of standards for the
definitions of terms used in health insurance coverage, including
insurance-related terms.
(f) Efficiency in Administration.--The Commissioner shall issue
regulations for the effective and efficient administration of the
Health Insurance Exchange and affordability credits under subtitle C,
including, with respect to the determination of eligibility for
affordability credits, the use of personnel who are employed in
accordance with the requirements of title 5, United States Code, to
carry out the duties of the Commissioner or, in the case of sections
308 and 341(b)(2), the use of State personnel who are employed in
accordance with standards prescribed by the Office of Personnel
Management pursuant to section 208 of the Intergovernmental Personnel
Act of 1970 (42 U.S.C. 4728).
SEC. 243. CONSULTATION AND COORDINATION.
(a) Consultation.--In carrying out the Commissioner's duties under
this division, the Commissioner, as appropriate, shall consult at least
with the following:
(1) State attorneys general and State insurance regulators,
including concerning the standards for health insurance
coverage that is a qualified health benefits plan under this
title and enforcement of such standards.
(2) The National Association of Insurance Commissioners,
including for purposes of using model guidelines established by
such association for purposes of subtitles B and D.
(3) Appropriate State agencies, specifically concerning the
administration of individual affordability credits under
subtitle C of title III and the offering of Exchange-
participating health benefits plans, to Medicaid eligible
individuals under subtitle A of such title.
(4) The Federal Trade Commission, specifically concerning
the development and issuance of guidance, rules, or standards
regarding fair marketing practices under section 231 or
otherwise, or any consumer disclosure requirements under
section 233 or otherwise.
(5) Other appropriate Federal agencies.
(6) Indian tribes and tribal organizations.
(b) Coordination.--
(1) In general.--In carrying out the functions of the
Commissioner, including with respect to the enforcement of the
provisions of this division, the Commissioner shall work in
coordination with existing Federal and State entities to the
maximum extent feasible consistent with this division and in a
manner that prevents conflicts of interest in duties and
ensures effective enforcement.
(2) Uniform standards.--The Commissioner, in coordination
with such entities, shall seek to achieve uniform standards
that adequately protect consumers in a manner that does not
unreasonably affect employers and insurers.
SEC. 244. HEALTH INSURANCE OMBUDSMAN.
(a) In General.--The Commissioner shall appoint within the Health
Choices Administration a Qualified Health Benefits Plan Ombudsman who
shall have expertise and experience in the fields of health care and
education of (and assistance to) individuals.
(b) Duties.--The Qualified Health Benefits Plan Ombudsman shall, in
a linguistically appropriate manner--
(1) receive complaints, grievances, and requests for
information submitted by individuals through means such as the
mail, by telephone, electronically, and in person;
(2) provide assistance with respect to complaints,
grievances, and requests referred to in paragraph (1),
including--
(A) helping individuals determine the relevant
information needed to seek an appeal of a decision or
determination;
(B) assistance to such individuals in choosing a
qualified health benefits plan in which to enroll;
(C) assistance to such individuals with any
problems arising from disenrollment from such a plan;
and
(D) assistance to such individuals in presenting
information under subtitle C (relating to affordability
credits); and
(3) submit annual reports to Congress and the Commissioner
that describe the activities of the Ombudsman and that include
such recommendations for improvement in the administration of
this division as the Ombudsman determines appropriate. The
Ombudsman shall not serve as an advocate for any increases in
payments or new coverage of services, but may identify issues
and problems in payment or coverage policies.
Subtitle F--Relation to Other Requirements; Miscellaneous
SEC. 251. RELATION TO OTHER REQUIREMENTS.
(a) Coverage Not Offered Through Exchange.--
(1) In general.--In the case of health insurance coverage
not offered through the Health Insurance Exchange (whether or
not offered in connection with an employment-based health
plan), and in the case of employment-based health plans, the
requirements of this title do not supercede any requirements
applicable under titles XXII and XXVII of the Public Health
Service Act, parts 6 and 7 of subtitle B of title I of the
Employee Retirement Income Security Act of 1974, or State law,
except insofar as such requirements prevent the application of
a requirement of this division, as determined by the
Commissioner.
(2) Construction.--Nothing in paragraphs (1) or (2) shall
be construed as affecting the application of section 514 of the
Employee Retirement Income Security Act of 1974.
(b) Coverage Offered Through Exchange.--
(1) In general.--In the case of health insurance coverage
offered through the Health Insurance Exchange--
(A) the requirements of this title do not supercede
any requirements (including requirements relating to
genetic information nondiscrimination and mental health
parity) applicable under title XXVII of the Public
Health Service Act or under State law, except insofar
as such requirements prevent the application of a
requirement of this division, as determined by the
Commissioner; and
(B) individual rights and remedies under State laws
shall apply.
(2) Construction.--In the case of coverage described in
paragraph (1), nothing in such paragraph shall be construed as
preventing the application of rights and remedies under State
laws to health insurance issuers generally with respect to any
requirement referred to in paragraph (1)(A). The previous
sentence shall not be construed as providing for the
applicability of rights or remedies under State laws with
respect to requirements applicable to employers or other plan
sponsors in connection with arrangements which are treated as
group health plans under section 802(a)(1) of the Employee
Retirement Income Security Act of 1974.
SEC. 252. PROHIBITING DISCRIMINATION IN HEALTH CARE.
(a) In General.--Except as otherwise explicitly permitted by this
Act and by subsequent regulations consistent with this Act, all health
care and related services (including insurance coverage and public
health activities) covered by this Act shall be provided without regard
to personal characteristics extraneous to the provision of high quality
health care or related services.
(b) Implementation.--To implement the requirement set forth in
subsection (a), the Secretary of Health and Human Services shall, not
later than 18 months after the date of the enactment of this Act,
promulgate such regulations as are necessary or appropriate to insure
that all health care and related services (including insurance coverage
and public health activities) covered by this Act are provided (whether
directly or through contractual, licensing, or other arrangements)
without regard to personal characteristics extraneous to the provision
of high quality health care or related services.
SEC. 253. WHISTLEBLOWER PROTECTION.
(a) Retaliation Prohibited.--No employer may discharge any employee
or otherwise discriminate against any employee with respect to his
compensation, terms, conditions, or other privileges of employment
because the employee (or any person acting pursuant to a request of the
employee)--
(1) 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 Act or any order, rule, or regulation promulgated under
this Act;
(2) testified or is about to testify in a proceeding
concerning such violation;
(3) assisted or participated or is about to assist or
participate in such a proceeding; or
(4) 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 Act or any order, rule, or regulation
promulgated under this Act.
(b) Enforcement Action.--An employee covered by this section who
alleges discrimination by an employer in violation of subsection (a)
may bring an action governed by the rules, procedures, legal burdens of
proof, and remedies set forth in section 40(b) of the Consumer Product
Safety Act (15 U.S.C. 2087(b)).
(c) Employer Defined.--As used in this section, the term
``employer'' means any person (including one or more individuals,
partnerships, associations, corporations, trusts, professional
membership organization including a certification, disciplinary, or
other professional body, unincorporated organizations, nongovernmental
organizations, or trustees) engaged in profit or nonprofit business or
industry whose activities are governed by this Act, and any agent,
contractor, subcontractor, grantee, or consultant of such person.
(d) Rule of Construction.--The rule of construction set forth in
section 20109(h) of title 49, United States Code, shall also apply to
this section.
SEC. 254. CONSTRUCTION REGARDING COLLECTIVE BARGAINING.
Nothing in this division shall be construed to alter or supersede
any statutory or other obligation to engage in collective bargaining
over the terms or conditions of employment related to health care. Any
plan amendment made pursuant to a collective bargaining agreement
relating to the plan which amends the plan solely to conform to any
requirement added by this division shall not be treated as a
termination of such collective bargaining agreement.
SEC. 255. SEVERABILITY.
If any provision of this Act, or any application of such provision
to any person or circumstance, is held to be unconstitutional, the
remainder of the provisions of this Act and the application of the
provision to any other person or circumstance shall not be affected.
SEC. 256. TREATMENT OF HAWAII PREPAID HEALTH CARE ACT.
(a) In General.--Subject to this section--
(1) nothing in this division (or an amendment made by this
division) shall be construed to modify or limit the application
of the exemption for the Hawaii 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)), and such exemption shall
also apply with respect to the provisions of this division; and
(2) for purposes of this division (and the amendments made
by this division), coverage provided pursuant to the Hawaii
Prepaid Health Care Act shall be treated as a qualified health
benefits plan providing acceptable coverage so long as the
Secretary of Labor determines that such coverage for employees
(taking into account the benefits and the cost to employees for
such benefits) is substantially equivalent to or greater than
the coverage provided for employees pursuant to the essential
benefits package.
(b) Coordination With State Law of Hawaii.--The Commissioner shall,
based on ongoing consultation with the appropriate officials of the
State of Hawaii, make adjustments to rules and regulations of the
Commissioner under this division as may be necessary, as determined by
the Commissioner, to most effectively coordinate the provisions of this
division with the provisions of the Hawaii Prepaid Health Care Act,
taking into account any changes made from time to time to the Hawaii
Prepaid Health Care Act and related laws of such State.
SEC. 257. ACTIONS BY STATE ATTORNEYS GENERAL.
Any State attorney general may bring a civil action in the name of
such State as parens patriae on behalf of natural persons residing in
such State, in any district court of the United States or State court
having jurisdiction of the defendant to secure monetary or equitable
relief for violation of any provisions of this title or regulations
issued thereunder. Nothing in this section shall be construed as
affecting the application of section 514 of the Employee Retirement
Income Security Act of 1974.
SEC. 258. APPLICATION OF STATE AND FEDERAL LAWS REGARDING ABORTION.
(a) 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.
(b) No Effect on Federal Laws Regarding Abortion.--
(1) In general.--Nothing in this Act shall be construed to
have any effect on Federal laws regarding--
(A) conscience protection;
(B) willingness or refusal to provide abortion; and
(C) 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.
(c) No Effect on Federal Civil Rights Law.--Nothing in this section
shall alter the rights and obligations of employees and employers under
title VII of the Civil Rights Act of 1964.
SEC. 259. NONDISCRIMINATION ON ABORTION AND RESPECT FOR RIGHTS OF
CONSCIENCE.
(a) Nondiscrimination.--A Federal agency or program, and any State
or local government that receives Federal financial assistance under
this Act (or an amendment made by this Act), may not--
(1) subject any individual or institutional health care
entity to discrimination; or
(2) require any health plan created or regulated under this
Act (or an amendment made by this Act) to subject any
individual or institutional health care entity to
discrimination,
on the basis that the health care entity does not provide, pay for,
provide coverage of, or refer for abortions.
(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) 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, and coordinate the investigation
of such complaints.
SEC. 260. AUTHORITY OF FEDERAL TRADE COMMISSION.
Section 6 of the Federal Trade Commission Act (15 U.S.C. 46) is
amended by striking ``and prepare reports'' and all that follows and
inserting the following: ``and prepare reports, and to share
information under clauses (f) and (k), relating to the business of
insurance. Notwithstanding section 4, such authority shall include the
authority to conduct studies and prepare reports, and to share
information under clauses (f) and (k), relating to the business of
insurance, without regard to whether the entity or entities that is the
subject of such studies, reports, or information is a for-profit or
not-for-profit entity.''.
SEC. 261. CONSTRUCTION REGARDING STANDARD OF CARE.
(a) In General.--The development, recognition, or implementation of
any guideline or other standard under a provision described in
subsection (b) shall not be construed to establish the standard of care
or duty of care owed by health care providers to their patients in any
medical malpractice action or claim (as defined in section 431(7) of
the Health Care Quality Improvement Act of 1986 (42 U.S.C. 11151(7)).
(b) Provisions Described.--The provisions described in this
subsection are the following:
(1) Section 324 (relating to modernized payment initiatives
and delivery system reform under the public health option).
(2) The amendments made by section 1151 (relating to
reducing potentially preventable hospital readmissions).
(3) The amendments made by section 1751 (relating to health
care acquired conditions).
(4) Section 3131 of the Public Health Service Act (relating
to the Task Force on Clinical Preventive Services), added by
section 2301.
(5) Part D of title IX of the Public Health Service Act
(relating to implementation of best practices in the delivery
of health care), added by section 2401.
SEC. 262. RESTORING APPLICATION OF ANTITRUST LAWS TO HEALTH SECTOR
INSURERS.
(a) Amendment to McCarran-Ferguson Act.--Section 3 of the Act of
March 9, 1945 (15 U.S.C. 1013), commonly known as the McCarran-Ferguson
Act, is amended by adding at the end the following:
``(c)(1) Except as provided in paragraph (2), nothing contained in
this Act shall modify, impair, or supersede the operation of any of the
antitrust laws with respect to price fixing, market allocation, or
monopolization (or attempting to monopolize) by--
``(A) a person engaged in the business of health insurance,
in connection with providing health insurance; or
``(B) a person engaged in the business of medical
malpractice insurance, in connection with providing medical
malpractice insurance.
``(2) Paragraph (1) shall not apply to--
``(A) collecting, compiling, classifying, or disseminating
historical loss data;
``(B) determining a loss development factor applicable to
historical loss data;
``(C) performing actuarial services if doing so does not
involve a restraint of trade; or
``(D) information gathering and rate setting activities of
a State insurance commission or other State regulatory entity
with authority to set insurance rates.
``(3) For purposes of this subsection--
``(A) the term `antitrust laws' has the meaning given it 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) the term `historical loss data' means information
respecting claims paid, or reserves held for claims reported,
by any person engaged in the business of insurance; and
``(C) the term `loss development factor' means an
adjustment to be made to the aggregate of losses incurred
during a prior period of time that have been paid, or for which
claims have been received and reserves are being held, in order
to estimate the aggregate of the losses incurred during such
period that will ultimately be paid.''.
(b) Related Provision.--For purposes of section 5 of the Federal
Trade Commission Act (15 U.S.C. 45) to the extent such section applies
to unfair methods of competition, section 3(c) of the McCarran-Ferguson
Act shall apply with respect to the business of health insurance, and
with respect to the business of medical malpractice insurance, without
regard to whether such business is carried on for profit,
notwithstanding the definition of ``Corporation'' contained in section
4 of the Federal Trade Commission Act.
(c) Related Preservation of Antitrust Laws.--Except as provided in
subsections (a) and (b), nothing in this Act, or in the amendments made
by this Act, shall be construed to modify, impair, or supersede the
operation of any of the antitrust laws. For purposes of the preceding
sentence, the term ``antitrust laws'' has the meaning given it in
subsection (a) of the first section of the Clayton Act, except that it
includes section 5 of the Federal Trade Commission Act to the extent
that such section 5 applies to unfair methods of competition.
SEC. 263. STUDY AND REPORT ON METHODS TO INCREASE EHR USE BY SMALL
HEALTH CARE PROVIDERS.
(a) Study.--The Secretary of Health and Human Services shall
conduct a study of potential methods to increase the use of qualified
electronic health records (as defined in section 3000(13) of the Public
Health Service Act) by small health care providers. Such study shall
consider at least the following methods:
(1) Providing for higher rates of reimbursement or other
incentives for such health care providers to use electronic
health records (taking into consideration initiatives by
private health insurance companies and incentives provided
under Medicare under title XVIII of the Social Security Act,
Medicaid under title XIX of such Act, and other programs).
(2) Promoting low-cost electronic health record software
packages that are available for use by such health care
providers, including software packages that are available to
health care providers through the Veterans Administration and
other sources.
(3) Training and education of such health care providers on
the use of electronic health records.
(4) Providing assistance to such health care providers on
the implementation of electronic health records.
(b) Report.--Not later than December 31, 2013, the Secretary of
Health and Human Services shall submit to Congress a report containing
the results of the study conducted under subsection (a), including
recommendations for legislation or administrative action to increase
the use of electronic health records by small health care providers
that include the use of both public and private funding sources.
TITLE III--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS
Subtitle A--Health Insurance Exchange
SEC. 301. ESTABLISHMENT OF HEALTH INSURANCE EXCHANGE; OUTLINE OF
DUTIES; DEFINITIONS.
(a) Establishment.--There is established within the Health Choices
Administration and under the direction of the Commissioner a Health
Insurance Exchange in order to facilitate access of individuals and
employers, through a transparent process, to a variety of choices of
affordable, quality health insurance coverage, including a public
health insurance option.
(b) Outline of Duties of Commissioner.--In accordance with this
subtitle and in coordination with appropriate Federal and State
officials as provided under section 243(b), the Commissioner shall--
(1) under section 304 establish standards for, accept bids
from, and negotiate and enter into contracts with, QHBP
offering entities for the offering of health benefits plans
through the Health Insurance Exchange, with different levels of
benefits required under section 303, and including with respect
to oversight and enforcement;
(2) under section 305 facilitate outreach and enrollment in
such plans of Exchange-eligible individuals and employers
described in section 302; and
(3) conduct such activities related to the Health Insurance
Exchange as required, including establishment of a risk pooling
mechanism under section 306 and consumer protections under
subtitle D of title II.
SEC. 302. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS.
(a) Access to Coverage.--In accordance with this section, all
individuals are eligible to obtain coverage through enrollment in an
Exchange-participating health benefits plan offered through the Health
Insurance Exchange unless such individuals are enrolled in another
qualified health benefits plan or other acceptable coverage.
(b) Definitions.--In this division:
(1) Exchange-eligible individual.--The term ``Exchange-
eligible individual'' means an individual who is eligible under
this section to be enrolled through the Health Insurance
Exchange in an Exchange-participating health benefits plan and,
with respect to family coverage, includes dependents of such
individual.
(2) Exchange-eligible employer.--The term ``Exchange-
eligible employer'' means an employer that is eligible under
this section to enroll through the Health Insurance Exchange
employees of the employer (and their dependents) in Exchange-
eligible health benefits plans.
(3) Employment-related definitions.--The terms
``employer'', ``employee'', ``full-time employee'', and ``part-
time employee'' have the meanings given such terms by the
Commissioner for purposes of this division.
(c) Transition.--Individuals and employers shall only be eligible
to enroll or participate in the Health Insurance Exchange in accordance
with the following transition schedule:
(1) First year.--In Y1 (as defined in section 100(c))--
(A) individuals described in subsection (d)(1),
including individuals described in subsection (d)(3);
and
(B) smallest employers described in subsection
(e)(1).
(2) Second year.--In Y2--
(A) individuals and employers described in
paragraph (1); and
(B) smaller employers described in subsection
(e)(2).
(3) Third and subsequent years.--In Y3--
(A) individuals and employers described in
paragraph (2);
(B) small employers described in subsection (e)(3);
and
(C) larger employers as permitted by the
Commissioner under subsection (e)(4).
(d) Individuals.--
(1) Individual described.--Subject to the succeeding
provisions of this subsection, an individual described in this
paragraph is an individual who--
(A) is not enrolled in coverage described in
subparagraph (C) or (D) of paragraph (2); and
(B) is not enrolled in coverage as a full-time
employee (or as a dependent of such an employee) under
a group health plan if the coverage and an employer
contribution under the plan meet the requirements of
section 412.
For purposes of subparagraph (B), in the case of an individual
who is self-employed, who has at least 1 employee, and who
meets the requirements of section 412, such individual shall be
deemed a full-time employee described in such subparagraph.
(2) Acceptable coverage.--For purposes of this division,
the term ``acceptable coverage'' means any of the following:
(A) Qualified health benefits plan coverage.--
Coverage under a qualified health benefits plan.
(B) Grandfathered health insurance coverage;
coverage under current group health plan.--Coverage
under a grandfathered health insurance coverage (as
defined in subsection (a) of section 202) or under a
current group health plan (described in subsection (b)
of such section).
(C) Medicare.--Coverage under part A of title XVIII
of the Social Security Act.
(D) Medicaid.--Coverage for medical assistance
under title XIX of the Social Security Act, excluding
such coverage that is only available because of the
application of subsection (u), (z), or (aa) of section
1902 of such Act.
(E) Members of the armed forces and dependents
(including tricare).--Coverage under chapter 55 of
title 10, United States Code, including similar
coverage furnished under section 1781 of title 38 of
such Code.
(F) VA.--Coverage under the veteran's health care
program under chapter 17 of title 38, United States
Code.
(G) Other coverage.--Such other health benefits
coverage, such as a State health benefits risk pool, as
the Commissioner, in coordination with the Secretary of
the Treasury, recognizes for purposes of this
paragraph.
The Commissioner shall make determinations under this paragraph
in coordination with the Secretary of the Treasury.
(3) Continuing eligibility permitted.--
(A) In general.--Except as provided in subparagraph
(B), once an individual qualifies as an Exchange-
eligible individual under this subsection (including as
an employee or dependent of an employee of an Exchange-
eligible employer) and enrolls under an Exchange-
participating health benefits plan through the Health
Insurance Exchange, the individual shall continue to be
treated as an Exchange-eligible individual until the
individual is no longer enrolled with an Exchange-
participating health benefits plan.
(B) Exceptions.--
(i) In general.--Subparagraph (A) shall not
apply to an individual once the individual
becomes eligible for coverage--
(I) under part A of the Medicare
program;
(II) under the Medicaid program as
a Medicaid-eligible individual, except
as permitted under clause (ii); or
(III) in such other circumstances
as the Commissioner may provide.
(ii) Transition period.--In the case
described in clause (i)(II), the Commissioner
shall permit the individual to continue
treatment under subparagraph (A) until such
limited time as the Commissioner determines it
is administratively feasible, consistent with
minimizing disruption in the individual's
access to health care.
(4) Transition for chip eligibles.--An individual who is
eligible for child health assistance under title XXI of the
Social Security Act for a period during Y1 shall not be an
Exchange-eligible individual during such period.
(e) Employers.--
(1) Smallest employer.--Subject to paragraph (5), smallest
employers described in this paragraph are employers with 25 or
fewer employees.
(2) Smaller employers.--Subject to paragraph (5), smaller
employers described in this paragraph are employers that are
not smallest employers described in paragraph (1) and have 50
or fewer employees.
(3) Small employers.--Subject to paragraph (5), small
employers described in this paragraph are employers that are
not described in paragraph (1) or (2) and have 100 or fewer
employees.
(4) Larger employers.--
(A) In general.--Beginning with Y3, the
Commissioner may permit employers not described in
paragraph (1), (2), or (3) to be Exchange-eligible
employers.
(B) Phase-in.--In applying subparagraph (A), the
Commissioner may phase-in the application of such
subparagraph based on the number of full-time employees
of an employer and such other considerations as the
Commissioner deems appropriate.
(5) Continuing eligibility.--Once an employer is permitted
to be an Exchange-eligible employer under this subsection and
enrolls employees through the Health Insurance Exchange, the
employer shall continue to be treated as an Exchange-eligible
employer for each subsequent plan year regardless of the number
of employees involved unless and until the employer meets the
requirement of section 411(a) through paragraph (1) of such
section by offering a group health plan and not through
offering an Exchange-participating health benefits plan.
(6) Employer participation and contributions.--
(A) Satisfaction of employer responsibility.--For
any year in which an employer is an Exchange-eligible
employer, such employer may meet the requirements of
section 412 with respect to employees of such employer
by offering such employees the option of enrolling with
Exchange-participating health benefits plans through
the Health Insurance Exchange consistent with the
provisions of subtitle B of title IV.
(B) Employee choice.--Any employee offered
Exchange-participating health benefits plans by the
employer of such employee under subparagraph (A) may
choose coverage under any such plan. That choice
includes, with respect to family coverage, coverage of
the dependents of such employee.
(7) Affiliated groups.--Any employer which is part of a
group of employers who are 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, for purposes of this
subtitle, as a single employer.
(8) Treatment of multi-employer plans.--The plan sponsor of
a group health plan (as defined in section 773(a) of the
Employee Retirement Income Security Act of 1974) that is a
multi-employer plan (as defined in section 3(37) of such Act)
may obtain health insurance coverage with respect to
participants in the plan through the Exchange to the same
extent that an employer not described in paragraph (1) or (2)
is permitted by the Commissioner to obtain health insurance
coverage through the Exchange as an Exchange-eligible employer.
(9) Other counting rules.--The Commissioner shall establish
rules relating to how employees are counted for purposes of
carrying out this subsection.
(f) Special Situation Authority.--The Commissioner shall have the
authority to establish such rules as may be necessary to deal with
special situations with regard to uninsured individuals and employers
participating as Exchange-eligible individuals and employers, such as
transition periods for individuals and employers who gain, or lose,
Exchange-eligible participation status, and to establish grace periods
for premium payment.
(g) Surveys of Individuals and Employers.--The Commissioner shall
provide for periodic surveys of Exchange-eligible individuals and
employers concerning satisfaction of such individuals and employers
with the Health Insurance Exchange and Exchange-participating health
benefits plans.
(h) Exchange Access Study.--
(1) In general.--The Commissioner shall conduct a study of
access to the Health Insurance Exchange for individuals and for
employers, including individuals and employers who are not
eligible and enrolled in Exchange-participating health benefits
plans. The goal of the study is to determine if there are
significant groups and types of individuals and employers who
are not Exchange-eligible individuals or employers, but who
would have improved benefits and affordability if made eligible
for coverage in the Exchange.
(2) Items included in study.--Such study also shall
examine--
(A) the terms, conditions, and affordability of
group health coverage offered by employers and QHBP
offering entities outside of the Exchange compared to
Exchange-participating health benefits plans; and
(B) the affordability-test standard for access of
certain employed individuals to coverage in the Health
Insurance Exchange.
(3) Report.--Not later than January 1 of Y3, in Y6, and
thereafter, the Commissioner shall submit to Congress a report
on the study conducted under this subsection and shall include
in such report recommendations regarding changes in standards
for Exchange eligibility for individuals and employers.
SEC. 303. BENEFITS PACKAGE LEVELS.
(a) In General.--The Commissioner shall specify the benefits to be
made available under Exchange-participating health benefits plans
during each plan year, consistent with subtitle C of title II and this
section.
(b) Limitation on Health Benefits Plans Offered by Offering
Entities.--The Commissioner may not enter into a contract with a QHBP
offering entity under section 304(c) for the offering of an Exchange-
participating health benefits plan in a service area unless the
following requirements are met:
(1) Required offering of basic plan.--The entity offers
only one basic plan for such service area.
(2) Optional offering of enhanced plan.--If and only if the
entity offers a basic plan for such service area, the entity
may offer one enhanced plan for such area.
(3) Optional offering of premium plan.--If and only if the
entity offers an enhanced plan for such service area, the
entity may offer one premium plan for such area.
(4) Optional offering of premium-plus plans.--If and only
if the entity offers a premium plan for such service area, the
entity may offer one or more premium-plus plans for such area.
All such plans may be offered under a single contract with the
Commissioner.
(c) Specification of Benefit Levels for Plans.--
(1) In general.--The Commissioner shall establish the
following standards consistent with this subsection and title
II:
(A) Basic, enhanced, and premium plans.--Standards
for 3 levels of Exchange-participating health benefits
plans: basic, enhanced, and premium (in this division
referred to as a ``basic plan'', ``enhanced plan'', and
``premium plan'', respectively).
(B) Premium-plus plan benefits.--Standards for
additional benefits that may be offered, consistent
with this subsection and subtitle C of title II, under
a premium plan (such a plan with additional benefits
referred to in this division as a ``premium-plus
plan'') .
(2) Basic plan.--
(A) In general.--A basic plan shall offer the
essential benefits package required under title II for
a qualified health benefits plan with an actuarial
value of 70 percent of the full actuarial value of the
benefits provided under the reference benefits package.
(B) Tiered cost-sharing for affordable credit
eligible individuals.--In the case of an affordable
credit eligible individual (as defined in section
342(a)(1)) enrolled in an Exchange-participating health
benefits plan, the benefits under a basic plan are
modified to provide for the reduced cost-sharing for
the income tier applicable to the individual under
section 324(c).
(3) Enhanced plan.--An enhanced plan shall offer, in
addition to the level of benefits under the basic plan, a lower
level of cost-sharing as provided under title II consistent
with section 223(b)(5)(A).
(4) Premium plan.--A premium plan shall offer, in addition
to the level of benefits under the basic plan, a lower level of
cost-sharing as provided under title II consistent with section
223(b)(5)(B).
(5) Premium-plus plan.--A premium-plus plan is a premium
plan that also provides additional benefits, such as adult oral
health and vision care, approved by the Commissioner. The
portion of the premium that is attributable to such additional
benefits shall be separately specified.
(6) Range of permissible variation in cost-sharing.--The
Commissioner shall establish a permissible range of variation
of cost-sharing for each basic, enhanced, and premium plan,
except with respect to any benefit for which there is no cost-
sharing permitted under the essential benefits package. Such
variation shall permit a variation of not more than plus (or
minus) 10 percent in cost-sharing with respect to each benefit
category specified under section 222. Nothing in this subtitle
shall be construed as prohibiting tiering in cost-sharing,
including through preferred and participating providers and
prescription drugs. In applying this paragraph, a health
benefits plan may increase the cost-sharing by 10 percent
within each category or tier, as applicable, and may decrease
or eliminate cost-sharing in any category or tier as compared
to the essential benefits package.
(d) Treatment of State Benefit Mandates.--Insofar as a State
requires a health insurance issuer offering health insurance coverage
to include benefits beyond the essential benefits package, such
requirement shall continue to apply to an Exchange-participating health
benefits plan, if the State has entered into an arrangement
satisfactory to the Commissioner to reimburse the Commissioner for the
amount of any net increase in affordability premium credits under
subtitle C as a result of an increase in premium in basic plans as a
result of application of such requirement.
(e) Rules Regarding Coverage of and Affordability Credits for
Specified Services.--
(1) Assured availability of varied coverage through the
health insurance exchange.--The Commissioner shall assure that,
of the Exchange participating health benefits plan offered in
each premium rating area of the Health Insurance Exchange--
(A) there is at least one such plan that provides
coverage of services described in subparagraphs (A) and
(B) of section 222(d)(4); and
(B) there is at least one such plan that does not
provide coverage of services described in section
222(d)(4)(A) which plan may also be one that does not
provide coverage of services described in section
222(d)(4)(B).
(2) Segregation of funds.--If a qualified health benefits
plan provides coverage of services described in section
222(d)(4)(A), the plan shall provide assurances satisfactory to
the Commissioner that--
(A) any affordability credits provided under
subtitle C of title II are not used for purposes of
paying for such services; and
(B) only premium amounts attributable to the
actuarial value described in section 213(b) are used
for such purpose.
SEC. 304. CONTRACTS FOR THE OFFERING OF EXCHANGE-PARTICIPATING HEALTH
BENEFITS PLANS.
(a) Contracting Duties.--In carrying out section 301(b)(1) and
consistent with this subtitle:
(1) Offering entity and plan standards.--The Commissioner
shall--
(A) establish standards necessary to implement the
requirements of this title and title II for--
(i) QHBP offering entities for the offering
of an Exchange-participating health benefits
plan; and
(ii) Exchange-participating health benefits
plans; and
(B) certify QHBP offering entities and qualified
health benefits plans as meeting such standards and
requirements of this title and title II for purposes of
this subtitle.
(2) Soliciting and negotiating bids; contracts.--
(A) Bid solicitation.--The Commissioner shall
solicit bids from QHBP offering entities for the
offering of Exchange-participating health benefits
plans. Such bids shall include justification for
proposed premiums.
(B) Bid review and negotiation.--The Commissioner
shall, based upon a review of such bids including the
premiums and their affordability, negotiate with such
entities for the offering of such plans.
(C) Denial of excessive premiums.--The Commissioner
shall deny excessive premiums and premium increases.
(D) Contracts.--The Commissioner shall enter into
contracts with such entities for the offering of such
plans through the Health Insurance Exchange under terms
(consistent with this title) negotiated between the
Commissioner and such entities.
(3) Federal acquisition regulation.--In carrying out this
subtitle, the Commissioner may waive such provisions of the
Federal Acquisition Regulation that the Commissioner determines
to be inconsistent with the furtherance of this subtitle, other
than provisions relating to confidentiality of information.
Competitive procedures shall be used in awarding contracts
under this subtitle to the extent that such procedures are
consistent with this subtitle.
(b) Standards for QHBP Offering Entities To Offer Exchange-
Participating Health Benefits Plans.--The standards established under
subsection (a)(1)(A) shall require that, in order for a QHBP offering
entity to offer an Exchange-participating health benefits plan, the
entity must meet the following requirements:
(1) Licensed.--The entity shall be licensed to offer health
insurance coverage under State law for each State in which it
is offering such coverage.
(2) Data reporting.--The entity shall provide for the
reporting of such information as the Commissioner may specify,
including information necessary to administer the risk pooling
mechanism described in section 306(b) and information to
address disparities in health and health care.
(3) Affordability.--The entity shall provide for affordable
premiums.
(4) Implementing affordability credits.--The entity shall
provide for implementation of the affordability credits
provided for enrollees under subtitle C, including the
reduction in cost-sharing under section 344(c).
(5) Enrollment.--The entity shall accept all enrollments
under this subtitle, subject to such exceptions (such as
capacity limitations) in accordance with the requirements under
title II for a qualified health benefits plan. The entity shall
notify the Commissioner if the entity projects or anticipates
reaching such a capacity limitation that would result in a
limitation in enrollment.
(6) Risk pooling participation.--The entity shall
participate in such risk pooling mechanism as the Commissioner
establishes under section 306(b).
(7) Essential community providers.--With respect to the
basic plan offered by the entity, the entity shall include
within the plan network those essential community providers,
where available, that serve predominantly 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 amended by
section 221 of Public Law 111-8). The Commissioner shall
specify the extent to which and manner in which the previous
sentence shall apply in the case of a basic plan with respect
to which the Commissioner determines provides substantially all
benefits through a health maintenance organization, as defined
in section 2791(b)(3) of the Public Health Service Act. This
paragraph shall not be construed to require a basic plan to
contract with a provider if such provider refuses to accept the
generally applicable payment rates of such plan.
(8) Culturally and linguistically appropriate services and
communications.--The entity shall provide for culturally and
linguistically appropriate communication and health services.
(9) Special rules with respect to indian enrollees and
indian health care providers.--
(A) Choice of providers.--The entity shall--
(i) demonstrate to the satisfaction of the
Commissioner that it has contracted with a
sufficient number of Indian health care
providers to ensure timely access to covered
services furnished by such providers to
individual Indians through the entity's
Exchange-participating health benefits plan;
and
(ii) agree to pay Indian health care
providers, whether such providers are
participating or nonparticipating providers
with respect to the entity, for covered
services provided to those enrollees who are
eligible to receive services from such
providers at a rate that is not less than the
level and amount of payment which the entity
would make for the services of a participating
provider which is not an Indian health care
provider.
(B) Special rule relating to indian health care
providers.--Provision of services by an Indian health
care provider exclusively to Indians and their
dependents shall not constitute discrimination under
this Act.
(10) Program integrity standards.--The entity shall
establish and operate a program to protect and promote the
integrity of Exchange-participating health benefits plans it
offers, in accordance with standards and functions established
by the Commissioner.
(11) Additional requirements.--The entity shall comply with
other applicable requirements of this title, as specified by
the Commissioner, which shall include standards regarding
billing and collection practices for premiums and related grace
periods and which may include standards to ensure that the
entity does not use coercive practices to force providers not
to contract with other entities offering coverage through the
Health Insurance Exchange.
(c) Contracts.--
(1) Bid application.--To be eligible to enter into a
contract under this section, a QHBP offering entity shall
submit to the Commissioner a bid at such time, in such manner,
and containing such information as the Commissioner may
require.
(2) Term.--Each contract with a QHBP offering entity under
this section shall be for a term of not less than one year, but
may be made automatically renewable from term to term in the
absence of notice of termination by either party.
(3) Enforcement of network adequacy.--In the case of a
health benefits plan of a QHBP offering entity that uses a
provider network, the contract under this section with the
entity shall provide that if--
(A) the Commissioner determines that such provider
network does not meet such standards as the
Commissioner shall establish under section 215; and
(B) an individual enrolled in such plan receives an
item or service from a provider that is not within such
network;
then any cost-sharing for such item or service shall be equal
to the amount of such cost-sharing that would be imposed if
such item or service was furnished by a provider within such
network.
(4) Oversight and enforcement responsibilities.--The
Commissioner shall establish processes, in coordination with
State insurance regulators, to oversee, monitor, and enforce
applicable requirements of this title with respect to QHBP
offering entities offering Exchange-participating health
benefits plans, including the marketing of such plans. Such
processes shall include the following:
(A) Grievance and complaint mechanisms.--The
Commissioner shall establish, in coordination with
State insurance regulators, a process under which
Exchange-eligible individuals and employers may file
complaints concerning violations of such standards.
(B) Enforcement.--In carrying out authorities under
this division relating to the Health Insurance
Exchange, the Commissioner may impose one or more of
the intermediate sanctions described in section 242(d).
(C) Termination.--
(i) In general.--The Commissioner may
terminate a contract with a QHBP offering
entity under this section for the offering of
an Exchange-participating health benefits plan
if such entity fails to comply with the
applicable requirements of this title. Any
determination by the Commissioner to terminate
a contract shall be made in accordance with
formal investigation and compliance procedures
established by the Commissioner under which--
(I) the Commissioner provides the
entity with the reasonable opportunity
to develop and implement a corrective
action plan to correct the deficiencies
that were the basis of the
Commissioner's determination; and
(II) the Commissioner provides the
entity with reasonable notice and
opportunity for hearing (including the
right to appeal an initial decision)
before terminating the contract.
(ii) Exception for imminent and serious
risk to health.--Clause (i) shall not apply if
the Commissioner determines that a delay in
termination, resulting from compliance with the
procedures specified in such clause prior to
termination, would pose an imminent and serious
risk to the health of individuals enrolled
under the qualified health benefits plan of the
QHBP offering entity.
(D) Construction.--Nothing in this subsection shall
be construed as preventing the application of other
sanctions under subtitle E of title II with respect to
an entity for a violation of such a requirement.
(5) Special rule related to cost-sharing and indian health
care providers.--The contract under this section with a QHBP
offering entity for a health benefits plan shall provide that
if an individual who is an Indian is enrolled in such a plan
and such individual receives a covered item or service from an
Indian health care provider (regardless of whether such
provider is in the plan's provider network), the cost-sharing
for such item or service shall be equal to the amount of cost-
sharing that would be imposed if such item or service--
(A) had been furnished by another provider in the
plan's provider network; or
(B) in the case that the plan has no such network,
was furnished by a non-Indian provider.
(6) National plan.--Nothing in this section shall be
construed as preventing the Commissioner from entering into a
contract under this subsection with a QHBP offering entity for
the offering of a health benefits plan with the same benefits
in every State so long as such entity is licensed to offer such
plan in each State and the benefits meet the applicable
requirements in each such State.
(d) No Discrimination on the Basis of Provision of Abortion.--No
Exchange participating health benefits plan may discriminate against
any individual health care provider or health care facility because of
its willingness or unwillingness to provide, pay for, provide coverage
of, or refer for abortions.
SEC. 305. OUTREACH AND ENROLLMENT OF EXCHANGE-ELIGIBLE INDIVIDUALS AND
EMPLOYERS IN EXCHANGE-PARTICIPATING HEALTH BENEFITS PLAN.
(a) In General.--
(1) Outreach.--The Commissioner shall conduct outreach
activities consistent with subsection (c), including through
use of appropriate entities as described in paragraph (3) of
such subsection, to inform and educate individuals and
employers about the Health Insurance Exchange and Exchange-
participating health benefits plan options. Such outreach shall
include outreach specific to vulnerable populations, such as
children, individuals with disabilities, individuals with
mental illness, and individuals with other cognitive
impairments.
(2) Eligibility.--The Commissioner shall make timely
determinations of whether individuals and employers are
Exchange-eligible individuals and employers (as defined in
section 302).
(3) Enrollment.--The Commissioner shall establish and carry
out an enrollment process for Exchange-eligible individuals and
employers, including at community locations, in accordance with
subsection (b).
(b) Enrollment Process.--
(1) In general.--The Commissioner shall establish a process
consistent with this title for enrollments in Exchange-
participating health benefits plans. Such process shall provide
for enrollment through means such as the mail, by telephone,
electronically, and in person.
(2) Enrollment periods.--
(A) Open enrollment period.--The Commissioner shall
establish an annual open enrollment period during which
an Exchange-eligible individual or employer may elect
to enroll in an Exchange-participating health benefits
plan for the following plan year and an enrollment
period for affordability credits under subtitle C. Such
periods shall be during September through November of
each year, or such other time that would maximize
timeliness of income verification for purposes of such
subtitle. The open enrollment period shall not be less
than 30 days.
(B) Special enrollment.--The Commissioner shall
also provide for special enrollment periods to take
into account special circumstances of individuals and
employers, such as an individual who--
(i) loses acceptable coverage;
(ii) experiences a change in marital or
other dependent status;
(iii) moves outside the service area of the
Exchange-participating health benefits plan in
which the individual is enrolled; or
(iv) experiences a significant change in
income.
(C) Enrollment information.--The Commissioner shall
provide for the broad dissemination of information to
prospective enrollees on the enrollment process,
including before each open enrollment period. In
carrying out the previous sentence, the Commissioner
may work with other appropriate entities to facilitate
such provision of information.
(3) Automatic enrollment for non-medicaid eligible
individuals.--
(A) In general.--The Commissioner shall provide for
a process under which individuals who are Exchange-
eligible individuals described in subparagraph (B) are
automatically enrolled under an appropriate Exchange-
participating health benefits plan. Such process may
involve a random assignment or some other form of
assignment that takes into account the health care
providers used by the individual involved or such other
relevant factors as the Commissioner may specify.
(B) Subsidized individuals described.--An
individual described in this subparagraph is an
Exchange-eligible individual who is either of the
following:
(i) Affordability credit eligible
individuals.--The individual--
(I) has applied for, and been
determined eligible for, affordability
credits under subtitle C;
(II) has not opted out from
receiving such affordability credit;
and
(III) does not otherwise enroll in
another Exchange-participating health
benefits plan.
(ii) Individuals enrolled in a terminated
plan.--The individual who is enrolled in an
Exchange-participating health benefits plan
that is terminated (during or at the end of a
plan year) and who does not otherwise enroll in
another Exchange-participating health benefits
plan.
(4) Direct payment of premiums to plans.--Under the
enrollment process, individuals enrolled in an Exchange-
participating health benefits plan shall pay such plans
directly, and not through the Commissioner or the Health
Insurance Exchange.
(c) Coverage Information and Assistance.--
(1) Coverage information.--The Commissioner shall provide
for the broad dissemination of information on Exchange-
participating health benefits plans offered under this title.
Such information shall be provided in a comparative manner, and
shall include information on benefits, premiums, cost-sharing,
quality, provider networks, and consumer satisfaction.
(2) Consumer assistance with choice.--To provide assistance
to Exchange-eligible individuals and employers, the
Commissioner shall--
(A) provide for the operation of a toll-free
telephone hotline to respond to requests for assistance
and maintain an Internet Web site through which
individuals may obtain information on coverage under
Exchange-participating health benefits plans and file
complaints;
(B) develop and disseminate information to
Exchange-eligible enrollees on their rights and
responsibilities;
(C) assist Exchange-eligible individuals in
selecting Exchange-participating health benefits plans
and obtaining benefits through such plans; and
(D) ensure that the Internet Web site described in
subparagraph (A) and the information described in
subparagraph (B) is developed using plain language (as
defined in section 233(a)(2)).
(3) Use of other entities.--In carrying out this
subsection, the Commissioner may work with other appropriate
entities to facilitate the dissemination of information under
this subsection and to provide assistance as described in
paragraph (2).
(d) Coverage for Certain Newborns Under Medicaid.--
(1) In general.--In the case of a child born in the United
States who at the time of birth is not otherwise covered under
acceptable coverage, for the period of time beginning on the
date of birth and ending on the date the child otherwise is
covered under acceptable coverage (or, if earlier, the end of
the month in which the 60-day period, beginning on the date of
birth, ends), the child shall be deemed--
(A) to be a Medicaid eligible individual for
purposes of this division and Medicaid; and
(B) to be automatically enrolled in Medicaid as a
traditional Medicaid eligible individual (as defined in
section 1943(c) of the Social Security Act).
(2) Extended treatment as medicaid eligible individual.--In
the case of a child described in paragraph (1) who at the end
of the period referred to in such paragraph is not otherwise
covered under acceptable coverage, the child shall be deemed
(until such time as the child obtains such coverage or the
State otherwise makes a determination of the child's
eligibility for medical assistance under its Medicaid plan
pursuant to section 1943(b)(1) of the Social Security Act) to
be a Medicaid eligible individual described in section
1902(l)(1)(B) of such Act.
(e) Medicaid Coverage for Medicaid Eligible Individuals.--
(1) Medicaid enrollment obligation.--An individual may
apply, in the manner described in section 341(b)(1), for a
determination of whether the individual is a Medicaid-eligible
individual. If the individual is determined to be so eligible,
the Commissioner, through the Medicaid memorandum of
understanding under paragraph (2), shall provide for the
enrollment of the individual under the State Medicaid plan in
accordance with such memorandum of understanding. In the case
of such an enrollment, the State shall provide for the same
periodic redetermination of eligibility under Medicaid as would
otherwise apply if the individual had directly applied for
medical assistance to the State Medicaid agency.
(2) Coordinated enrollment with state through memorandum of
understanding.--The Commissioner, in consultation with the
Secretary of Health and Human Services, shall enter into a
memorandum of understanding with each State with respect to
coordinating enrollment of individuals in Exchange-
participating health benefits plans and under the State's
Medicaid program consistent with this section and to otherwise
coordinate the implementation of the provisions of this
division with respect to the Medicaid program. Such memorandum
shall permit the exchange of information consistent with the
limitations described in section 1902(a)(7) of the Social
Security Act. Nothing in this section shall be construed as
permitting such memorandum to modify or vitiate any requirement
of a State Medicaid plan.
(f) Effective Culturally and Linguistically Appropriate
Communication.--In carrying out this section, the Commissioner shall
establish effective methods for communicating in plain language and a
culturally and linguistically appropriate manner.
(g) Role for Enrollment Agents and Brokers.--Nothing in this
division shall be construed to affect the role of enrollment agents and
brokers under State law, including with regard to the enrollment of
individuals and employers in qualified health benefits plans including
the public health insurance option.
(h) Assistance for Small Employers.--
(1) In general.--The Commissioner, in consultation with the
Small Business Administration, shall establish and carry out a
program to provide to small employers counseling and technical
assistance with respect to the provision of health insurance to
employees of such employers through the Health Insurance
Exchange.
(2) Duties.--The program established under paragraph (1)
shall include the following services:
(A) Educational activities to increase awareness of
the Health Insurance Exchange and available small
employer health plan options.
(B) Distribution of information to small employers
with respect to the enrollment and selection process
for health plans available under the Health Insurance
Exchange, including standardized comparative
information on the health plans available under the
Health Insurance Exchange.
(C) Distribution of information to small employers
with respect to available affordability credits or
other financial assistance.
(D) Referrals to appropriate entities of complaints
and questions relating to the Health Insurance
Exchange.
(E) Enrollment and plan selection assistance for
employers with respect to the Health Insurance
Exchange.
(F) Responses to questions relating to the Health
Insurance Exchange and the program established under
paragraph (1).
(3) Authority to provide services directly or by
contract.--The Commissioner may provide services under
paragraph (2) directly or by contract with nonprofit entities
that the Commissioner determines capable of carrying out such
services.
(4) Small employer defined.--In this subsection, the term
``small employer'' means an employer with less than 100
employees.
(i) Participation of Small Employer Benefit Arrangements.--
(1) In general.--The Commissioner may enter into contracts
with small employer benefit arrangements to provide consumer
information, outreach, and assistance in the enrollment of
small employers (and their employees) who are members of such
an arrangement under Exchange participating health benefits
plans.
(2) Small employer benefit arrangement defined.--In this
subsection, the term ``small employer benefit arrangement''
means a not-for-profit agricultural or other cooperative that--
(A) consists solely of its members and is operated
for the primary purpose of providing affordable
employee benefits to its members;
(B) only has as members small employers in the same
industry or line of business;
(C) has no member that has more than a 5 percent
voting interest in the cooperative; and
(D) is governed by a board of directors elected by
its members.
SEC. 306. OTHER FUNCTIONS.
(a) Coordination of Affordability Credits.--The Commissioner shall
coordinate the distribution of affordability premium and cost-sharing
credits under subtitle C to QHBP offering entities offering Exchange-
participating health benefits plans.
(b) Coordination of Risk Pooling.--The Commissioner shall establish
a mechanism whereby there is an adjustment made of the premium amounts
payable among QHBP offering entities offering Exchange-participating
health benefits plans of premiums collected for such plans that takes
into account (in a manner specified by the Commissioner) the
differences in the risk characteristics of individuals and employees
enrolled under the different Exchange-participating health benefits
plans offered by such entities so as to minimize the impact of adverse
selection of enrollees among the plans offered by such entities. For
purposes of the previous sentence, the Commissioner may utilize data
regarding enrollee demographics, inpatient and outpatient diagnoses (in
a similar manner as such data are used under parts C and D of title
XVIII of the Social Security Act), and such other information as the
Secretary determines may be necessary, such as the actual medical costs
of enrollees during the previous year.
SEC. 307. HEALTH INSURANCE EXCHANGE TRUST FUND.
(a) Establishment of Health Insurance Exchange Trust Fund.--There
is created within the Treasury of the United States a trust fund to be
known as the ``Health Insurance Exchange Trust Fund'' (in this section
referred to as the ``Trust Fund''), consisting of such amounts as may
be appropriated or credited to the Trust Fund under this section or any
other provision of law.
(b) Payments From Trust Fund.--The Commissioner shall pay from time
to time from the Trust Fund such amounts as the Commissioner determines
are necessary to make payments to operate the Health Insurance
Exchange, including payments under subtitle C (relating to
affordability credits).
(c) Transfers to Trust Fund.--
(1) Dedicated payments.--There are hereby appropriated to
the Trust Fund amounts equivalent to the following:
(A) Taxes on individuals not obtaining acceptable
coverage.--The amounts received in the Treasury under
section 59B of the Internal Revenue Code of 1986
(relating to requirement of health insurance coverage
for individuals).
(B) Employment taxes on employers not providing
acceptable coverage.--The amounts received in the
Treasury under sections 3111(c) and 3221(c) of the
Internal Revenue Code of 1986 (relating to employers
electing to not provide health benefits).
(C) Excise tax on failures to meet certain health
coverage requirements.--The amounts received in the
Treasury under section 4980H(b) (relating to excise tax
with respect to failure to meet health coverage
participation requirements).
(2) Appropriations to cover government contributions.--
There are hereby appropriated, out of any moneys in the
Treasury not otherwise appropriated, to the Trust Fund, an
amount equivalent to the amount of payments made from the Trust
Fund under subsection (b) plus such amounts as are necessary
reduced by the amounts deposited under paragraph (1).
(d) Application of Certain Rules.--Rules similar to the rules of
subchapter B of chapter 98 of the Internal Revenue Code of 1986 shall
apply with respect to the Trust Fund.
SEC. 308. OPTIONAL OPERATION OF STATE-BASED HEALTH INSURANCE EXCHANGES.
(a) In General.--If--
(1) a State (or group of States, subject to the approval of
the Commissioner) applies to the Commissioner for approval of a
State-based Health Insurance Exchange to operate in the State
(or group of States); and
(2) the Commissioner approves such State-based Health
Insurance Exchange,
then, subject to subsections (c) and (d), the State-based Health
Insurance Exchange shall operate, instead of the Health Insurance
Exchange, with respect to such State (or group of States). The
Commissioner shall approve a State-based Health Insurance Exchange if
it meets the requirements for approval under subsection (b).
(b) Requirements for Approval.--
(1) In general.--The Commissioner may not approve a State-
based Health Insurance Exchange under this section unless the
following requirements are met:
(A) The State-based Health Insurance Exchange must
demonstrate the capacity to and provide assurances
satisfactory to the Commissioner that the State-based
Health Insurance Exchange will carry out the functions
specified for the Health Insurance Exchange in the
State (or States) involved, including--
(i) negotiating and contracting with QHBP
offering entities for the offering of Exchange-
participating health benefits plans, which
satisfy the standards and requirements of this
title and title II;
(ii) enrolling Exchange-eligible
individuals and employers in such State in such
plans;
(iii) the establishment of sufficient local
offices to meet the needs of Exchange-eligible
individuals and employers;
(iv) administering affordability credits
under subtitle B using the same methodologies
(and at least the same income verification
methods) as would otherwise apply under such
subtitle and at a cost to the Federal
Government which does exceed the cost to the
Federal Government if this section did not
apply; and
(v) enforcement activities consistent with
Federal requirements.
(B) There is no more than one Health Insurance
Exchange operating with respect to any one State.
(C) The State provides assurances satisfactory to
the Commissioner that approval of such an Exchange will
not result in any net increase in expenditures to the
Federal Government.
(D) The State provides for reporting of such
information as the Commissioner determines and
assurances satisfactory to the Commissioner that it
will vigorously enforce violations of applicable
requirements.
(E) Such other requirements as the Commissioner may
specify.
(2) Presumption for certain state-operated exchanges.--
(A) In general.--In the case of a State operating
an Exchange prior to January 1, 2010, that seeks to
operate the State-based Health Insurance Exchange under
this section, the Commissioner shall presume that such
Exchange meets the standards under this section unless
the Commissioner determines, after completion of the
process established under subparagraph (B), that the
Exchange does not comply with such standards.
(B) Process.--The Commissioner shall establish a
process to work with a State described in subparagraph
(A) to provide assistance necessary to assure that the
State's Exchange comes into compliance with the
standards for approval under this section.
(c) Ceasing Operation.--
(1) In general.--A State-based Health Insurance Exchange
may, at the option of each State involved, and only after
providing timely and reasonable notice to the Commissioner,
cease operation as such an Exchange, in which case the Health
Insurance Exchange shall operate, instead of such State-based
Health Insurance Exchange, with respect to such State (or
States).
(2) Termination; health insurance exchange resumption of
functions.--The Commissioner may terminate the approval (for
some or all functions) of a State-based Health Insurance
Exchange under this section if the Commissioner determines that
such Exchange no longer meets the requirements of subsection
(b) or is no longer capable of carrying out such functions in
accordance with the requirements of this subtitle. In lieu of
terminating such approval, the Commissioner may temporarily
assume some or all functions of the State-based Health
Insurance Exchange until such time as the Commissioner
determines the State-based Health Insurance Exchange meets such
requirements of subsection (b) and is capable of carrying out
such functions in accordance with the requirements of this
subtitle.
(3) Effectiveness.--The ceasing or termination of a State-
based Health Insurance Exchange under this subsection shall be
effective in such time and manner as the Commissioner shall
specify.
(d) Retention of Authority.--
(1) Authority retained.--Enforcement authorities of the
Commissioner shall be retained by the Commissioner.
(2) Discretion to retain additional authority.--The
Commissioner may specify functions of the Health Insurance
Exchange that--
(A) may not be performed by a State-based Health
Insurance Exchange under this section; or
(B) may be performed by the Commissioner and by
such a State-based Health Insurance Exchange.
(e) References.--In the case of a State-based Health Insurance
Exchange, except as the Commissioner may otherwise specify under
subsection (d), any references in this subtitle to the Health Insurance
Exchange or to the Commissioner in the area in which the State-based
Health Insurance Exchange operates shall be deemed a reference to the
State-based Health Insurance Exchange and the head of such Exchange,
respectively.
(f) Funding.--In the case of a State-based Health Insurance
Exchange, there shall be assistance provided for the operation of such
Exchange in the form of a matching grant with a State share of
expenditures required.
SEC. 309. INTERSTATE HEALTH INSURANCE COMPACTS.
(a) In General.--Effective January 1, 2015, 2 or more States may
form Health Care Choice Compacts (in this section referred to as
``compacts'') to facilitate the purchase of individual health insurance
coverage across State lines.
(b) Model Guidelines.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall request the
National Association of Insurance Commissioners (in this section
referred to as ``NAIC'') to develop model guidelines for the creation
of compacts. In developing such guidelines, the NAIC shall consult with
consumers, health insurance issuers, the Secretary, and other
interested parties. Such guidelines shall--
(1) provide for the sale of health insurance coverage to
residents of all compacting States subject to the laws and
regulations of a primary State designated by the health
insurance issuer;
(2) require health insurance issuers issuing health
insurance coverage in secondary States to maintain licensure in
every such State;
(3) preserve the authority of the State of an individual's
residence to address--
(A) market conduct;
(B) unfair trade practices;
(C) network adequacy;
(D) consumer protection standards;
(E) grievance and appeals;
(F) fair claims payment requirements; and
(G) prompt payment of claims;
(4) permit State insurance commissioners and other State
agencies in secondary States access to the records of a health
insurance issuer to the same extent as if the policy were
written in that State; and
(5) provide for clear and conspicuous disclosure to
consumers that the policy may not be subject to all the laws
and regulations of the State in which the purchaser resides.
(c) Required Consideration.--If model guidelines developed under
subsection (b) are submitted to the Secretary by January 1, 2013, the
Secretary shall issue them as regulations. If the NAIC fails to submit
such model guidelines by such date, the Secretary shall, no later than
October 1, 2013, develop and promulgate the regulations implementing
model guidelines described in subsection (b).
(d) No Requirement to Compact.--Nothing in this section shall be
construed to require a State to join a compact.
(e) State Authority.--A State may not enter into a compact under
this subsection unless the State enacts a law after the date of
enactment of this Act that specifically authorizes the State to enter
into such compact.
(f) Consumer Protections.--If a State enters into a compact it must
retain responsibility for the consumer protections of its residents and
its residents retain the right to bring a claim in a State court in the
State in which the resident resides.
(g) Assistance to Compacting States.--
(1) In general.--Beginning January 1, 2015, the Secretary
shall make awards, from amounts appropriated under paragraph
(5), to States in the amount specified in paragraph (2) for the
uses described in paragraph (3).
(2) Amount specified.--
(A) In general.--For each fiscal year, the
Secretary shall determine the total amount that the
Secretary will make available for grants under this
subsection.
(B) State amount.--For each State that is awarded a
grant under paragraph (1), the amount of such grants
shall be based on a formula established by the
Secretary, not to exceed $1 million per State, under
which States shall receive an award in the amount that
is based on the following two components:
(i) A minimum amount for each State.
(ii) An additional amount based on
population of the State.
(3) Use of funds.--A State shall use amounts awarded under
this subsection for activities (including planning activities)
related regulating health insurance coverage sold in secondary
States.
(4) Renewability of grant.--The Secretary may renew a grant
award under paragraph (1) if the State receiving the grant
continues to be a member of a compact.
(5) Authorization of appropriations.--There are authorized
to be appropriated such sums as may be necessary to carry out
this subsection in each of fiscal years 2015 through 2020.
SEC. 310. HEALTH INSURANCE COOPERATIVES.
(a) Establishment.--Not later than 6 months after the date of the
enactment of this Act, the Commissioner, in consultation with the
Secretary of the Treasury, shall establish a Consumer Operated and
Oriented Plan program (in this section referred to as the ``CO-OP
program'') under which the Commissioner may make grants and loans for
the establishment and initial operation of not-for-profit, member-run
health insurance cooperatives (in this section individually referred to
as a ``cooperative'') that provide insurance through the Health
Insurance Exchange or a State-based Health Insurance Exchange under
section 308. Nothing in this section shall be construed as requiring a
State to establish such a cooperative.
(b) Start-up and Solvency Grants and Loans.--
(1) In general.--Not later than 36 months after the date of
the enactment of this Act, the Commissioner, acting through the
CO-OP program, may make--
(A) loans (of such period and with such terms as
the Secretary may specify) to cooperatives to assist
such cooperatives with start-up costs; and
(B) grants to cooperatives to assist such
cooperatives in meeting State solvency requirements in
the States in which such cooperative offers or issues
insurance coverage.
(2) Conditions.--A grant or loan may not be awarded under
this subsection with respect to a cooperative unless the
following conditions are met:
(A) The cooperative is structured as a not-for-
profit, member organization under the law of each State
in which such cooperative offers, intends to offer, or
issues insurance coverage, with the membership of the
cooperative being made up entirely of beneficiaries of
the insurance coverage offered by such cooperative.
(B) The cooperative did not offer insurance on or
before July 16, 2009, and the cooperative is not an
affiliate or successor to an insurance company offering
insurance on or before such date.
(C) The governing documents of the cooperative
incorporate ethical and conflict of interest standards
designed to protect against insurance industry
involvement and interference in the governance of the
cooperative.
(D) The cooperative is not sponsored by a State
government.
(E) Substantially all of the activities of the
cooperative consist of the issuance of qualified health
benefits plans through the Health Insurance Exchange or
a State-based health insurance exchange.
(F) The cooperative is licensed to offer insurance
in each State in which it offers insurance.
(G) The governance of the cooperative must be
subject to a majority vote of its members.
(H) As provided in guidance issued by the Secretary
of Health and Human Services, the cooperative operates
with a strong consumer focus, including timeliness,
responsiveness, and accountability to members.
(I) Any profits made by the cooperative are used to
lower premiums, improve benefits, or to otherwise
improve the quality of health care delivered to
members.
(3) Priority.--The Commissioner, in making grants and loans
under this subsection, shall give priority to cooperatives
that--
(A) operate on a statewide basis;
(B) use an integrated delivery system; or
(C) have a significant level of financial support
from nongovernmental sources.
(4) Rules of construction.--Nothing in this section shall
be construed to prevent a cooperative established in one State
from integrating with a cooperative established in another
State the administration, issuance of coverage, or other
activities related to acting as a QHBP offering entity. Nothing
in this section shall be construed as preventing State
governments from taking actions to permit such integration.
(5) Amortization of grants and loans.--The Secretary shall
provide for the repayment of grants or loans provided under
this subsection to the Treasury in an amortized manner over a
10-year period.
(6) Repayment for violations of terms of program.--If a
cooperative violates the terms of the CO-OP program and fails
to correct the violation within a reasonable period of time, as
determined by the Commissioner, the cooperative shall repay the
total amount of any loan or grant received by such cooperative
under this section, plus interest (at a rate determined by the
Secretary).
(7) Authorization of appropriations.--There is authorized
to be appropriated $5,000,000,000 for the period of fiscal
years 2010 through 2014 to provide for grants and loans under
this subsection.
(c) Definitions.--For purposes of this section:
(1) State.--The term ``State'' means each of the 50 States
and the District of Columbia.
(2) Member.--The term ``member'', with respect to a
cooperative, means an individual who, after the cooperative
offers health insurance coverage, is enrolled in such coverage.
SEC. 311. RETENTION OF DOD AND VA AUTHORITY.
Nothing in this subtitle shall be construed as affecting any
authority under title 38, United States Code, or chapter 55 of title
10, United States Code.
Subtitle B--Public Health Insurance Option
SEC. 321. ESTABLISHMENT AND ADMINISTRATION OF A PUBLIC HEALTH INSURANCE
OPTION AS AN EXCHANGE-QUALIFIED HEALTH BENEFITS PLAN.
(a) Establishment.--For years beginning with Y1, the Secretary of
Health and Human Services (in this subtitle referred to as the
``Secretary'') shall provide for the offering of an Exchange-
participating health benefits plan (in this division referred to as the
``public health insurance option'') that ensures choice, competition,
and stability of affordable, high quality coverage throughout the
United States in accordance with this subtitle. In designing the
option, the Secretary's primary responsibility is to create a low-cost
plan without compromising quality or access to care.
(b) Offering as an Exchange-participating Health Benefits Plan.--
(1) Exclusive to the exchange.--The public health insurance
option shall only be made available through the Health
Insurance Exchange.
(2) Ensuring a level playing field.--Consistent with this
subtitle, the public health insurance option shall comply with
requirements that are applicable under this title to an
Exchange-participating health benefits plan, including
requirements related to benefits, benefit levels, provider
networks, notices, consumer protections, and cost-sharing.
(3) Provision of benefit levels.--The public health
insurance option--
(A) shall offer basic, enhanced, and premium plans;
and
(B) may offer premium-plus plans.
(c) Administrative Contracting.--The Secretary may enter into
contracts 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 the public health insurance
option in the same manner as the Secretary may enter into contracts
under subsection (a)(1) of such section. The Secretary has the same
authority with respect to the public health insurance option 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. Contracts
under this subsection shall not involve the transfer of insurance risk
to such entity.
(d) Ombudsman.--The Secretary shall establish an office of the
ombudsman for the public health insurance option which shall have
duties with respect to the public health insurance option similar to
the duties of the Medicare Beneficiary Ombudsman under section
1808(c)(2) of the Social Security Act.
(e) Data Collection.--The Secretary shall collect such data as may
be required to establish premiums and payment rates for the public
health insurance option and for other purposes under this subtitle,
including to improve quality and to reduce racial, ethnic, and other
disparities in health and health care. Nothing in this subtitle may be
construed as authorizing the Secretary (or any employee or contractor)
to create or maintain lists of non-medical personal property.
(f) Treatment of Public Health Insurance Option.--With respect to
the public health insurance option, the Secretary shall be treated as a
QHBP offering entity offering an Exchange-participating health benefits
plan.
(g) Access to Federal Courts.--The provisions of Medicare (and
related provisions of title II of the Social Security Act) relating to
access of Medicare beneficiaries to Federal courts for the enforcement
of rights under Medicare, including with respect to amounts in
controversy, shall apply to the public health insurance option and
individuals enrolled under such option under this title in the same
manner as such provisions apply to Medicare and Medicare beneficiaries.
SEC. 322. PREMIUMS AND FINANCING.
(a) Establishment of Premiums.--
(1) In general.--The Secretary shall establish
geographically adjusted premium rates for the public health
insurance option--
(A) in a manner that complies with the premium
rules established by the Commissioner under section 213
for Exchange-participating health benefits plans; and
(B) at a level sufficient to fully finance the
costs of--
(i) health benefits provided by the public
health insurance option; and
(ii) administrative costs related to
operating the public health insurance option.
(2) Contingency margin.--In establishing premium rates
under paragraph (1), the Secretary shall include an appropriate
amount for a contingency margin (which shall be not less than
90 days of estimated claims). Before setting such appropriate
amount for years starting with Y3, the Secretary shall solicit
a recommendation on such amount from the American Academy of
Actuaries.
(b) Account.--
(1) Establishment.--There is established in the Treasury of
the United States an Account for the receipts and disbursements
attributable to the operation of the public health insurance
option, including the start-up funding under paragraph (2).
Section 1854(g) of the Social Security Act shall apply to
receipts described in the previous sentence in the same manner
as such section applies to payments or premiums described in
such section.
(2) Start-up funding.--
(A) In general.--In order to provide for the
establishment of the public health insurance option,
there is hereby appropriated to the Secretary, out of
any funds in the Treasury not otherwise appropriated,
$2,000,000,000. In order to provide for initial claims
reserves before the collection of premiums, there are
hereby appropriated to the Secretary, out of any funds
in the Treasury not otherwise appropriated, such sums
as necessary to cover 90 days worth of claims reserves
based on projected enrollment.
(B) Amortization of start-up funding.--The
Secretary shall provide for the repayment of the
startup funding provided under subparagraph (A) to the
Treasury in an amortized manner over the 10-year period
beginning with Y1.
(C) Limitation on funding.--Nothing in this section
shall be construed as authorizing any additional
appropriations to the Account, other than such amounts
as are otherwise provided with respect to other
Exchange-participating health benefits plans.
(3) No bailouts.--In no case shall the public health
insurance option receive any Federal funds for purposes of
insolvency in any manner similar to the manner in which
entities receive Federal funding under the Troubled Assets
Relief Program of the Secretary of the Treasury.
SEC. 323. PAYMENT RATES FOR ITEMS AND SERVICES.
(a) Negotiation of Payment Rates.--
(1) In general.--The Secretary shall negotiate payment for
the public health insurance option for health care providers
and items and services, including prescription drugs,
consistent with this section and section 324.
(2) Manner of negotiation.--The Secretary shall negotiate
such rates in a manner that results in payment rates that are
not lower, in the aggregate, than rates under title XVIII of
the Social Security Act, and not higher, in the aggregate, than
the average rates paid by other QHBP offering entities for
services and health care providers.
(3) Innovative payment methods.--Nothing in this subsection
shall be construed as preventing the use of innovative payment
methods such as those described in section 324 in connection
with the negotiation of payment rates under this subsection.
(b) Establishment of a Provider Network.--
(1) In general.--Health care providers (including
physicians and hospitals) participating in Medicare are
participating providers in the public health insurance option
unless they opt out in a process established by the Secretary
consistent with this subsection.
(2) Requirements for opt-out process.--Under the process
established under paragraph (1)--
(A) providers described in such paragraph shall be
provided at least a 1-year period prior to the first
day of Y1 to opt out of participating in the public
health insurance option;
(B) no provider shall be subject to a penalty for
not participating in the public health insurance
option;
(C) the Secretary shall include information on how
providers participating in Medicare who chose to opt
out of participating in the public health insurance
option may opt back in; and
(D) there shall be an annual enrollment period in
which providers may decide whether to participate in
the public health insurance option.
(3) Rulemaking.--Not later than 18 months before the first
day of Y1, the Secretary shall promulgate rules (pursuant to
notice and comment) for the process described in paragraph (1).
(c) Limitations on Review.--There shall be no administrative or
judicial review of a payment rate or methodology established under this
section or under section 324.
SEC. 324. MODERNIZED PAYMENT INITIATIVES AND DELIVERY SYSTEM REFORM.
(a) In General.--For plan years beginning with Y1, the Secretary
may utilize innovative payment mechanisms and policies to determine
payments for items and services under the public health insurance
option. The payment mechanisms and policies under this section may
include patient-centered medical home and other care management
payments, accountable care organizations, value-based purchasing,
bundling of services, differential payment rates, performance or
utilization based payments, partial capitation, and direct contracting
with providers.
(b) Requirements for Innovative Payments.--The Secretary shall
design and implement the payment mechanisms and policies under this
section in a manner that--
(1) seeks to--
(A) improve health outcomes;
(B) reduce health disparities (including racial,
ethnic, and other disparities);
(C) provide efficient and affordable care;
(D) address geographic variation in the provision
of health services; or
(E) prevent or manage chronic illness; and
(2) promotes care that is integrated, patient-centered,
quality, and efficient.
(c) Encouraging the Use of High Value Services.--To the extent
allowed by the benefit standards applied to all Exchange-participating
health benefits plans, the public health insurance option may modify
cost-sharing and payment rates to encourage the use of services that
promote health and value.
(d) Promotion of Delivery System Reform.--The Secretary shall
monitor and evaluate the progress of payment and delivery system
reforms under this Act and shall seek to implement such reforms subject
to the following:
(1) To the extent that the Secretary finds a payment and
delivery system reform successful in improving quality and
reducing costs, the Secretary shall implement such reform on as
large a geographic scale as practical and economical.
(2) The Secretary may delay the implementation of such a
reform in geographic areas in which such implementation would
place the public health insurance option at a competitive
disadvantage.
(3) The Secretary may prioritize implementation of such a
reform in high cost geographic areas or otherwise in order to
reduce total program costs or to promote high value care.
(e) Non-uniformity Permitted.--Nothing in this subtitle shall
prevent the Secretary from varying payments based on different payment
structure models (such as accountable care organizations and medical
homes) under the public health insurance option for different
geographic areas.
SEC. 325. PROVIDER PARTICIPATION.
(a) In General.--The Secretary shall establish conditions of
participation for health care providers under the public health
insurance option.
(b) Licensure or Certification.--
(1) In general.--Except as provided in paragraph (2), the
Secretary shall not allow a health care provider to participate
in the public health insurance option unless such provider is
appropriately licensed, certified, or otherwise permitted to
practice under State law.
(2) Special rule for ihs facilities and providers.--The
requirements under paragraph (1) shall not apply to--
(A) a facility that is operated by the Indian
Health Service;
(B) a facility operated by an Indian Tribe or
tribal organization under the Indian Self-Determination
Act (Public Law 93-638);
(C) a health care professional employed by the
Indian Health Service; or
(D) a health care professional--
(i) who is employed to provide health care
services in a facility operated by an Indian
Tribe or tribal organization under the Indian
Self-Determination Act; and
(ii) who is licensed or certified in any
State.
(c) Payment Terms for Providers.--
(1) Physicians.--The Secretary shall provide for the annual
participation of physicians under the public health insurance
option, for which payment may be made for services furnished
during the year, in one of 2 classes:
(A) Preferred physicians.--Those physicians who
agree to accept the payment under section 323 (without
regard to cost-sharing) as the payment in full.
(B) Participating, non-preferred physicians.--Those
physicians who agree not to impose charges (in relation
to the payment described in section 323 for such
physicians) that exceed the sum of the in-network cost-
sharing plus 15 percent of the total payment for each
item and service. The Secretary shall reduce the
payment described in section 323 for such physicians.
(2) Other providers.--The Secretary shall provide for the
participation (on an annual or other basis specified by the
Secretary) of health care providers (other than physicians)
under the public health insurance option under which payment
shall only be available if the provider agrees to accept the
payment under section 323 (without regard to cost-sharing) as
the payment in full.
(d) Exclusion of Certain Providers.--The Secretary shall exclude
from participation under the public health insurance option a health
care provider that is excluded from participation in a Federal health
care program (as defined in section 1128B(f) of the Social Security
Act).
SEC. 326. APPLICATION OF FRAUD AND ABUSE PROVISIONS.
Provisions of civil law identified by the Secretary by regulation,
in consultation with the Inspector General of the Department of Health
and Human Services, that impose sanctions with respect to waste, fraud,
and abuse under Medicare, such as sections 3729 through 3733 of title
31, United States Code (commonly known as the False Claims Act), shall
also apply to the public health insurance option.
SEC. 327. APPLICATION OF HIPAA INSURANCE REQUIREMENTS.
The requirements of sections 2701 through 2792 of the Public Health
Service Act shall apply to the public health insurance option in the
same manner as they apply to health insurance coverage offered by a
health insurance issuer in the individual market.
SEC. 328. APPLICATION OF HEALTH INFORMATION PRIVACY, SECURITY, AND
ELECTRONIC TRANSACTION REQUIREMENTS.
Part C of title XI of the Social Security Act, relating to
standards for protections against the wrongful disclosure of
individually identifiable health information, health information
security, and the electronic exchange of health care information, shall
apply to the public health insurance option in the same manner as such
part applies to other health plans (as defined in section 1171(5) of
such Act).
SEC. 329. ENROLLMENT IN PUBLIC HEALTH INSURANCE OPTION IS VOLUNTARY.
Nothing in this division shall be construed as requiring anyone to
enroll in the public health insurance option. Enrollment in such option
is voluntary.
SEC. 330. ENROLLMENT IN PUBLIC HEALTH INSURANCE OPTION BY MEMBERS OF
CONGRESS.
Notwithstanding any other provision of this Act, Members of
Congress may enroll in the public health insurance option.
SEC. 331. REIMBURSEMENT OF SECRETARY OF VETERANS AFFAIRS.
The Secretary of Health and Human Services shall seek to enter into
a memorandum of understanding with the Secretary of Veterans Affairs
regarding the recovery of costs related to non-service-connected care
or services provided by the Secretary of Veterans Affairs to an
individual covered under the public health insurance option in a manner
consistent with recovery of costs related to non-service-connected care
from private health insurance plans.
Subtitle C--Individual Affordability Credits
SEC. 341. AVAILABILITY THROUGH HEALTH INSURANCE EXCHANGE.
(a) In General.--Subject to the succeeding provisions of this
subtitle, in the case of an affordable credit eligible individual
enrolled in an Exchange-participating health benefits plan--
(1) the individual shall be eligible for, in accordance
with this subtitle, affordability credits consisting of--
(A) an affordability premium credit under section
343 to be applied against the premium for the Exchange-
participating health benefits plan in which the
individual is enrolled; and
(B) an affordability cost-sharing credit under
section 344 to be applied as a reduction of the cost-
sharing otherwise applicable to such plan; and
(2) the Commissioner shall pay the QHBP offering entity
that offers such plan from the Health Insurance Exchange Trust
Fund the aggregate amount of affordability credits for all
affordable credit eligible individuals enrolled in such plan.
(b) Application.--
(1) In general.--An Exchange eligible individual may apply
to the Commissioner through the Health Insurance Exchange or
through another entity under an arrangement made with the
Commissioner, in a form and manner specified by the
Commissioner. The Commissioner through the Health Insurance
Exchange or through another public entity under an arrangement
made with the Commissioner shall make a determination as to
eligibility of an individual for affordability credits under
this subtitle. The Commissioner shall establish a process
whereby, on the basis of information otherwise available,
individuals may be deemed to be affordable credit eligible
individuals. In carrying this subtitle, the Commissioner shall
establish effective methods that ensure that individuals with
limited English proficiency are able to apply for affordability
credits.
(2) Use of state medicaid agencies.--If the Commissioner
determines that a State Medicaid agency has the capacity to
make a determination of eligibility for affordability credits
under this subtitle and under the same standards as used by the
Commissioner, under the Medicaid memorandum of understanding
under section 305(e)(2)--
(A) the State Medicaid agency is authorized to
conduct such determinations for any Exchange-eligible
individual who requests such a determination; and
(B) the Commissioner shall reimburse the State
Medicaid agency for the costs of conducting such
determinations.
(3) Medicaid screen and enroll obligation.--In the case of
an application made under paragraph (1), there shall be a
determination of whether the individual is a Medicaid-eligible
individual. If the individual is determined to be so eligible,
the Commissioner, through the Medicaid memorandum of
understanding under section 305(e)(2), shall provide for the
enrollment of the individual under the State Medicaid plan in
accordance with such Medicaid memorandum of understanding. In
the case of such an enrollment, the State shall provide for the
same periodic redetermination of eligibility under Medicaid as
would otherwise apply if the individual had directly applied
for medical assistance to the State Medicaid agency.
(4) Application and verification of requirement of
citizenship or lawful presence in the united states.--
(A) Requirement.--No individual shall be an
affordable credit eligible individual (as defined in
section 342(a)(1)) unless the individual is a citizen
or national of the United States or is lawfully present
in a State in the United States (other than as a
nonimmigrant described in a subparagraph (excluding
subparagraphs (K), (T), (U), and (V)) of section
101(a)(15) of the Immigration and Nationality Act).
(B) Declaration of citizenship or lawful
immigration status.--No individual shall be an
affordable credit eligible individual unless there has
been a declaration made, in a form and manner specified
by the Health Choices Commissioner similar to the
manner required under section 1137(d)(1) of the Social
Security Act and under penalty of perjury, that the
individual--
(i) is a citizen or national of the United
States; or
(ii) is not such a citizen or national but
is lawfully present in a State in the United
States (other than as a nonimmigrant described
in a subparagraph (excluding subparagraphs (K),
(T), (U), and (V)) of section 101(a)(15) of the
Immigration and Nationality Act).
Such declaration shall be verified in accordance with
subparagraph (C) or (D), as the case may be.
(C) Verification process for citizens.--
(i) In general.--In the case of an
individual making the declaration described in
subparagraph (B)(i), subject to clause (ii),
section 1902(ee) of the Social Security Act
shall apply to such declaration in the same
manner as such section applies to a declaration
described in paragraph (1) of such section.
(ii) Special rules.--In applying section
1902(ee) of such Act under clause (i)--
(I) any reference in such section
to a State is deemed a reference to the
Commissioner (or other public entity
making the eligibility determination);
(II) any reference to medical
assistance or enrollment under a State
plan is deemed a reference to provision
of affordability credits under this
subtitle;
(III) a reference to a newly
enrolled individual under paragraph
(2)(A) of such section is deemed a
reference to an individual newly in
receipt of an affordability credit
under this subtitle;
(IV) approval by the Secretary
shall not be required in applying
paragraph (2)(B)(ii) of such section;
(V) paragraph (3) of such section
shall not apply; and
(VI) before the end of Y2, the
Health Choices Commissioner, in
consultation with the Commissioner of
Social Security, may extend the periods
specified in paragraph (1)(B)(ii) of
such section.
(D) Verification process for noncitizens.--
(i) In general.--In the case of an
individual making the declaration described in
subparagraph (B)(ii), subject to clause (ii),
the verification procedures of paragraphs (2)
through (5) of section 1137(d) of the Social
Security Act shall apply to such declaration in
the same manner as such procedures apply to a
declaration described in paragraph (1) of such
section.
(ii) Special rules.--In applying such
paragraphs of section 1137(d) of such Act under
clause (i)--
(I) any reference in such
paragraphs to a State is deemed a
reference to the Health Choices
Commissioner; and
(II) any reference to benefits
under a program is deemed a reference
to affordability credits under this
subtitle.
(iii) Application to state-based
exchanges.--In the case of the application of
the verification process under this
subparagraph to a State-based Health Insurance
Exchange approved under section 308, section
1137(e) of such Act shall apply to the Health
Choices Commissioner in relation to the State.
(E) Annual reports.--The Health Choices
Commissioner shall report to Congress annually on the
number of applicants for affordability credits under
this subtitle, their citizenship or immigration status,
and the disposition of their applications. Such report
shall be made publicly available and shall include
information on--
(i) the number of applicants whose
declaration of citizenship or immigration
status, name, or social security account number
was not consistent with records maintained by
the Commissioner of Social Security or the
Department of Homeland Security and, of such
applicants, the number who contested the
inconsistency and sought to document their
citizenship or immigration status, name, or
social security account number or to correct
the information maintained in such records and,
of those, the results of such contestations;
and
(ii) the administrative costs of conducting
the status verification under this paragraph.
(F) GAO report.--Not later than the end of Y2, the
Comptroller General of the United States shall submit
to the Committee on Ways and Means, the Committee on
Energy and Commerce, the Committee on Education and
Labor, and the Committee on the Judiciary of the House
of Representatives and the Committee on Finance, the
Committee on Health, Education, Labor, and Pensions,
and the Committee on the Judiciary of the Senate a
report examining the effectiveness of the citizenship
and immigration verification systems applied under this
paragraph. Such report shall include an analysis of the
following:
(i) The causes of erroneous determinations
under such systems.
(ii) The effectiveness of the processes
used in remedying such erroneous
determinations.
(iii) The impact of such systems on
individuals, health care providers, and Federal
and State agencies, including the effect of
erroneous determinations under such systems.
(iv) The effectiveness of such systems in
preventing ineligible individuals from
receiving for affordability credits.
(v) The characteristics of applicants
described in subparagraph (E)(i).
(G) Prohibition of database.--Nothing in this
paragraph or the amendments made by paragraph (6) shall
be construed as authorizing the Health Choices
Commissioner or the Commissioner of Social Security to
establish a database of information on citizenship or
immigration status.
(H) Initial funding.--
(i) In general.--Out of any funds in the
Treasury not otherwise appropriated, there is
appropriated to the Commissioner of Social
Security $30,000,000, to be available without
fiscal year limit to carry out this paragraph
and section 205(v) of the Social Security Act.
(ii) Funding limitation.--In no case shall
funds from the Social Security Administration's
Limitation on Administrative Expenses be used
to carry out activities related to this
paragraph or section 205(v) of the Social
Security Act.
(5) Agreement with social security commissioner.--
(A) In general.--The Health Choices Commissioner
shall enter into and maintain an agreement described in
section 205(v)(2) of the Social Security Act with the
Commissioner of Social Security.
(B) Funding.--The agreement entered into under
subparagraph (A) shall, for each fiscal year (beginning
with fiscal year 2013)--
(i) provide funds to the Commissioner of
Social Security for the full costs of the
responsibilities of the Commissioner of Social
Security under paragraph (4), including--
(I) acquiring, installing, and
maintaining technological equipment and
systems necessary for the fulfillment
of the responsibilities of the
Commissioner of Social Security under
paragraph (4), but only that portion of
such costs that are attributable to
such responsibilities; and
(II) responding to individuals who
contest with the Commissioner of Social
Security a reported inconsistency with
records maintained by the Commissioner
of Social Security or the Department of
Homeland Security relating to
citizenship or immigration status,
name, or social security account number
under paragraph (4);
(ii) based on an estimating methodology
agreed to by the Commissioner of Social
Security and the Health Choices Commissioner,
provide such funds, within 10 calendar days of
the beginning of the fiscal year for the first
quarter and in advance for all subsequent
quarters in that fiscal year; and
(iii) provide for an annual accounting and
reconciliation of the actual costs incurred and
the funds provided under the agreement.
(C) Review of accounting.--The annual accounting
and reconciliation conducted pursuant to subparagraph
(B)(iii) shall be reviewed by the Inspectors General of
the Social Security Administration and the Health
Choices Administration, including an analysis of
consistency with the requirements of paragraph (4).
(D) Contingency.--In any case in which agreement
with respect to the provisions required under
subparagraph (B) for any fiscal year has not been
reached as of the first day of such fiscal year, the
latest agreement with respect to such provisions shall
be deemed in effect on an interim basis for such fiscal
year until such time as an agreement relating to such
provisions is subsequently reached. In any case in
which an interim agreement applies for any fiscal year
under this subparagraph, the Commissioner of Social
Security shall, not later than the first day of such
fiscal year, notify the appropriate Committees of the
Congress of the failure to reach the agreement with
respect to such provisions for such fiscal year. Until
such time as the agreement with respect to such
provisions has been reached for such fiscal year, the
Commissioner of Social Security shall, not later than
the end of each 90-day period after October 1 of such
fiscal year, notify such Committees of the status of
negotiations between such Commissioner and the Health
Choices Commissioner in order to reach such an
agreement.
(E) Application to public entities administering
affordability credits.--If the Health Choices
Commissioner provides for the conduct of verifications
under paragraph (4) through a public entity, the Health
Choices Commissioner shall require the public entity to
enter into an agreement with the Commissioner of Social
Security which provides the same terms as the agreement
described in this paragraph (and section 205(v) of the
Social Security Act) between the Health Choices
Commissioner and the Commissioner of Social Security,
except that the Health Choices Commissioner shall be
responsible for providing funds for the Commissioner of
Social Security in accordance with subparagraphs (B)
through (D).
(6) Amendments to social security act.--
(A) Coordination of information between social
security administration and health choices
administration.--
(i) In general.--Section 205 of the Social
Security Act (42 U.S.C. 405) is amended by
adding at the end the following new subsection:
``Coordination of Information With Health Choices Administration
``(v)(1) The Health Choices Commissioner may collect and use the
names and social security account numbers of individuals as required to
provide for verification of citizenship under subsection (b)(4)(C) of
section 341 of the Affordable Health Care for America Act in connection
with determinations of eligibility for affordability credits under such
section.
``(2)(A) The Commissioner of Social Security shall enter into and
maintain an agreement with the Health Choices Commissioner for the
purpose of establishing, in compliance with the requirements of section
1902(ee) as applied pursuant to section 341(b)(4)(C) of the Affordable
Health Care for America Act, a program for verifying information
required to be collected by the Health Choices Commissioner under such
section 341(b)(4)(C).
``(B) The agreement entered into pursuant to subparagraph (A) shall
include such safeguards as are necessary to ensure the maintenance of
confidentiality of any information disclosed for purposes of verifying
information described in subparagraph (A) and to provide procedures for
permitting the Health Choices Commissioner to use the information for
purposes of maintaining the records of the Health Choices
Administration.
``(C) The agreement entered into pursuant to subparagraph (A) shall
provide that information provided by the Commissioner of Social
Security to the Health Choices Commissioner pursuant to the agreement
shall be provided at such time, at such place, and in such manner as
the Commissioner of Social Security determines appropriate.
``(D) Information provided by the Commissioner of Social Security
to the Health Choices Commissioner pursuant to an agreement entered
into pursuant to subparagraph (A) shall be considered as strictly
confidential and shall be used only for the purposes described in this
paragraph and for carrying out such agreement. Any officer or employee
or former officer or employee of the Health Choices Commissioner, or
any officer or employee or former officer or employee of a contractor
of the Health Choices Commissioner, who, without the written authority
of the Commissioner of Social Security, publishes or communicates any
information in such individual's possession by reason of such
employment or position as such an officer shall be guilty of a felony
and, upon conviction thereof, shall be fined or imprisoned, or both, as
described in section 208.
``(3) The agreement entered into under paragraph (2) shall provide
for funding to the Commissioner of Social Security consistent with
section 341(b)(5) of Affordable Health Care for America Act.
``(4) This subsection shall apply in the case of a public entity
that conducts verifications under section 341(b)(4) of the Affordable
Health Care for America Act and the obligations of this subsection
shall apply to such an entity in the same manner as such obligations
apply to the Health Choices Commissioner when such Commissioner is
conducting such verifications.''.
(ii) Conforming amendment.--Section
205(c)(2)(C) of such Act (42 U.S.C.
405(c)(2)(C)) is amended by adding at the end
the following new clause:
``(x) For purposes of the administration of the verification
procedures described in section 341(b)(4) of the Affordable Health Care
for America Act, the Health Choices Commissioner may collect and use
social security account numbers as provided for in section
205(v)(1).''.
(B) Improving the integrity of data and
effectiveness of save.--Section 1137(d) of the Social
Security Act (42 U.S.C. 1320b-7(d)) is amended by
adding at the end the following new paragraphs:
``(6)(A) With respect to the use by any agency of the system
described in subsection (b) by programs specified in subsection (b) or
any other use of such system, the U.S. Citizenship and Immigration
Services and any other agency charged with the management of the system
shall establish appropriate safeguards necessary to protect and improve
the integrity and accuracy of data relating to individuals by--
``(i) establishing a process though which such individuals
are provided access to, and the ability to amend, correct, and
update, their own personally identifiable information contained
within the system;
``(ii) providing a written response, without undue delay,
to any individual who has made such a request to amend,
correct, or update such individual's own personally
identifiable information contained within the system; and
``(iii) developing a written notice for user agencies to
provide to individuals who are denied a benefit due to a
determination of ineligibility based on a final verification
determination under the system.
``(B) The notice described in subparagraph (A)(ii) shall include--
``(i) information about the reason for such notice;
``(ii) a description of the right of the recipient of the
notice under subparagraph (A)(i) to contest such notice;
``(iii) a description of the right of the recipient under
subparagraph (A)(i) to access and attempt to amend, correct,
and update the recipient's own personally identifiable
information contained within records of the system described in
paragraph (3); and
``(iv) instructions on how to contest such notice and
attempt to correct records of such system relating to the
recipient, including contact information for relevant
agencies.''.
(C) Streamlining administration of verification
process for united states citizens.--Section
1902(ee)(2) of the Social Security Act (42 U.S.C.
1396a(ee)(2)) is amended by adding at the end the
following:
``(D) In carrying out the verification procedures under this
subsection with respect to a State, if the Commissioner of Social
Security determines that the records maintained by such Commissioner
are not consistent with an individual's allegation of United States
citizenship, pursuant to procedures which shall be established by the
State in coordination with the Commissioner of Social Security, the
Secretary of Homeland Security, and the Secretary of Health and Human
Services--
``(i) the Commissioner of Social Security shall inform the
State of the inconsistency;
``(ii) upon being so informed of the inconsistency, the
State shall submit the information on the individual to the
Secretary of Homeland Security for a determination of whether
the records of the Department of Homeland Security indicate
that the individual is a citizen;
``(iii) upon making such determination, the Department of
Homeland Security shall inform the State of such determination;
and
``(iv) information provided by the Commissioner of Social
Security shall be considered as strictly confidential and shall
only be used by the State and the Secretary of Homeland
Security for the purposes of such verification procedures.
``(E) Verification of status eligibility pursuant to the procedures
established under this subsection shall be deemed a verification of
status eligibility for purposes of this title, title XXI, and
affordability credits under section 341(b)(4) of the Affordable Health
Care for America Act, regardless of the program in which the individual
is applying for benefits.''.
(c) Use of Affordability Credits.--
(1) In general.--In Y1 and Y2 an affordable credit eligible
individual may use an affordability credit only with respect to
a basic plan.
(2) Flexibility in plan enrollment authorized.--Beginning
with Y3, the Commissioner shall establish a process to allow an
affordability premium credit under section 343, but not the
affordability cost-sharing credit under section 344, to be used
for enrollees in enhanced or premium plans. In the case of an
affordable credit eligible individual who enrolls in an
enhanced or premium plan, the individual shall be responsible
for any difference between the premium for such plan and the
affordability credit amount otherwise applicable if the
individual had enrolled in a basic plan.
(3) Prohibition of use of public funds for abortion
coverage.--An affordability credit may not be used for payment
for services described in section 222(d)(4)(A).
(d) Access to Data.--In carrying out this subtitle, the
Commissioner shall request from the Secretary of the Treasury
consistent with section 6103 of the Internal Revenue Code of 1986 such
information as may be required to carry out this subtitle.
(e) No Cash Rebates.--In no case shall an affordable credit
eligible individual receive any cash payment as a result of the
application of this subtitle.
SEC. 342. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL.
(a) Definition.--
(1) In general.--For purposes of this division, the term
``affordable credit eligible individual'' means, subject to
subsection (b) and section 346, an individual who is lawfully
present in a State in the United States (other than as a
nonimmigrant described in a subparagraph (excluding
subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) of
the Immigration and Nationality Act)--
(A) who is enrolled under an Exchange-participating
health benefits plan and is not enrolled under such
plan as an employee (or dependent of an employee)
through an employer qualified health benefits plan that
meets the requirements of section 412;
(B) with modified adjusted gross income below 400
percent of the Federal poverty level for a family of
the size involved;
(C) who is not a Medicaid eligible individual,
other than an individual during a transition period
under section 302(d)(3)(B)(ii); and
(D) subject to paragraph (3), who is not enrolled
in acceptable coverage (other than an Exchange-
participating health benefits plan).
(2) Treatment of family.--Except as the Commissioner may
otherwise provide, members of the same family who are
affordable credit eligible individuals shall be treated as a
single affordable credit individual eligible for the applicable
credit for such a family under this subtitle.
(3) Special rule for indians.--Subparagraph (D) of
paragraph (1) shall not apply to an individual who has coverage
that is treated as acceptable coverage for purposes of section
59B(d)(2) of the Internal Revenue Code of 1986 but is not
treated as acceptable coverage for purposes of this division.
(b) Limitations on Employee and Dependent Disqualification.--
(1) In general.--Subject to paragraph (2), the term
``affordable credit eligible individual'' does not include a
full-time employee of an employer if the employer offers the
employee coverage (for the employee and dependents) as a full-
time employee under a group health plan if the coverage and
employer contribution under the plan meet the requirements of
section 412.
(2) Exceptions.--
(A) For certain family circumstances.--The
Commissioner shall establish such exceptions and
special rules in the case described in paragraph (1) as
may be appropriate in the case of a divorced or
separated individual or such a dependent of an employee
who would otherwise be an affordable credit eligible
individual.
(B) For unaffordable employer coverage.--Beginning
in Y2, in the case of full-time employees for which the
cost of the employee premium for coverage under a group
health plan would exceed 12 percent of current modified
adjusted gross income (determined by the Commissioner
on the basis of verifiable documentation), paragraph
(1) shall not apply.
(c) Income Defined.--
(1) In general.--In this title, the term ``income'' means
modified adjusted gross income (as defined in section 59B of
the Internal Revenue Code of 1986).
(2) Study of income disregards.--The Commissioner shall
conduct a study that examines the application of income
disregards for purposes of this subtitle. Not later than the
first day of Y2, the Commissioner shall submit to Congress a
report on such study and shall include such recommendations as
the Commissioner determines appropriate.
(d) Clarification of Treatment of Affordability Credits.--
Affordability credits under this subtitle shall not be treated, for
purposes of title IV of the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996, to be a benefit provided under
section 403 of such title.
SEC. 343. AFFORDABILITY PREMIUM CREDIT.
(a) In General.--The affordability premium credit under this
section for an affordable credit eligible individual enrolled in an
Exchange-participating health benefits plan is in an amount equal to
the amount (if any) by which the reference premium amount specified in
subsection (c), exceeds the affordable premium amount specified in
subsection (b) for the individual, except that in no case shall the
affordable premium credit exceed the premium for the plan.
(b) Affordable Premium Amount.--
(1) In general.--The affordable premium amount specified in
this subsection for an individual for the annual premium in a
plan year shall be equal to the product of--
(A) the premium percentage limit specified in
paragraph (2) for the individual based upon the
individual's modified adjusted gross income for the
plan year; and
(B) the individual's modified adjusted gross income
for such plan year.
(2) Premium percentage limits based on table.--The
Commissioner shall establish premium percentage limits so that
for individuals whose modified adjusted gross income is within
an income tier specified in the table in subsection (d) such
percentage limits shall increase, on a sliding scale in a
linear manner, from the initial premium percentage to the final
premium percentage specified in such table for such income
tier.
(c) Reference Premium Amount.--The reference premium amount
specified in this subsection for a plan year for an individual in a
premium rating area is equal to the average premium for the 3 basic
plans in the area for the plan year with the lowest premium levels. In
computing such amount the Commissioner may exclude plans with extremely
limited enrollments.
(d) Table of Premium Percentage Limits, Actuarial Value
Percentages, and Out-of-pocket Limits for Y1 Based on Income Tier.--
(1) In general.--For purposes of this subtitle, subject to
paragraph (3) and section 346, the table specified in this
subsection is as follows:
In the case of modified
adjusted gross income The out-of-
(expressed as a percent of The initial premium The final premium The actuarial value pocket
FPL) within the following percentage is-- percentage is-- percentage is-- limit for
income tier: Y1 is--
133% through 150% 1.5% 3.0% 97% $500
150% through 200% 3.0% 5.5% 93% $1,000
200% through 250% 5.5% 8.0% 85% $2,000
250% through 300% 8.0% 10.0% 78% $4,000
300% through 350% 10.0% 11.0% 72% $4,500
350% through 400% 11.0% 12.0% 70% $5,000
(2) Special rules.--For purposes of applying the table
under paragraph (1):
(A) For lowest level of income.--In the case of an
individual with income that does not exceed 133 percent
of FPL, the individual shall be considered to have
income that is 133 percent of FPL.
(B) Application of higher actuarial value
percentage at tier transition points.--If two actuarial
value percentages may be determined with respect to an
individual, the actuarial value percentage shall be the
higher of such percentages.
(3) Indexing.--For years after Y1, the Commissioner shall
adjust the initial and final premium percentages to maintain
the ratio of governmental to enrollee shares of premiums over
time, for each income tier identified in the table in paragraph
(1).
SEC. 344. AFFORDABILITY COST-SHARING CREDIT.
(a) In General.--The affordability cost-sharing credit under this
section for an affordable credit eligible individual enrolled in an
Exchange-participating health benefits plan is in the form of the cost-
sharing reduction described in subsection (b) provided under this
section for the income tier in which the individual is classified based
on the individual's modified adjusted gross income.
(b) Cost-sharing Reductions.--The Commissioner shall specify a
reduction in cost-sharing amounts and the annual limitation on cost-
sharing specified in section 222(c)(2)(B) under a basic plan for each
income tier specified in the table under section 343(d), with respect
to a year, in a manner so that, as estimated by the Commissioner--
(1) the actuarial value of the coverage with such reduced
cost-sharing amounts (and the reduced annual cost-sharing
limit) is equal to the actuarial value percentage (specified in
the table under section 343(d) for the income tier involved) of
the full actuarial value if there were no cost-sharing imposed
under the plan; and
(2) the annual limitation on cost-sharing specified in
section 222(c)(2)(B) is reduced to a level that does not exceed
the maximum out-of-pocket limit specified in subsection (c).
(c) Maximum Out-of-pocket Limit.--
(1) In general.--Subject to paragraph (2), the maximum out-
of-pocket limit specified in this subsection for an individual
within an income tier--
(A) for individual coverage--
(i) for Y1 is the out-of-pocket limit for
Y1 specified in subsection (c) in the table
under section 343(d) for the income tier
involved; or
(ii) for a subsequent year is such out-of-
pocket limit for the previous year under this
subparagraph increased (rounded to the nearest
$10) for each subsequent year by the percentage
increase in the enrollment-weighted average of
premium increases for basic plans applicable to
such year; or
(B) for family coverage is twice the maximum out-
of-pocket limit under subparagraph (A) for the year
involved.
(2) Adjustment.--The Commissioner shall adjust the maximum
out-of-pocket limits under paragraph (1) to ensure that such
limits meet the actuarial value percentage specified in the
table under section 343(d) for the income tier involved.
(d) Determination and Payment of Cost-sharing Affordability
Credit.--In the case of an affordable credit eligible individual in a
tier enrolled in an Exchange-participating health benefits plan offered
by a QHBP offering entity, the Commissioner shall provide for payment
to the offering entity of an amount equivalent to the increased
actuarial value of the benefits under the plan provided under section
303(c)(2)(B) resulting from the reduction in cost-sharing described in
subsections (b) and (c).
SEC. 345. INCOME DETERMINATIONS.
(a) In General.--In applying this subtitle for an affordability
credit for an individual for a plan year, the individual's income shall
be the income (as defined in section 342(c)) for the individual for the
most recent taxable year (as determined in accordance with rules of the
Commissioner). The Federal poverty level applied shall be such level in
effect as of the date of the application.
(b) Program Integrity; Income Verification Procedures.--
(1) Program integrity.--The Commissioner shall take such
steps as may be appropriate to ensure the accuracy of
determinations and redeterminations under this subtitle.
(2) Income verification.--
(A) In general.--Upon an initial application of an
individual for an affordability credit under this
subtitle (or in applying section 342(b)) or upon an
application for a change in the affordability credit
based upon a significant change in modified adjusted
gross income described in subsection (c)(1)--
(i) the Commissioner shall request from the
Secretary of the Treasury the disclosure to the
Commissioner of such information as may be
permitted to verify the information contained
in such application; and
(ii) the Commissioner shall use the
information so disclosed to verify such
information.
(B) Alternative procedures.--The Commissioner shall
establish procedures for the verification of income for
purposes of this subtitle if no income tax return is
available for the most recent completed tax year.
(c) Special Rules.--
(1) Changes in income as a percent of fpl.--In the case
that an individual's income (expressed as a percentage of the
Federal poverty level for a family of the size involved) for a
plan year is expected (in a manner specified by the
Commissioner) to be significantly different from the income (as
so expressed) used under subsection (a), the Commissioner shall
establish rules requiring an individual to report, consistent
with the mechanism established under paragraph (2), significant
changes in such income (including a significant change in
family composition) to the Commissioner and requiring the
substitution of such income for the income otherwise
applicable.
(2) Reporting of significant changes in income.--The
Commissioner shall establish rules under which an individual
determined to be an affordable credit eligible individual would
be required to inform the Commissioner when there is a
significant change in the modified adjusted gross income of the
individual (expressed as a percentage of the FPL for a family
of the size involved) and of the information regarding such
change. Such mechanism shall provide for guidelines that
specify the circumstances that qualify as a significant change,
the verifiable information required to document such a change,
and the process for submission of such information. If the
Commissioner receives new information from an individual
regarding the modified adjusted gross income of the individual,
the Commissioner shall provide for a redetermination of the
individual's eligibility to be an affordable credit eligible
individual.
(3) Transition for chip.--In the case of a child described
in section 302(d)(2), the Commissioner shall establish rules
under which the modified adjusted gross income of the child is
deemed to be no greater than the family income of the child as
most recently determined before Y1 by the State under title XXI
of the Social Security Act.
(4) Study of geographic variation in application of fpl.--
(A) In general.--The Secretary of Health and Human
Services shall conduct a study to examine the
feasibility and implication of adjusting the
application of the Federal poverty level under 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 the first day of Y1, 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.--
(i) In general.--The Secretary shall ensure
that the study under subparagraph (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.
(ii) Territories defined.--In this
subparagraph, 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.
(d) Penalties for Misrepresentation.--In the case of an individual
who intentionally misrepresents modified adjusted gross income or the
individual fails (without regard to intent) to disclose to the
Commissioner a significant change in modified adjusted gross income
under subsection (c) in a manner that results in the individual
becoming an affordable credit eligible individual when the individual
is not or in the amount of the affordability credit exceeding the
correct amount--
(1) the individual is liable for repayment of the amount of
the improper affordability credit; and
(2) in the case of such an intentional misrepresentation or
other egregious circumstances specified by the Commissioner,
the Commissioner may impose an additional penalty.
SEC. 346. SPECIAL RULES FOR APPLICATION TO TERRITORIES.
(a) One-time Election for Treatment and Application of Funding.--
(1) In general.--A territory may elect, in a form and
manner specified by the Commissioner in consultation with the
Secretary of Health and Human Services and the Secretary of the
Treasury and not later than October 1, 2012, either--
(A) to be treated as a State for purposes of
applying this title and title II; or
(B) not to be so treated but instead, to have the
dollar limitation otherwise applicable to the territory
under subsections (f) and (g) of section 1108 of the
Social Security Act (42 U.S.C. 1308) for a fiscal year
increased by a dollar amount equivalent to the cap
amount determined under subsection (c)(2) for the
territory as applied by the Secretary for the fiscal
year involved.
(2) Conditions for acceptance.--The Commissioner has the
nonreviewable authority to accept or reject an election
described in paragraph (1)(A). Any such acceptance is--
(A) contingent upon entering into an agreement
described in subsection (b) between the Commissioner
and the territory and subsection (c); and
(B) subject to the approval of the Secretary of
Health and Human Services and the Secretary of the
Treasury and subject to such other terms and conditions
as the Commissioner, in consultation with such
Secretaries, may specify.
(3) Default rule.--A territory failing to make such an
election (or having an election under paragraph (1)(A) not
accepted under paragraph (2)) shall be treated as having made
the election described in paragraph (1)(B).
(b) Agreement for Substitution of Percentages for Affordability
Credits.--
(1) Negotiation.--In the case of a territory making an
election under subsection (a)(1)(A) (in this section referred
to as an ``electing territory'') , the Commissioner, in
consultation with the Secretaries of Health and Human Services
and the Treasury, shall enter into negotiations with the
government of such territory so that, before Y1, there is an
agreement reached between the parties on the percentages that
shall be applied under paragraph (2) for that territory. The
Commissioner shall not enter into such an agreement unless--
(A) payments made under this subtitle with respect
to residents of the territory are consistent with the
cap established under subsection (c) for such territory
and with subsection (d); and
(B) the requirements of paragraphs (3) and (4) are
met.
(2) Application of substitute percentages and dollar
amounts.--In the case of an electing territory, there shall be
substituted in section 342(a)(1)(B) and in the table in section
341(d)(1) for 400 percent, 133 percent, and other percentages
and dollar amounts specified in such table, such respective
percentages and dollar amounts as are established under the
agreement under paragraph (1) consistent with the following:
(A) No income gap between medicaid and
affordability credits.--The substituted percentages
shall be specified in a manner so as to prevent any gap
in coverage for individuals between income level at
which medical assistance is available through Medicaid
and the income level at which affordability credits are
available.
(B) Adjustment for out-of-pocket responsibility for
premiums and cost-sharing in relation to income.--The
substituted percentages of FPL for income tiers under
such table shall be specified in a manner so that--
(i) affordable credit eligible individuals
residing in the territory bear the same out-of-
pocket responsibility for premiums and cost-
sharing in relation to average income for
residents in that territory, as
(ii) the out-of-pocket responsibility for
premiums and cost-sharing for affordable credit
eligible individuals residing in the 50 States
or the District of Columbia in relation to
average income for such residents.
(3) Special rules with respect to application of tax and
penalty provisions.--The electing territory shall enact one or
more laws under which provisions similar to the following
provisions apply with respect to such territory:
(A) Section 59B of the Internal Revenue Code of
1986, except that any resident of the territory who is
not an affordable credit eligible individual but who
would be an affordable credit eligible individual if
such resident were a resident of one of the 50 States
(and any qualifying child residing with such
individual) may be treated as covered by acceptable
coverage.
(B) Section 4980H of the Internal Revenue Code of
1986 and section 502(c)(11) of the Employee Retirement
Income Security Act of 1974.
(C) Section 3121(c) of the Internal Revenue Code of
1986.
(4) Implementation of insurance reform and consumer
protection requirements.--The electing territory shall enact
and implement such laws and regulations as may be required to
apply the requirements of title II with respect to health
insurance coverage offered in the territory.
(c) Cap on Additional Expenditures.--
(1) In general.--In entering into an agreement with an
electing territory under subsection (b), the Commissioner shall
ensure that the aggregate expenditures under this subtitle with
respect to residents of such territory during the period
beginning with Y1 and ending with 2019 will not exceed the cap
amount specified in paragraph (2) for such territory. The
Commissioner shall adjust from time to time the percentages
applicable under such agreement as needed in order to carry out
the previous sentence.
(2) Cap amount.--
(A) In general.--The cap amount specified in this
paragraph--
(i) for Puerto Rico is $3,700,000,000
increased by the amount (if any) elected under
subparagraph (C); or
(ii) for another territory is the portion
of $300,000,000 negotiated for such territory
under subparagraph (B).
(B) Negotiation for certain territories.--The
Commissioner in consultation with the Secretary of
Health and Human Services shall negotiate with the
governments of the territories (other than Puerto Rico)
to allocate the amount specified in subparagraph
(A)(ii) among such territories.
(C) Optional supplementation for puerto rico.--
(i) In general.--Puerto Rico may elect, in
a form and manner specified by the Secretary of
Health and Human Services in consultation with
the Commissioner to increase the dollar amount
specified in subparagraph (A)(i) by up to
$1,000,000,000.
(ii) Offset in medicaid cap.--If Puerto
Rico makes the election described in clause
(i), the Secretary shall decrease the dollar
limitation otherwise applicable to Puerto Rico
under subsections (f) and (g) of section 1108
of the Social Security Act (42 U.S.C. 1308) for
a fiscal year by the additional aggregate
payments the Secretary estimates will be
payable under this section for the fiscal year
because of such election.
(d) Limitation on Funding.--In no case shall this section
(including the agreement under subsection (b)) permit--
(1) the obligation of funds for expenditures under this
subtitle for periods beginning on or after January 1, 2020; or
(2) any increase in the dollar limitation described in
subsection (a)(1)(B) for any portion of any fiscal year
occurring on or after such date.
SEC. 347. NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS.
Nothing in this subtitle shall allow Federal payments for
affordability credits on behalf of individuals who are not lawfully
present in the United States.
TITLE IV--SHARED RESPONSIBILITY
Subtitle A--Individual Responsibility
SEC. 401. INDIVIDUAL RESPONSIBILITY.
For an individual's responsibility to obtain acceptable coverage,
see section 59B of the Internal Revenue Code of 1986 (as added by
section 501 of this Act).
Subtitle B--Employer Responsibility
PART 1--HEALTH COVERAGE PARTICIPATION REQUIREMENTS
SEC. 411. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.
An employer meets the requirements of this section if such employer
does all of the following:
(1) Offer of coverage.--The employer offers each employee
individual and family coverage under a qualified health
benefits plan (or under a current employment-based health plan
(within the meaning of section 202(b))) in accordance with
section 412.
(2) Contribution towards coverage.--If an employee accepts
such offer of coverage, the employer makes timely contributions
towards such coverage in accordance with section 412.
(3) Contribution in lieu of coverage.--Beginning with Y2,
if an employee declines such offer but otherwise obtains
coverage in an Exchange-participating health benefits plan
(other than by reason of being covered by family coverage as a
spouse or dependent of the primary insured), the employer shall
make a timely contribution to the Health Insurance Exchange
with respect to each such employee in accordance with section
413.
SEC. 412. EMPLOYER RESPONSIBILITY TO CONTRIBUTE TOWARD EMPLOYEE AND
DEPENDENT COVERAGE.
(a) In General.--An employer meets the requirements of this section
with respect to an employee if the following requirements are met:
(1) Offering of coverage.--The employer offers the coverage
described in section 411(1). In the case of an Exchange-
eligible employer, the employer may offer such coverage either
through an Exchange-participating health benefits plan or other
than through such a plan.
(2) Employer required contribution.--The employer timely
pays to the issuer of such coverage an amount not less than the
employer required contribution specified in subsection (b) for
such coverage.
(3) Provision of information.--The employer provides the
Health Choices Commissioner, the Secretary of Labor, the
Secretary of Health and Human Services, and the Secretary of
the Treasury, as applicable, with such information as the
Commissioner may require to ascertain compliance with the
requirements of this section, including the following:
(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 a qualified
health benefits plan or a current employment-based
health plan (within the meaning of section 202(b)).
(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 months during the calendar year for
which such coverage was available; and
(ii) the monthly premium for the lowest
cost option in each of the enrollment
categories under each such plan offered to
employees.
(D) 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 plans.
(4) Autoenrollment of employees.--The employer provides for
autoenrollment of the employee in accordance with subsection
(c).
This subsection shall supersede any law of a State which would prevent
automatic payroll deduction of employee contributions to an employment-
based health plan.
(b) Reduction of Employee Premiums Through Minimum Employer
Contribution.--
(1) Full-time employees.--The minimum employer contribution
described in this subsection for coverage of a full-time
employee (and, if any, the employee's spouse and qualifying
children (as defined in section 152(c) of the Internal Revenue
Code of 1986)) under a qualified health benefits plan (or
current employment-based health plan) is equal to--
(A) in case of individual coverage, not less than
72.5 percent of the applicable premium (as defined in
section 4980B(f)(4) of such Code, subject to paragraph
(2)) of the lowest cost plan offered by the employer
that is a qualified health benefits plan (or is such
current employment-based health plan); and
(B) in the case of family coverage which includes
coverage of such spouse and children, not less 65
percent of such applicable premium of such lowest cost
plan.
(2) Applicable premium for exchange coverage.--In this
subtitle, the amount of the applicable premium of the lowest
cost plan with respect to coverage of an employee under an
Exchange-participating health benefits plan is the reference
premium amount under section 343(c) for individual coverage
(or, if elected, family coverage) for the premium rating area
in which the individual or family resides.
(3) Minimum employer contribution for employees other than
full-time employees.--In the case of coverage for an employee
who is not a full-time employee, the amount of the minimum
employer contribution under this subsection shall be a
proportion (as determined in accordance with rules of the
Health Choices Commissioner, the Secretary of Labor, the
Secretary of Health and Human Services, and the Secretary of
the Treasury, as applicable) of the minimum employer
contribution under this subsection with respect to a full-time
employee that reflects the proportion of--
(A) the average weekly hours of employment of the
employee by the employer, to
(B) the minimum weekly hours specified by the
Commissioner for an employee to be a full-time
employee.
(4) Salary reductions not treated as employer
contributions.--For purposes of this section, any contribution
on behalf of an employee with respect to which there is a
corresponding reduction in the compensation of the employee
shall not be treated as an amount paid by the employer.
(c) Automatic Enrollment for Employer Sponsored Health Benefits.--
(1) In general.--The requirement of this subsection with
respect to an employer and an employee is that the employer
automatically enroll such employee into the employment-based
health benefits plan for individual coverage under the plan
option with the lowest applicable employee premium.
(2) Opt-out.--In no case may an employer automatically
enroll an employee in a plan under paragraph (1) if such
employee makes an affirmative election to opt out of such plan
or to elect coverage under an employment-based health benefits
plan offered by such employer. An employer shall provide an
employee with a 30-day period to make such an affirmative
election before the employer may automatically enroll the
employee in such a plan.
(3) Notice requirements.--
(A) In general.--Each employer described in
paragraph (1) who automatically enrolls an employee
into a plan as described in such paragraph shall
provide the employees, within a reasonable period
before the beginning of each plan year (or, in the case
of new employees, within a reasonable period before the
end of the enrollment period for such a new employee),
written notice of the employees' rights and obligations
relating to the automatic enrollment requirement under
such paragraph. Such notice must be comprehensive and
understood by the average employee to whom the
automatic enrollment requirement applies.
(B) Inclusion of specific information.--The written
notice under subparagraph (A) must explain an
employee's right to opt out of being automatically
enrolled in a plan and in the case that more than one
level of benefits or employee premium level is offered
by the employer involved, the notice must explain which
level of benefits and employee premium level the
employee will be automatically enrolled in the absence
of an affirmative election by the employee.
SEC. 413. EMPLOYER CONTRIBUTIONS IN LIEU OF COVERAGE.
(a) In General.--A contribution is made in accordance with this
section with respect to an employee if such contribution is equal to an
amount equal to 8 percent of the average wages paid by the employer
during the period of enrollment (determined by taking into account all
employees of the employer and in such manner as the Commissioner
provides, including rules providing for the appropriate aggregation of
related employers) but not to exceed the minimum employer contribution
described in section 412(b)(1)(A). Any such contribution--
(1) shall be paid to the Health Choices Commissioner for
deposit into the Health Insurance Exchange Trust Fund; and
(2) shall not be applied against the premium of the
employee under the Exchange-participating health benefits plan
in which the employee is enrolled.
(b) Special Rules for Small Employers.--
(1) In general.--In the case of any employer who is a small
employer for any calendar year, subsection (a) shall be applied
by substituting the applicable percentage determined in
accordance with the following table for ``8 percent'':
If the annual payroll of such employer The applicable percentage is:
for the preceding calendar year:
Does not exceed $500,000............. 0 percent
Exceeds $500,000, but does not exceed 2 percent
$585,000.
Exceeds $585,000, but does not exceed 4 percent
$670,000.
Exceeds $670,000, but does not exceed 6 percent
$750,000.
(2) Small employer.--For purposes of this subsection, the
term ``small employer'' means any employer for any calendar
year if the annual payroll of such employer for the preceding
calendar year does not exceed $750,000.
(3) Annual payroll.--For purposes of this paragraph, the
term ``annual payroll'' means, with respect to any employer for
any calendar year, the aggregate wages paid by the employer
during such calendar year.
(4) Aggregation rules.--Related employers and predecessors
shall be treated as a single employer for purposes of this
subsection.
SEC. 414. AUTHORITY RELATED TO IMPROPER STEERING.
The Health Choices Commissioner (in coordination with the Secretary
of Labor, the Secretary of Health and Human Services, and the Secretary
of the Treasury) shall have authority to set standards for determining
whether employers or insurers are undertaking any actions to affect the
risk pool within the Health Insurance Exchange by inducing individuals
to decline coverage under a qualified health benefits plan (or current
employment-based health plan (within the meaning of section 202(b))
offered by the employer and instead to enroll in an Exchange-
participating health benefits plan. An employer violating such
standards shall be treated as not meeting the requirements of this
section.
SEC. 415. IMPACT STUDY ON EMPLOYER RESPONSIBILITY REQUIREMENTS.
(a) In General.--The Secretary of Labor shall conduct a study to
examine the effect of the exemptions under section 512(a) and coverage
thresholds under this division (in this section referred to
collectively as "employer responsibility requirements)on employment-
based health plan sponsorship, generally and within specific
industries, and the effect of such requirements and thresholds on
employers, employment-based health plans, and employees in each
industry.
(b) Annual Report.--The Secretary of Labor annually shall submit to
Congress a report on findings on how employer responsibility
requirements have impacted and are likely to impact employers, plans,
and employees during the previous year and projected trends.
(c) Legislative Recommendations.--No later than January 1, 2012 and
on an annual basis thereafter, the Secretary of Labor shall submit
legislative recommendations to Congress to modify the employer
responsibility requirements if the Secretary determines that the
requirements are detrimentally affecting or will detrimentally affect
employer plan sponsorship or otherwise creating inequities among
employers, health plans, and employees. The Secretary may also submit
such recommendations as the Secretary determines necessary to improve
and strengthen employment-based health plan sponsorship, employer
responsibility, and related proposals that would enhance the delivery
of health care benefits between employers and employees.
SEC. 416. STUDY ON EMPLOYER HARDSHIP EXEMPTION.
(a) In General.--The Secretary of Labor together with the Secretary
of Treasury, the Secretary of Health and Human Services, and the
Commissioner, shall conduct a study to examine the impact of the
employer responsibility requirements described in section 415(a) and
make a recommendation to Congress about whether an employer hardship
exemption would be appropriate.
(b) Items Included in Study.--Within such study the Secretaries and
Commissioner shall examine cases where such employer responsibility
requirements may pose a particular hardship, and specifically look at
employers by industry, profit margin, length of time in business, and
size. In this examination, the economic conditions shall be considered,
including the rate of increase in business costs, the availability of
short-term credit lines, and abilities to restructure debt. In
addition, the study shall examine the impact an employer hardship
waiver could have on employees.
(c) Report.--Not later than January 1, 2012, the Secretaries and
Commissioner shall report to Congress on their findings and make a
recommendation regarding the need or lack of need for a partial or
complete employer hardship waiver. The Secretaries and Commissioner may
also submit recommendations about the criteria Congress should include
when developing eligibility requirements for the employer hardship
waiver and what safeguards are necessary to protect the employees of
that employer.
PART 2--SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS
SEC. 421. SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS
UNDER THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF
1974.
(a) In General.--Subtitle B of title I of the Employee Retirement
Income Security Act of 1974 is amended by adding at the end the
following new part:
``PART 8--NATIONAL HEALTH COVERAGE PARTICIPATION REQUIREMENTS
``SEC. 801. ELECTION OF EMPLOYER TO BE SUBJECT TO NATIONAL HEALTH
COVERAGE PARTICIPATION REQUIREMENTS.
``(a) In General.--An employer may make an election with the
Secretary to be subject to the health coverage participation
requirements.
``(b) Time and Manner.--An election under subsection (a) may be
made at such time and in such form and manner as the Secretary may
prescribe.
``SEC. 802. TREATMENT OF COVERAGE RESULTING FROM ELECTION.
``(a) In General.--If an employer makes an election to the
Secretary under section 801--
``(1) such election shall be treated as the establishment
and maintenance of a group health plan (as defined in section
733(a)) for purposes of this title, subject to section 251 of
the ; and
``(2) the health coverage participation requirements shall
be deemed to be included as terms and conditions of such plan.
``(b) Periodic Investigations To Discover Noncompliance.--The
Secretary shall regularly audit a representative sampling of employers
and group health plans and conduct investigations and other activities
under section 504 with respect to such sampling of plans so as to
discover noncompliance with the health coverage participation
requirements in connection with such plans. The Secretary shall
communicate findings of noncompliance made by the Secretary under this
subsection to the Secretary of the Treasury and the Health Choices
Commissioner. The Secretary shall take such timely enforcement action
as appropriate to achieve compliance.
``(c) Recordkeeping.--To facilitate the audits described in
subsection (b), the Secretary shall promulgate recordkeeping
requirements for employers to account for both employees of the
employer and individuals whom the employer has not treated as employees
of the employer but with whom the employer, in the course of its trade
or business, has engaged for the performance of labor or services. The
scope and content of such recordkeeping requirements shall be
determined by the Secretary and shall be designed to ensure that
employees who are not properly treated as such may be identified and
properly treated.
``SEC. 803. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.
``For purposes of this part, the term `health coverage
participation requirements' means the requirements of part 1 of
subtitle B of title IV of division A of (as in effect on the date of
the enactment of such Act).
``SEC. 804. RULES FOR APPLYING REQUIREMENTS.
``(a) Affiliated Groups.--In the case of any employer which is part
of a group of employers who are treated as a single employer under
subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue
Code of 1986, the election under section 801 shall be made by such
employer as the Secretary may provide. Any such election, once made,
shall apply to all members of such group.
``(b) Separate Elections.--Under regulations prescribed by the
Secretary, separate elections may be made under section 801 with
respect to--
``(1) separate lines of business, and
``(2) full-time employees and employees who are not full-
time employees.
``SEC. 805. TERMINATION OF ELECTION IN CASES OF SUBSTANTIAL
NONCOMPLIANCE.
``The Secretary may terminate the election of any employer under
section 801 if the Secretary (in coordination with the Health Choices
Commissioner) determines that such employer is in substantial
noncompliance with the health coverage participation requirements and
shall refer any such determination to the Secretary of the Treasury as
appropriate.
``SEC. 806. REGULATIONS.
``The Secretary may promulgate such regulations as may be necessary
or appropriate to carry out the provisions of this part, in accordance
with section 424(a) of the . The Secretary may promulgate any interim
final rules as the Secretary determines are appropriate to carry out
this part.''.
(b) Enforcement of Health Coverage Participation Requirements.--
Section 502 of such Act (29 U.S.C. 1132) is amended--
(1) in subsection (a)(6), by striking ``paragraph'' and all
that follows through ``subsection (c)'' and inserting
``paragraph (2), (4), (5), (6), (7), (8), (9), (10), or (11) of
subsection (c)''; and
(2) in subsection (c), by redesignating the second
paragraph (10) as paragraph (12) and by inserting after the
first paragraph (10) the following new paragraph:
``(11) Health coverage participation requirements.--
``(A) Civil penalties.--In the case of any employer
who fails (during any period with respect to which an
election under section 801(a) is in effect) to satisfy
the health coverage participation requirements with
respect to any employee, the Secretary may assess a
civil penalty against the employer of $100 for each day
in the period beginning on the date such failure first
occurs and ending on the date such failure is
corrected.
``(B) Health coverage participation requirements.--
For purposes of this paragraph, the term `health
coverage participation requirements' has the meaning
provided in section 803.
``(C) Limitations on amount of penalty.--
``(i) Penalty not to apply where failure
not discovered exercising reasonable
diligence.--No penalty shall be assessed under
subparagraph (A) with respect to any failure
during any period for which it is established
to the satisfaction of the Secretary that the
employer did not know, or exercising reasonable
diligence would not have known, that such
failure existed.
``(ii) Penalty not to apply to failures
corrected within 30 days.--No penalty shall be
assessed under subparagraph (A) with respect to
any 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.
``(iii) Overall limitation for
unintentional failures.--In the case of
failures which are due to reasonable cause and
not to willful neglect, the penalty assessed
under subparagraph (A) for failures during any
1-year period shall not exceed the amount equal
to the lesser of--
``(I) 10 percent of the aggregate
amount paid or incurred by the employer
(or predecessor employer) during the
preceding 1-year period for group
health plans, or
``(II) $500,000.
``(D) Advance notification of failure prior to
assessment.--Before a reasonable time prior to the
assessment of any penalty under this paragraph with
respect to any failure by an employer, the Secretary
shall inform the employer in writing of such failure
and shall provide the employer information regarding
efforts and procedures which may be undertaken by the
employer to correct such failure.
``(E) Coordination with excise tax.--Under
regulations prescribed in accordance with section 424
of the , the Secretary and the Secretary of the
Treasury shall coordinate the assessment of penalties
under this section in connection with failures to
satisfy health coverage participation requirements with
the imposition of excise taxes on such failures under
section 4980H(b) of the Internal Revenue Code of 1986
so as to avoid duplication of penalties with respect to
such failures.
``(F) Deposit of penalty collected.--Any amount of
penalty collected under this paragraph shall be
deposited as miscellaneous receipts in the Treasury of
the United States.''.
(c) Clerical Amendments.--The table of contents in section 1 of
such Act is amended by inserting after the item relating to section 734
the following new items:
``Part 8--National Health Coverage Participation Requirements
``Sec. 801. Election of employer to be subject to national health
coverage participation requirements.
``Sec. 802. Treatment of coverage resulting from election.
``Sec. 803. Health coverage participation requirements.
``Sec. 804. Rules for applying requirements.
``Sec. 805. Termination of election in cases of substantial
noncompliance.
``Sec. 806. Regulations.''.
(d) Effective Date.--The amendments made by this section shall
apply to periods beginning after December 31, 2012.
SEC. 422. SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS
UNDER THE INTERNAL REVENUE CODE OF 1986.
(a) Failure To Elect, or Substantially Comply With, Health Coverage
Participation Requirements.--For employment tax on employers who fail
to elect, or substantially comply with, the health coverage
participation requirements described in part 1, see section 3111(c) of
the Internal Revenue Code of 1986 (as added by section 512 of this
Act).
(b) Other Failures.--For excise tax on other failures of electing
employers to comply with such requirements, see section 4980H of the
Internal Revenue Code of 1986 (as added by section 511 of this Act).
SEC. 423. SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS
UNDER THE PUBLIC HEALTH SERVICE ACT.
(a) In General.--Part C of title XXVII of the Public Health Service
Act is amended by adding at the end the following new section:
``SEC. 2793. NATIONAL HEALTH COVERAGE PARTICIPATION REQUIREMENTS.
``(a) Election of Employer To Be Subject to National Health
Coverage Participation Requirements.--
``(1) In general.--An employer may make an election with
the Secretary to be subject to the health coverage
participation requirements.
``(2) Time and manner.--An election under paragraph (1) may
be made at such time and in such form and manner as the
Secretary may prescribe.
``(b) Treatment of Coverage Resulting From Election.--
``(1) In general.--If an employer makes an election to the
Secretary under subsection (a)--
``(A) such election shall be treated as the
establishment and maintenance of a group health plan
for purposes of this title, subject to section 251 of
the Affordable Health Care for America Act; and
``(B) the health coverage participation
requirements shall be deemed to be included as terms
and conditions of such plan.
``(2) Periodic investigations to determine compliance with
health coverage participation requirements.--The Secretary
shall regularly audit a representative sampling of employers
and conduct investigations and other activities with respect to
such sampling of employers so as to discover noncompliance with
the health coverage participation requirements in connection
with such employers (during any period with respect to which an
election under subsection (a) is in effect). The Secretary
shall communicate findings of noncompliance made by the
Secretary under this subsection to the Secretary of the
Treasury and the Health Choices Commissioner. The Secretary
shall take such timely enforcement action as appropriate to
achieve compliance.
``(3) Recordkeeping.--To facilitate the audits described in
subsection (b), the Secretary shall promulgate recordkeeping
requirements for employers to account for both employees of the
employer and individuals whom the employer has not treated as
employees of the employer but with whom the employer, in the
course of its trade or business, has engaged for the
performance of labor or services. The scope and content of such
recordkeeping requirements shall be determined by the Secretary
and shall be designed to ensure that employees who are not
properly treated as such may be identified and properly
treated.
``(c) Health Coverage Participation Requirements.--For purposes of
this section, the term `health coverage participation requirements'
means the requirements of part 1 of subtitle B of title IV of division
A of the (as in effect on the date of the enactment of this section).
``(d) Separate Elections.--Under regulations prescribed by the
Secretary, separate elections may be made under subsection (a) with
respect to full-time employees and employees who are not full-time
employees.
``(e) Termination of Election in Cases of Substantial
Noncompliance.--The Secretary may terminate the election of any
employer under subsection (a) if the Secretary (in coordination with
the Health Choices Commissioner) determines that such employer is in
substantial noncompliance with the health coverage participation
requirements and shall refer any such determination to the Secretary of
the Treasury as appropriate.
``(f) Enforcement of Health Coverage Participation Requirements.--
``(1) Civil penalties.--In the case of any employer who
fails (during any period with respect to which the election
under subsection (a) is in effect) to satisfy the health
coverage participation requirements with respect to any
employee, the Secretary may assess a civil penalty against the
employer of $100 for each day in the period beginning on the
date such failure first occurs and ending on the date such
failure is corrected.
``(2) Limitations on amount of penalty.--
``(A) Penalty not to apply where failure not
discovered exercising reasonable diligence.--No penalty
shall be assessed under paragraph (1) with respect to
any failure during any period for which it is
established to the satisfaction of the Secretary that
the employer did not know, or exercising reasonable
diligence would not have known, that such failure
existed.
``(B) Penalty not to apply to failures corrected
within 30 days.--No penalty shall be assessed under
paragraph (1) with respect to any 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) Overall limitation for unintentional
failures.--In the case of failures which are due to
reasonable cause and not to willful neglect, the
penalty assessed under paragraph (1) for failures
during any 1-year period shall not exceed the amount
equal to the lesser of--
``(i) 10 percent of the aggregate amount
paid or incurred by the employer (or
predecessor employer) during the preceding
taxable year for group health plans, or
``(ii) $500,000.
``(3) Advance notification of failure prior to
assessment.--Before a reasonable time prior to the assessment
of any penalty under paragraph (1) with respect to any failure
by an employer, the Secretary shall inform the employer in
writing of such failure and shall provide the employer
information regarding efforts and procedures which may be
undertaken by the employer to correct such failure.
``(4) Actions to enforce assessments.--The Secretary may
bring a civil action in any District Court of the United States
to collect any civil penalty under this subsection.
``(5) Coordination with excise tax.--Under regulations
prescribed in accordance with section 424 of the , the
Secretary and the Secretary of the Treasury shall coordinate
the assessment of penalties under paragraph (1) in connection
with failures to satisfy health coverage participation
requirements with the imposition of excise taxes on such
failures under section 4980H(b) of the Internal Revenue Code of
1986 so as to avoid duplication of penalties with respect to
such failures.
``(6) Deposit of penalty collected.--Any amount of penalty
collected under this subsection shall be deposited as
miscellaneous receipts in the Treasury of the United States.
``(g) Regulations.--The Secretary may promulgate such regulations
as may be necessary or appropriate to carry out the provisions of this
section, in accordance with section 424(a) of the . The Secretary may
promulgate any interim final rules as the Secretary determines are
appropriate to carry out this section.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to periods beginning after December 31, 2012.
SEC. 424. ADDITIONAL RULES RELATING TO HEALTH COVERAGE PARTICIPATION
REQUIREMENTS.
(a) Assuring Coordination.--The officers consisting of the
Secretary of Labor, the Secretary of the Treasury, the Secretary of
Health and Human Services, and the Health Choices Commissioner shall
ensure, through the execution of an interagency memorandum of
understanding among such officers, that--
(1) regulations, rulings, and interpretations issued by
such officers relating to the same matter over which two or
more of such officers have responsibility under subpart B of
part 8 of subtitle B of title I of the Employee Retirement
Income Security Act of 1974, section 4980H of the Internal
Revenue Code of 1986, and section 2793 of the Public Health
Service Act are administered so as to have the same effect at
all times; and
(2) coordination of policies relating to enforcing the same
requirements through such officers in order to have a
coordinated enforcement strategy that avoids duplication of
enforcement efforts and assigns priorities in enforcement.
(b) Multiemployer Plans.--In the case of a group health plan that
is a multiemployer plan (as defined in section 3(37) of the Employee
Retirement Income Security Act of 1974), the regulations prescribed in
accordance with subsection (a) by the officers referred to in
subsection (a) shall provide for the application of the health coverage
participation requirements to the plan sponsor and contributing
employers of such plan. For purposes of this division, contributions
made pursuant to a collective bargaining agreement or other agreement
to such a group health plan shall be treated as amounts paid by the
employer.
TITLE V--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986
Subtitle A--Provisions Relating to Health Care Reform
PART 1--SHARED RESPONSIBILITY
Subpart A--Individual Responsibility
SEC. 501. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE COVERAGE.
(a) In General.--Subchapter A of chapter 1 of the Internal Revenue
Code of 1986 is amended by adding at the end the following new part:
``PART VIII--HEALTH CARE RELATED TAXES
``subpart a. tax on individuals without acceptable health care
coverage.
``Subpart A--Tax on Individuals Without Acceptable Health Care Coverage
``Sec. 59B. Tax on individuals without acceptable health care coverage.
``SEC. 59B. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE COVERAGE.
``(a) Tax Imposed.--In the case of any individual who does not meet
the requirements of subsection (d) at any time during the taxable year,
there is hereby imposed a tax equal to 2.5 percent of the excess of--
``(1) the taxpayer's modified adjusted gross income for the
taxable year, over
``(2) the amount of gross income specified in section
6012(a)(1) with respect to the taxpayer.
``(b) Limitations.--
``(1) Tax limited to average premium.--
``(A) In general.--The tax imposed under subsection
(a) with respect to any taxpayer for any taxable year
shall not exceed the applicable national average
premium for such taxable year.
``(B) Applicable national average premium.--
``(i) In general.--For purposes of
subparagraph (A), the `applicable national
average premium' means, with respect to any
taxable year, the average premium (as
determined by the Secretary, in coordination
with the Health Choices Commissioner) for self-
only coverage under a basic plan which is
offered in a Health Insurance Exchange for the
calendar year in which such taxable year
begins.
``(ii) Failure to provide coverage for more
than one individual.--In the case of any
taxpayer who fails to meet the requirements of
subsection (d) with respect to more than one
individual during the taxable year, clause (i)
shall be applied by substituting `family
coverage' for `self-only coverage'.
``(2) Proration for part year failures.--The tax imposed
under subsection (a) with respect to any taxpayer for any
taxable year shall not exceed the amount which bears the same
ratio to the amount of tax so imposed (determined without
regard to this paragraph and after application of paragraph
(1)) as--
``(A) the aggregate periods during such taxable
year for which such individual failed to meet the
requirements of subsection (d), bears to
``(B) the entire taxable year.
``(c) Exceptions.--
``(1) Dependents.--Subsection (a) shall not apply to any
individual for any taxable year if a deduction is allowable
under section 151 with respect to such individual to another
taxpayer for any taxable year beginning in the same calendar
year as such taxable year.
``(2) Nonresident aliens.--Subsection (a) shall not apply
to any individual who is a nonresident alien.
``(3) Individuals residing outside united states.--Any
qualified individual (as defined in section 911(d)) (and any
qualifying child residing with such individual) shall be
treated for purposes of this section as covered by acceptable
coverage during the period described in subparagraph (A) or (B)
of section 911(d)(1), whichever is applicable.
``(4) Individuals residing in possessions of the united
states.--Any individual who is a bona fide resident of any
possession of the United States (as determined under section
937(a)) for any taxable year (and any qualifying child residing
with such individual) shall be treated for purposes of this
section as covered by acceptable coverage during such taxable
year.
``(5) Religious conscience exemption.--
``(A) In general.--Subsection (a) shall not apply
to any individual (and any qualifying child residing
with such individual) for any period if such individual
has in effect an exemption 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) Exemption.--An application for the exemption
described in subparagraph (A) shall be filed with the
Secretary at such time and in such form and manner as
the Secretary may prescribe. The Secretary may treat an
application for exemption under section 1402(g)(1) as
an application for exemption under this section, or may
otherwise coordinate applications under such sections,
as the Secretary determines appropriate. Any such
exemption granted by the Secretary shall be effective
for such period as the Secretary determines
appropriate.
``(d) Acceptable Coverage Requirement.--
``(1) In general.--The requirements of this subsection are
met with respect to any individual for any period if such
individual (and each qualifying child of such individual) is
covered by acceptable coverage at all times during such period.
``(2) Acceptable coverage.--For purposes of this section,
the term `acceptable coverage' means any of the following:
``(A) Qualified health benefits plan coverage.--
Coverage under a qualified health benefits plan (as
defined in section 100(c) of the ).
``(B) Grandfathered health insurance coverage;
coverage under grandfathered employment-based health
plan.--Coverage under a grandfathered health insurance
coverage (as defined in subsection (a) of section 202
of the ) or under a current employment-based health
plan (within the meaning of subsection (b) of such
section).
``(C) Medicare.--Coverage under part A of title
XVIII of the Social Security Act.
``(D) Medicaid.--Coverage for medical assistance
under title XIX of the Social Security Act.
``(E) Members of the armed forces and dependents
(including tricare).--Coverage under chapter 55 of
title 10, United States Code, including similar
coverage furnished under section 1781 of title 38 of
such Code.
``(F) VA.--Coverage under the veteran's health care
program under chapter 17 of title 38, United States
Code.
``(G) Members of indian tribes.--Health care
services made available through the Indian Health
Service, a tribal organization (as defined in section 4
of the Indian Health Care Improvement Act), or an urban
Indian organization (as defined in such section) to
members of an Indian tribe (as defined in such
section).
``(H) Other coverage.--Such other health benefits
coverage as the Secretary, in coordination with the
Health Choices Commissioner, recognizes for purposes of
this subsection.
``(e) Other Definitions and Special Rules.--
``(1) Qualifying child.--For purposes of this section, the
term `qualifying child' has the meaning given such term by
section 152(c). With respect to any period during which health
coverage for a child must be provided by an individual pursuant
to a child support order, such child shall be treated as a
qualifying child of such individual (and not as a qualifying
child of any other individual).
``(2) Basic plan.--For purposes of this section, the term
`basic plan' has the meaning given such term under section
100(c) of the .
``(3) Health insurance exchange.--For purposes of this
section, the term `Health Insurance Exchange' has the meaning
given such term under section 100(c) of the , including any
State-based health insurance exchange approved for operation
under section 308 of such Act.
``(4) Family coverage.--For purposes of this section, the
term `family coverage' means any coverage other than self-only
coverage.
``(5) Modified adjusted gross income.--For purposes of this
section, the term `modified adjusted gross income' means
adjusted gross income increased by--
``(A) any amount excluded from gross income under
section 911, and
``(B) any amount of interest received or accrued by
the taxpayer during the taxable year which is exempt
from tax.
``(6) Not treated as tax imposed by this chapter for
certain purposes.--The tax imposed under this section shall not
be treated as tax imposed by this chapter for purposes of
determining the amount of any credit under this chapter or for
purposes of section 55.
``(f) Regulations.--The Secretary shall prescribe such regulations
or other guidance as may be necessary or appropriate to carry out the
purposes of this section, including regulations or other guidance
(developed in coordination with the Health Choices Commissioner) which
provide--
``(1) exemption from the tax imposed under subsection (a)
in cases of de minimis lapses of acceptable coverage, and
``(2) a waiver of the application of subsection (a) in
cases of hardship, including a process for applying for such a
waiver.''.
(b) Information Reporting.--
(1) In general.--Subpart B of part III of subchapter A of
chapter 61 of such Code is amended by inserting after section
6050W the following new section:
``SEC. 6050X. RETURNS RELATING TO HEALTH INSURANCE COVERAGE.
``(a) Requirement of Reporting.--Every person who provides
acceptable coverage (as defined in section 59B(d)) to any individual
during any calendar year shall, at such time as the Secretary may
prescribe, make the return described in subsection (b) with respect to
such individual.
``(b) Form and Manner of Returns.--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, address, and TIN of the primary
insured and the name of each other individual obtaining
coverage under the policy,
``(B) the period for which each such individual was
provided with the coverage referred to in subsection
(a), and
``(C) such other information as the Secretary may
require.
``(c) Statements to Be Furnished to Individuals With Respect to
Whom Information Is Required.--Every person required to make a return
under subsection (a) shall furnish to each primary insured whose name
is required to be set forth in such return a written statement
showing--
``(1) the name and address of the person required to make
such return and the phone number of the information contact for
such person, and
``(2) the information required to be shown on the return
with respect to such individual.
The written statement required under the preceding sentence shall be
furnished on or before January 31 of the year following the calendar
year for which the return under subsection (a) is 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.''.
(2) Penalty for failure to file.--
(A) Return.--Subparagraph (B) of section 6724(d)(1)
of such Code 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 adding at
the end the following new clause:
``(xxiv) section 6050X (relating to returns
relating to health insurance coverage), and''.
(B) Statement.--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 6050X (relating to returns relating
to health insurance coverage).''.
(c) Return Requirement.--Subsection (a) of section 6012 of such
Code is amended by inserting after paragraph (9) the following new
paragraph:
``(10) Every individual to whom section 59B(a) applies and
who fails to meet the requirements of section 59B(d) with
respect to such individual or any qualifying child (as defined
in section 152(c)) of such individual.''.
(d) Clerical Amendments.--
(1) The table of parts for subchapter A of chapter 1 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new item:
``Part VIII. Health Care Related Taxes.''.
(2) The table of sections for subpart B of part III of
subchapter A of chapter 61 is amended by adding at the end the
following new item:
``Sec. 6050X. Returns relating to health insurance coverage.''.
(e) Section 15 Not to Apply.--The amendment made by subsection (a)
shall not be treated as a change in a rate of tax for purposes of
section 15 of the Internal Revenue Code of 1986.
(f) Effective Date.--
(1) In general.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2012.
(2) Returns.--The amendments made by subsection (b) shall
apply to calendar years beginning after December 31, 2012.
Subpart B--Employer Responsibility
SEC. 511. ELECTION TO SATISFY HEALTH COVERAGE PARTICIPATION
REQUIREMENTS.
(a) In General.--Chapter 43 of the Internal Revenue Code of 1986 is
amended by adding at the end the following new section:
``SEC. 4980H. ELECTION WITH RESPECT TO HEALTH COVERAGE PARTICIPATION
REQUIREMENTS.
``(a) Election of Employer Responsibility to Provide Health
Coverage.--
``(1) In general.--Subsection (b) shall apply to any
employer with respect to whom an election under paragraph (2)
is in effect.
``(2) Time and manner.--An employer may make an election
under this paragraph at such time and in such form and manner
as the Secretary may prescribe.
``(3) Affiliated groups.--In the case of any employer which
is part of a group of employers who are treated as a single
employer under subsection (b), (c), (m), or (o) of section 414,
the election under paragraph (2) shall be made by such person
as the Secretary may provide. Any such election, once made,
shall apply to all members of such group.
``(4) Separate elections.--Under regulations prescribed by
the Secretary, separate elections may be made under paragraph
(2) with respect to--
``(A) separate lines of business, and
``(B) full-time employees and employees who are not
full-time employees.
``(5) Termination of election in cases of substantial
noncompliance.--The Secretary may terminate the election of any
employer under paragraph (2) if the Secretary (in coordination
with the Health Choices Commissioner) determines that such
employer is in substantial noncompliance with the health
coverage participation requirements.
``(b) Excise Tax With Respect to Failure to Meet Health Coverage
Participation Requirements.--
``(1) In general.--In the case of any employer who fails
(during any period with respect to which the election under
subsection (a) is in effect) to satisfy the health coverage
participation requirements with respect to any employee to whom
such election applies, there is hereby imposed on each such
failure with respect to each such employee a tax of $100 for
each day in the period beginning on the date such failure first
occurs and ending on the date such failure is corrected.
``(2) Limitations on amount of tax.--
``(A) Tax not to apply where failure not discovered
exercising reasonable diligence.--No tax shall be
imposed by paragraph (1) on any failure during any
period for which it is established to the satisfaction
of the Secretary that the employer neither knew, nor
exercising reasonable diligence would have known, that
such failure existed.
``(B) Tax not to apply to failures corrected within
30 days.--No tax shall be imposed by paragraph (1) on
any 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) Overall limitation for unintentional
failures.--In the case of failures which are due to
reasonable cause and not to willful neglect, the tax
imposed by subsection (a) for failures during the
taxable year of the employer shall not exceed the
amount equal to the lesser of--
``(i) 10 percent of the aggregate amount
paid or incurred by the employer (or
predecessor employer) during the preceding
taxable year for employment-based health plans,
or
``(ii) $500,000.
``(D) Coordination with other enforcement
provisions.--The tax imposed under paragraph (1) with
respect to any failure shall be reduced (but not below
zero) by the amount of any civil penalty collected
under section 502(c)(11) of the Employee Retirement
Income Security Act of 1974 or section 2793(g) of the
Public Health Service Act with respect to such failure.
``(c) Health Coverage Participation Requirements.--For purposes of
this section, the term `health coverage participation requirements'
means the requirements of part I of subtitle B of title IV of the (as
in effect on the date of the enactment of this section).''.
(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. Election with respect to health coverage participation
requirements.''.
(c) Effective Date.--The amendments made by this section shall
apply to periods beginning after December 31, 2012.
SEC. 512. HEALTH CARE CONTRIBUTIONS OF NONELECTING EMPLOYERS.
(a) In General.--Section 3111 of the Internal Revenue Code of 1986
is amended by redesignating subsection (c) as subsection (d) and by
inserting after subsection (b) the following new subsection:
``(c) Employers Electing Not to Provide Health Benefits.--
``(1) In general.--In addition to other taxes, there is
hereby imposed on every nonelecting employer an excise tax,
with respect to having individuals in his employ, equal to 8
percent of the wages (as defined in section 3121(a)) paid by
him with respect to employment (as defined in section 3121(b)).
``(2) Special rules for small employers.--
``(A) In general.--In the case of any employer who
is small employer for any calendar year, paragraph (1)
shall be applied by substituting the applicable
percentage determined in accordance with the following
table for `8 percent':
``If the annual payroll of such The applicable percentage is:
employer for the preceding calendar
year:
Does not exceed $500,000............. 0 percent
Exceeds $500,000, but does not exceed 2 percent
$585,000.
Exceeds $585,000, but does not exceed 4 percent
$670,000.
Exceeds $670,000, but does not exceed 6 percent
$750,000.
``(B) Small employer.--For purposes of this
paragraph, the term `small employer' means any employer
for any calendar year if the annual payroll of such
employer for the preceding calendar year does not
exceed $750,000.
``(C) Annual payroll.--For purposes of this
paragraph, the term `annual payroll' means, with
respect to any employer for any calendar year, the
aggregate wages (as defined in section 3121(a)) paid by
him with respect to employment (as defined in section
3121(b)) during such calendar year.
``(3) Nonelecting employer.--For purposes of paragraph (1),
the term `nonelecting employer' means any employer for any
period with respect to which such employer does not have an
election under section 4980H(a) in effect.
``(4) Special rule for separate elections.--In the case of
an employer who makes a separate election described in section
4980H(a)(4) for any period, paragraph (1) shall be applied for
such period by taking into account only the wages paid to
employees who are not subject to such election.
``(5) Aggregation; predecessors.--For purposes of this
subsection--
``(A) all persons treated as a single employer
under subsection (b), (c), (m), or (o) of section 414
shall be treated as 1 employer, and
``(B) any reference to any person shall be treated
as including a reference to any predecessor of such
person.''.
(b) Definitions.--Section 3121 of such Code is amended by adding at
the end the following new subsection:
``(aa) Special Rules for Tax on Employers Electing Not to Provide
Health Benefits.--For purposes of section 3111(c)--
``(1) Paragraphs (1), (5), and (19) of subsection (b) shall
not apply.
``(2) Paragraph (7) of subsection (b) shall apply by
treating all services as not covered by the retirement systems
referred to in subparagraphs (C) and (F) thereof.
``(3) Subsection (e) shall not apply and the term `State'
shall include the District of Columbia.''.
(c) Conforming Amendment.--Subsection (d) of section 3111 of such
Code, as redesignated by this section, is amended by striking ``this
section'' and inserting ``subsections (a) and (b)''.
(d) Application to Railroads.--
(1) In general.--Section 3221 of such Code is amended by
redesignating subsection (c) as subsection (d) and by inserting
after subsection (b) the following new subsection:
``(c) Employers Electing Not to Provide Health Benefits.--
``(1) In general.--In addition to other taxes, there is
hereby imposed on every nonelecting employer an excise tax,
with respect to having individuals in his employ, equal to 8
percent of the compensation paid during any calendar year by
such employer for services rendered to such employer.
``(2) Exception for small employers.--Rules similar to the
rules of section 3111(c)(2) shall apply for purposes of this
subsection.
``(3) Nonelecting employer.--For purposes of paragraph (1),
the term `nonelecting employer' means any employer for any
period with respect to which such employer does not have an
election under section 4980H(a) in effect.
``(4) Special rule for separate elections.--In the case of
an employer who makes a separate election described in section
4980H(a)(4) for any period, subsection (a) shall be applied for
such period by taking into account only the compensation paid
to employees who are not subject to such election.''.
(2) Definitions.--Subsection (e) of section 3231 of such
Code is amended by adding at the end the following new
paragraph:
``(13) Special rules for tax on employers electing not to
provide health benefits.--For purposes of section 3221(c)--
``(A) Paragraph (1) shall be applied without regard
to the third sentence thereof.
``(B) Paragraph (2) shall not apply.''.
(3) Conforming amendment.--Subsection (d) of section 3221
of such Code, as redesignated by this section, is amended by
striking ``subsections (a) and (b), see section 3231(e)(2)''
and inserting ``this section, see paragraphs (2) and (13)(B) of
section 3231(e)''.
(e) Effective Date.--The amendments made by this section shall
apply to periods beginning after December 31, 2012.
PART 2--CREDIT FOR SMALL BUSINESS EMPLOYEE HEALTH COVERAGE EXPENSES
SEC. 521. CREDIT FOR SMALL BUSINESS EMPLOYEE HEALTH COVERAGE EXPENSES.
(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 adding at the end the following new section:
``SEC. 45R. SMALL BUSINESS EMPLOYEE HEALTH COVERAGE CREDIT.
``(a) In General.--For purposes of section 38, in the case of a
qualified small employer, the small business employee health coverage
credit determined under this section for the taxable year is an amount
equal to the applicable percentage of the qualified employee health
coverage expenses of such employer for such taxable year.
``(b) Applicable Percentage.--
``(1) In general.--For purposes of this section, the
applicable percentage is 50 percent.
``(2) Phaseout based on average compensation of
employees.--In the case of an employer whose average annual
employee compensation for the taxable year exceeds $20,000, the
percentage specified in paragraph (1) shall be reduced by a
number of percentage points which bears the same ratio to 50 as
such excess bears to $20,000.
``(c) Limitations.--
``(1) Phaseout based on employer size.--In the case of an
employer who employs more than 10 qualified employees during
the taxable year, the credit determined under subsection (a)
shall be reduced by an amount which bears the same ratio to the
amount of such credit (determined without regard to this
paragraph and after the application of the other provisions of
this section) as--
``(A) the excess of--
``(i) the number of qualified employees
employed by the employer during the taxable
year, over
``(ii) 10, bears to
``(B) 15.
``(2) Credit not allowed with respect to certain highly
compensated employees.--No credit shall be determined under
subsection (a) with respect to qualified employee health
coverage expenses paid or incurred with respect to any employee
for any taxable year if the aggregate compensation paid by the
employer to such employee during such taxable year exceeds
$80,000.
``(3) Credit allowed for only 2 taxable years.--No credit
shall be determined under subsection (a) with respect to any
employer for any taxable year unless the employer elects to
have this section apply for such taxable year. An employer may
elect the application of this section with respect to not more
than 2 taxable years.
``(d) Qualified Employee Health Coverage Expenses.--For purposes of
this section--
``(1) In general.--The term `qualified employee health
coverage expenses' means, with respect to any employer for any
taxable year, the aggregate amount paid or incurred by such
employer during such taxable year for coverage of any qualified
employee of the employer (including any family coverage which
covers such employee) under qualified health coverage.
``(2) Qualified health coverage.--The term `qualified
health coverage' means acceptable coverage (as defined in
section 59B(d)) which--
``(A) is provided pursuant to an election under
section 4980H(a), and
``(B) satisfies the requirements referred to in
section 4980H(c).
``(e) Other Definitions.--For purposes of this section--
``(1) Qualified small employer.--For purposes of this
section, the term `qualified small employer' means any employer
for any taxable year if--
``(A) the number of qualified employees employed by
such employer during the taxable year does not exceed
25, and
``(B) the average annual employee compensation of
such employer for such taxable year does not exceed the
sum of the dollar amounts in effect under subsection
(b)(2).
``(2) Qualified employee.--The term `qualified employee'
means any employee of an employer for any taxable year of the
employer if such employee received at least $5,000 of
compensation from such employer for services performed in the
trade or business of such employer during such taxable year.
``(3) Average annual employee compensation.--The term
`average annual employee compensation' means, with respect to
any employer for any taxable year, the average amount of
compensation paid by such employer to qualified employees of
such employer during such taxable year.
``(4) Compensation.--The term `compensation' has the
meaning given such term in section 408(p)(6)(A).
``(5) Family coverage.--The term `family coverage' means
any coverage other than self-only coverage.
``(f) Special Rules.--For purposes of this section--
``(1) Special rule for partnerships and self-employed.--In
the case of a partnership (or a trade or business carried on by
an individual) which has one or more qualified employees
(determined without regard to this paragraph) with respect to
whom the election under section 4980H(a) applies, each partner
(or, in the case of a trade or business carried on by an
individual, such individual) shall be treated as an employee.
``(2) Aggregation rule.--All persons treated as a single
employer under subsection (b), (c), (m), or (o) of section 414
shall be treated as 1 employer.
``(3) Predecessors.--Any reference in this section to an
employer shall include a reference to any predecessor of such
employer.
``(4) Denial of double benefit.--Any deduction otherwise
allowable with respect to amounts paid or incurred for health
insurance coverage to which subsection (a) applies shall be
reduced by the amount of the credit determined under this
section.
``(5) Inflation adjustment.--In the case of any taxable
year beginning after 2013, each of the dollar amounts in
subsections (b)(2), (c)(2), and (e)(2) 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 2012' 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) Credit to Be Part of General Business Credit.--Subsection (b)
of section 38 of such Code (relating to general 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 adding at the end the following new paragraph:
``(36) in the case of a qualified small employer (as
defined in section 45R(e)), the small business employee health
coverage credit determined under section 45R(a).''.
(c) Clerical Amendment.--The table of sections for subpart D of
part IV of subchapter A of chapter 1 of such Code is amended by
inserting after the item relating to section 45Q the following new
item:
``Sec. 45R. Small business employee health coverage credit.''.
(d) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2012.
PART 3--LIMITATIONS ON HEALTH CARE RELATED EXPENDITURES
SEC. 531. 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 or is insulin.''.
(b) Archer MSAs.--Subparagraph (A) of section 220(d)(2) of such
Code 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 or is insulin.''.
(c) Health Flexible Spending Arrangements and Health Reimbursement
Arrangements.--Section 106 of such Code 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 or is insulin.''.
(d) Effective Dates.--The amendment made by this section shall
apply to expenses incurred after December 31, 2010.
SEC. 532. 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.--
``(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) Inflation adjustment.--In the case of any taxable
year beginning after 2013, the dollar amount in paragraph (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 2012' 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 amendments made by this section shall
apply to taxable years beginning after December 31, 2012.
SEC. 533. INCREASE IN PENALTY FOR NONQUALIFIED DISTRIBUTIONS FROM
HEALTH SAVINGS ACCOUNTS.
(a) In General.--Subparagraph (A) of section 223(f)(4) of the
Internal Revenue Code of 1986 is amended by striking ``10 percent'' and
inserting ``20 percent''.
(b) Effective Date.--The amendment made by this section shall apply
to taxable years beginning after December 31, 2010.
SEC. 534. DENIAL OF DEDUCTION FOR FEDERAL SUBSIDIES FOR PRESCRIPTION
DRUG PLANS WHICH HAVE BEEN EXCLUDED FROM GROSS INCOME.
(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.
PART 4--OTHER PROVISIONS TO CARRY OUT HEALTH INSURANCE REFORM
SEC. 541. DISCLOSURES TO CARRY OUT HEALTH INSURANCE EXCHANGE SUBSIDIES.
(a) In General.--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 health
insurance exchange subsidies.--
``(A) In general.--The Secretary, upon written
request from the Health Choices Commissioner or the
head of a State-based health insurance exchange
approved for operation under section 308 of the , shall
disclose to officers and employees of the Health
Choices Administration or such State-based health
insurance exchange, as the case may be, return
information of any taxpayer whose income is relevant in
determining any affordability credit described in
subtitle C of title III of the . 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 modified adjusted gross income
of such taxpayer (as defined in section
59B(e)(5)),
``(iv) the number of dependents of the
taxpayer,
``(v) such other information as is
prescribed by the Secretary by regulation as
might indicate whether the taxpayer is eligible
for such affordability credits (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) Restriction on use of disclosed
information.--Return information disclosed under
subparagraph (A) may be used by officers and employees
of the Health Choices Administration or such State-
based health insurance exchange, as the case may be,
only for the purposes of, and to the extent necessary
in, establishing and verifying the appropriate amount
of any affordability credit described in subtitle C of
title III of the and providing for the repayment of any
such credit which was in excess of such appropriate
amount.''.
(b) 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).
(c) 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. 542. OFFERING OF EXCHANGE-PARTICIPATING HEALTH BENEFITS 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 health benefits plans
not qualified.--
``(A) In general.--The term `qualified benefit'
shall not include any exchange-participating health
benefits plan (as defined in section 101(c) of the ).
``(B) Exception for exchange-eligible employers.--
Subparagraph (A) shall not apply with respect to any
employee if such employee's employer is an exchange-
eligible employer (as defined in section 302 of the
).''.
(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, 2012.
SEC. 543. EXCLUSION FROM GROSS INCOME OF PAYMENTS MADE UNDER
REINSURANCE PROGRAM FOR RETIREES.
(a) In General.--Section 139A of the Internal Revenue Code of 1986
is amended--
(1) by striking ``Gross income'' and inserting the
following:
``(a) Federal Subsidies for Prescription Drug Plans.--Gross
income'', and
(2) by adding at the end the following new subsection:
``(b) Federal Reinsurance Program for Retirees.--A rule similar to
the rule of subsection (a) shall apply with respect to payments made
under section 111 of the Affordable Health Care for America Act.''.
(b) Conforming Amendment.--The heading of section 139A of such Code
(and the item relating to such section in the table of sections for
part III of subchapter B of chapter 1 of such Code) is amended by
inserting ``and retiree health plans'' after ``prescription drug
plans''.
(c) Effective Date.--The amendments made by this section shall
apply to taxable years ending after the date of the enactment of this
Act.
SEC. 544. CLASS PROGRAM TREATED IN SAME MANNER AS LONG-TERM CARE
INSURANCE.
(a) In General.--Subsection (f) of section 7702B of the Internal
Revenue Code of 1986 is amended--
(1) by striking ``State long-term care plan'' in paragraph
(1)(A) and inserting ``government long-term care plan'',
(2) by redesignating paragraph (2) as paragraph (3), and
(3) by inserting after paragraph (2) the following new
paragraph:
``(2) Government long-term care plan.--For purposes of this
subsection, the term `government long-term care plan' means--
``(A) the CLASS program established under title
XXXII of the Public Health Service Act, and
``(B) any State long-term care plan.''.
(b) Conforming Amendments.--
(1) Paragraph (3) of section 7702B(f) of such Code, as
redesignated by subsection (a), is amended by striking
``paragraph (1)'' and inserting ``this subsection''.
(2) Subsection (f) of section 7702(B) of such Code is
amended by striking ``State-maintained'' in the heading thereof
and inserting ``Government''.
(c) Effective Date.--The amendments made by this section shall
apply to taxable years ending after December 31, 2010.
SEC. 545. EXCLUSION FROM GROSS INCOME FOR MEDICAL CARE PROVIDED FOR
INDIANS.
(a) In General.--Part III of subchapter B of chapter 1 of the
Internal Revenue Code of 1986 (relating to items specifically excluded
from gross income) is amended by inserting after section 139C the
following new section:
``SEC. 139D. MEDICAL CARE PROVIDED FOR INDIANS.
``(a) In General.--Gross income does not include--
``(1) health services or benefits provided or purchased by
the Indian Health Service, either directly or indirectly,
through a grant to or a contract or compact with an Indian
tribe or tribal organization or through programs of third
parties funded by the Indian Health Service,
``(2) medical care provided by an Indian tribe or tribal
organization to a member of an Indian tribe (including for this
purpose, to the member's spouse or dependents) through any one
of the following: provided or purchased medical care services;
accident or health insurance (or an arrangement having the
effect of accident or health insurance); or amounts paid,
directly or indirectly, to reimburse the member for expenses
incurred for medical care,
``(3) the value of accident or health plan coverage
provided by an Indian tribe or tribal organization for medical
care to a member of an Indian tribe (including for this
purpose, coverage that extends to such member's spouse or
dependents) under an accident or health plan (or through an
arrangement having the effect of accident or health insurance),
and
``(4) any other medical care provided by an Indian tribe
that supplements, replaces, or substitutes for the programs and
services provided by the Federal Government to Indian tribes or
Indians.
``(b) Definitions.--For purposes of this section--
``(1) In general.--The terms `accident or health insurance'
and `accident or health plan' have the same meaning as when
used in sections 104 and 106.
``(2) Medical care.--The term `medical care' has the
meaning given such term in section 213.
``(3) Dependent.--The term `dependent' has the meaning
given such term in section 152, determined without regard to
subsections (b)(1), (b)(2), and (d)(1)(B).
``(4) Indian tribe.--The term `Indian tribe' means any
Indian tribe, band, nation, pueblo, or other organized group or
community, including any Alaska Native village, or regional or
village corporation, as defined in, or established pursuant to,
the Alaska Native Claims Settlement Act (43 U.S.C. 1601 et
seq.), which is recognized as eligible for the special programs
and services provided by the United States to Indians because
of their status as Indians.
``(5) Tribal organization.--The term `tribal organization'
has the meaning given such term in section 4(l) of the Indian
Self-Determination and Education Assistance Act (25 U.S.C.
450b(l)).''.
(b) Clerical Amendment.--The table of sections for such part III is
amended by inserting after the item relating to section 139C the
following new item:
``Sec. 139D. Medical care provided for Indians.''.
(c) Effective Date.--The amendments made by this section shall
apply to health benefits and coverage provided after the date of
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 Indian tribes that are not within
the scope of this section, and
(2) health benefits or coverage provided by Indian tribes
prior to the effective date of this section.
Subtitle B--Other Revenue Provisions
PART 1--GENERAL PROVISIONS
SEC. 551. SURCHARGE ON HIGH INCOME INDIVIDUALS.
(a) In General.--Part VIII of subchapter A of chapter 1 of the
Internal Revenue Code of 1986, as added by this title, is amended by
adding at the end the following new subpart:
``Subpart B--Surcharge on High Income Individuals
``Sec. 59C. Surcharge on high income individuals.
``SEC. 59C. SURCHARGE ON HIGH INCOME INDIVIDUALS.
``(a) General Rule.--In the case of a taxpayer other than a
corporation, there is hereby imposed (in addition to any other tax
imposed by this subtitle) a tax equal to 5.4 percent of so much of the
modified adjusted gross income of the taxpayer as exceeds $1,000,000.
``(b) Taxpayers Not Making a Joint Return.--In the case of any
taxpayer other than a taxpayer making a joint return under section 6013
or a surviving spouse (as defined in section 2(a)), subsection (a)
shall be applied by substituting `$500,000' for `$1,000,000'.
``(c) Modified Adjusted Gross Income.--For purposes of this
section, the term `modified adjusted gross income' means adjusted gross
income reduced by any deduction (not taken into account in determining
adjusted gross income) allowed for investment interest (as defined in
section 163(d)). In the case of an estate or trust, adjusted gross
income shall be determined as provided in section 67(e).
``(d) Special Rules.--
``(1) Nonresident alien.--In the case of a nonresident
alien individual, only amounts taken into account in connection
with the tax imposed under section 871(b) shall be taken into
account under this section.
``(2) Citizens and residents living abroad.--The dollar
amount in effect under subsection (a) (after the application of
subsection (b)) shall be decreased by the excess of--
``(A) the amounts excluded from the taxpayer's
gross income under section 911, over
``(B) the amounts of any deductions or exclusions
disallowed under section 911(d)(6) with respect to the
amounts described in subparagraph (A).
``(3) Charitable trusts.--Subsection (a) shall not apply to
a trust all the unexpired interests in which are devoted to one
or more of the purposes described in section 170(c)(2)(B).
``(4) Not treated as tax imposed by this chapter for
certain purposes.--The tax imposed under this section shall not
be treated as tax imposed by this chapter for purposes of
determining the amount of any credit under this chapter or for
purposes of section 55.''.
(b) Clerical Amendment.--The table of subparts for part VIII of
subchapter A of chapter 1 of such Code, as added by this title, is
amended by inserting after the item relating to subpart A the following
new item:
``subpart b. surcharge on high income individuals.''.
(c) Section 15 Not to Apply.--The amendment made by subsection (a)
shall not be treated as a change in a rate of tax for purposes of
section 15 of the Internal Revenue Code of 1986.
(d) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2010.
SEC. 552. EXCISE TAX ON MEDICAL DEVICES.
(a) In General.--Chapter 31 of the Internal Revenue Code of 1986 is
amended by adding at the end the following new subchapter:
``Subchapter D--Medical Devices
``Sec. 4061. Medical devices.
``SEC. 4061. MEDICAL DEVICES.
``(a) In General.--There is hereby imposed on the first taxable
sale of any medical device a tax equal to 2.5 percent of the price for
which so sold.
``(b) First Taxable Sale.--For purposes of this section--
``(1) In general.--The term `first taxable sale' means the
first sale, for a purpose other than for resale, after
production, manufacture, or importation.
``(2) Exception for sales at retail establishments.--Such
term shall not include the sale of any medical device if--
``(A) such sale is made at a retail establishment
on terms which are available to the general public, and
``(B) such medical device is of a type (and
purchased in a quantity) which is purchased by the
general public.
``(3) Exception for exports, etc.--Rules similar to the
rules of sections 4221 (other than paragraphs (3), (4), (5),
and (6) of subsection (a) thereof) and 4222 shall apply for
purposes of this section. To the extent provided by the
Secretary, section 4222 may be extended to, and made applicable
with respect to, the exemption provided by paragraph (2).
``(4) Sales to patients not treated as resales.--If a
medical device is sold for use in connection with providing any
health care service to an individual, such sale shall not be
treated as being for the purpose of resale (even if such device
is sold to such individual).
``(c) Other Definitions and Special Rules.--For purposes of this
section--
``(1) Medical device.--The term `medical device' means any
device (as defined in section 201(h) of the Federal Food, Drug,
and Cosmetic Act) intended for humans.
``(2) Lease treated as sale.--Rules similar to the rules of
section 4217 shall apply.
``(3) Use treated as sale.--
``(A) In general.--If any person uses a medical
device before the first taxable sale of such device,
then such person shall be liable for tax under such
subsection in the same manner as if such use were the
first taxable sale of such device.
``(B) Exceptions.--The preceding sentence shall not
apply to--
``(i) use of a medical device as material
in the manufacture or production of, or as a
component part of, another medical device to be
manufactured or produced by such person, or
``(ii) use of a medical device after a sale
described in subsection (b)(2).
``(4) Determination of price.--
``(A) In general.--Rules similar to the rules of
subsections (a), (c), and (d) of section 4216 shall
apply for purposes of this section.
``(B) Constructive sale price.--If--
``(i) a medical device is sold (otherwise
than through an arm's length transaction) at
less than the fair market price, or
``(ii) a person is liable for tax for a use
described in paragraph (3),
the tax under this section shall be computed on the
price for which such or similar devices are sold in the
ordinary course of trade as determined by the
Secretary.
``(5) Resales pursuant to certain contract arrangements.--
``(A) In general.--In the case of a specified
contract sale of a medical device, the seller referred
to in subparagraph (B)(i) shall be entitled to recover
from the producer, manufacturer, or importer referred
to in subparagraph (B)(ii) the amount of the tax paid
by such seller under this section with respect to such
sale.
``(B) Specified contract sale.--For purposes of
this paragraph, the term `specified contract sale'
means, with respect to any medical device, the first
taxable sale of such device if--
``(i) the seller is not the producer,
manufacturer, or importer of such device,
``(ii) the price at which such device is so
sold is determined in accordance with a
contract between the producer, manufacturer, or
importer of such device and the person to whom
such device is so sold.
``(C) Special rules related to credits and
refunds.--In the case of any credit or refund under
section 6416 of the tax imposed under this section on a
specified contract sale of a medical device--
``(i) such credit or refund shall be
allowed or made only if the seller has filed
with the Secretary the written consent of the
producer, manufacturer, or importer referred to
in subparagraph (B)(ii) to the allowance of
such credit or the making of such refund, and
``(ii) the amount of tax taken into account
under subparagraph (A) shall be reduced by the
amount of such credit or refund.''.
(b) Conforming Amendments.--
(1) Paragraph (2) of section 6416(b) of such Code is
amended--
(A) by inserting ``or 4061'' after ``under section
4051'', and
(B) by adding at the end the following: ``In the
case of the tax imposed by section 4061, subparagraphs
(B), (C), (D), and (E) shall not apply.''.
(2) The table of subchapters for chapter 31 of such Code is
amended by adding at the end the following new item:
``subchapter d. medical devices.''.
(c) Effective Date.--The amendments made by this section shall
apply to sales (and leases and uses treated as sales) after December
31, 2012.
SEC. 553. 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. 554. DELAY IN APPLICATION OF WORLDWIDE ALLOCATION OF INTEREST.
(a) In General.--Paragraphs (5)(D) and (6) of section 864(f) of the
Internal Revenue Code of 1986 are each amended by striking ``December
31, 2010'' and inserting ``December 31, 2019''.
(b) Transition.--Subsection (f) of section 864 of such Code is
amended by striking paragraph (7).
PART 2--PREVENTION OF TAX AVOIDANCE
SEC. 561. LIMITATION ON TREATY BENEFITS FOR CERTAIN DEDUCTIBLE
PAYMENTS.
(a) In General.--Section 894 of the Internal Revenue Code of 1986
(relating to income affected by treaty) is amended by adding at the end
the following new subsection:
``(d) Limitation on Treaty Benefits for Certain Deductible
Payments.--
``(1) In general.--In the case of any deductible related-
party payment, any withholding tax imposed under chapter 3 (and
any tax imposed under subpart A or B of this part) with respect
to such payment may not be reduced under any treaty of the
United States unless any such withholding tax would be reduced
under a treaty of the United States if such payment were made
directly to the foreign parent corporation.
``(2) Deductible related-party payment.--For purposes of
this subsection, the term `deductible related-party payment'
means any payment made, directly or indirectly, by any person
to any other person if the payment is allowable as a deduction
under this chapter and both persons are members of the same
foreign controlled group of entities.
``(3) Foreign controlled group of entities.--For purposes
of this subsection--
``(A) In general.--The term `foreign controlled
group of entities' means a controlled group of entities
the common parent of which is a foreign corporation.
``(B) Controlled group of entities.--The term
`controlled group of entities' means a controlled group
of corporations as defined in section 1563(a)(1),
except that--
``(i) `more than 50 percent' shall be
substituted for `at least 80 percent' each
place it appears therein, and
``(ii) the determination shall be made
without regard to subsections (a)(4) and (b)(2)
of section 1563.
A partnership or any other entity (other than a
corporation) shall be treated as a member of a
controlled group of entities if such entity is
controlled (within the meaning of section 954(d)(3)) by
members of such group (including any entity treated as
a member of such group by reason of this sentence).
``(4) Foreign parent corporation.--For purposes of this
subsection, the term `foreign parent corporation' means, with
respect to any deductible related-party payment, the common
parent of the foreign controlled group of entities referred to
in paragraph (3)(A).
``(5) Regulations.--The Secretary may prescribe such
regulations or other guidance as are necessary or appropriate
to carry out the purposes of this subsection, including
regulations or other guidance which provide for--
``(A) the treatment of two or more persons as
members of a foreign controlled group of entities if
such persons would be the common parent of such group
if treated as one corporation, and
``(B) the treatment of any member of a foreign
controlled group of entities as the common parent of
such group if such treatment is appropriate taking into
account the economic relationships among such
entities.''.
(b) Effective Date.--The amendment made by this section shall apply
to payments made after the date of the enactment of this Act.
SEC. 562. CODIFICATION OF ECONOMIC SUBSTANCE DOCTRINE; PENALTIES.
(a) In General.--Section 7701 of the Internal Revenue Code of 1986
is amended by redesignating subsection (o) as subsection (p) and by
inserting after subsection (n) the following new subsection:
``(o) Clarification of Economic Substance Doctrine.--
``(1) Application of doctrine.--In the case of any
transaction to which the economic substance doctrine is
relevant, such transaction shall be treated as having economic
substance only if--
``(A) the transaction changes in a meaningful way
(apart from Federal income tax effects) the taxpayer's
economic position, and
``(B) the taxpayer has a substantial purpose (apart
from Federal income tax effects) for entering into such
transaction.
``(2) Special rule where taxpayer relies on profit
potential.--
``(A) In general.--The potential for profit of a
transaction shall be taken into account in determining
whether the requirements of subparagraphs (A) and (B)
of paragraph (1) are met with respect to the
transaction only if the present value of the reasonably
expected pre-tax profit from the transaction is
substantial in relation to the present value of the
expected net tax benefits that would be allowed if the
transaction were respected.
``(B) Treatment of fees and foreign taxes.--Fees
and other transaction expenses and foreign taxes shall
be taken into account as expenses in determining pre-
tax profit under subparagraph (A).
``(3) State and local tax benefits.--For purposes of
paragraph (1), any State or local income tax effect which is
related to a Federal income tax effect shall be treated in the
same manner as a Federal income tax effect.
``(4) Financial accounting benefits.--For purposes of
paragraph (1)(B), achieving a financial accounting benefit
shall not be taken into account as a purpose for entering into
a transaction if the origin of such financial accounting
benefit is a reduction of Federal income tax.
``(5) Definitions and special rules.--For purposes of this
subsection--
``(A) Economic substance doctrine.--The term
`economic substance doctrine' means the common law
doctrine under which tax benefits under subtitle A with
respect to a transaction are not allowable if the
transaction does not have economic substance or lacks a
business purpose.
``(B) Exception for personal transactions of
individuals.--In the case of an individual, paragraph
(1) shall apply only to transactions entered into in
connection with a trade or business or an activity
engaged in for the production of income.
``(C) Other common law doctrines not affected.--
Except as specifically provided in this subsection, the
provisions of this subsection shall not be construed as
altering or supplanting any other rule of law, and the
requirements of this subsection shall be construed as
being in addition to any such other rule of law.
``(D) Determination of application of doctrine not
affected.--The determination of whether the economic
substance doctrine is relevant to a transaction (or
series of transactions) shall be made in the same
manner as if this subsection had never been enacted.
``(6) Regulations.--The Secretary shall prescribe such
regulations as may be necessary or appropriate to carry out the
purposes of this subsection.''.
(b) Penalty for Underpayments Attributable to Transactions Lacking
Economic Substance.--
(1) In general.--Subsection (b) of section 6662 of such
Code is amended by inserting after paragraph (5) the following
new paragraph:
``(6) Any disallowance of claimed tax benefits by reason of
a transaction lacking economic substance (within the meaning of
section 7701(o)) or failing to meet the requirements of any
similar rule of law.''.
(2) Increased penalty for nondisclosed transactions.--
Section 6662 of such Code is amended by adding at the end the
following new subsection:
``(i) Increase in Penalty in Case of Nondisclosed Noneconomic
Substance Transactions.--
``(1) In general.--In the case of any portion of an
underpayment which is attributable to one or more nondisclosed
noneconomic substance transactions, subsection (a) shall be
applied with respect to such portion by substituting `40
percent' for `20 percent'.
``(2) Nondisclosed noneconomic substance transactions.--For
purposes of this subsection, the term `nondisclosed noneconomic
substance transaction' means any portion of a transaction
described in subsection (b)(6) with respect to which the
relevant facts affecting the tax treatment are not adequately
disclosed in the return nor in a statement attached to the
return.
``(3) Special rule for amended returns.--Except as provided
in regulations, in no event shall any amendment or supplement
to a return of tax be taken into account for purposes of this
subsection if the amendment or supplement is filed after the
earlier of the date the taxpayer is first contacted by the
Secretary regarding the examination of the return or such other
date as is specified by the Secretary.''.
(3) Conforming amendment.--Subparagraph (B) of section
6662A(e)(2) of such Code is amended--
(A) by striking ``section 6662(h)'' and inserting
``subsections (h) or (i) of section 6662'', and
(B) by striking ``gross valuation misstatement
penalty'' in the heading and inserting ``certain
increased underpayment penalties''.
(c) Reasonable Cause Exception Not Applicable to Noneconomic
Substance Transactions and Tax Shelters.--
(1) Reasonable cause exception for underpayments.--
Subsection (c) of section 6664 of such Code is amended--
(A) by redesignating paragraphs (2) and (3) as
paragraphs (3) and (4), respectively,
(B) by striking ``paragraph (2)'' in paragraph
(4)(A), as so redesignated, and inserting ``paragraph
(3)'', and
(C) by inserting after paragraph (1) the following
new paragraph:
``(2) Exception.--Paragraph (1) shall not apply to any
portion of an underpayment which is attributable to one or more
tax shelters (as defined in section 6662(d)(2)(C)) or
transactions described in section 6662(b)(6).''.
(2) Reasonable cause exception for reportable transaction
understatements.--Subsection (d) of section 6664 of such Code
is amended--
(A) by redesignating paragraphs (2) and (3) as
paragraphs (3) and (4), respectively,
(B) by striking ``paragraph (2)(C)'' in paragraph
(4), as so redesignated, and inserting ``paragraph
(3)(C)'', and
(C) by inserting after paragraph (1) the following
new paragraph:
``(2) Exception.--Paragraph (1) shall not apply to any
portion of a reportable transaction understatement which is
attributable to one or more tax shelters (as defined in section
6662(d)(2)(C)) or transactions described in section
6662(b)(6).''.
(d) Application of Penalty for Erroneous Claim for Refund or Credit
to Noneconomic Substance Transactions.--Section 6676 of such Code is
amended by redesignating subsection (c) as subsection (d) and inserting
after subsection (b) the following new subsection:
``(c) Noneconomic Substance Transactions Treated as Lacking
Reasonable Basis.--For purposes of this section, any excessive amount
which is attributable to any transaction described in section
6662(b)(6) shall not be treated as having a reasonable basis.''.
(e) Effective Date.--
(1) In general.--Except as otherwise provided in this
subsection, the amendments made by this section shall apply to
transactions entered into after the date of the enactment of
this Act.
(2) Underpayments.--The amendments made by subsections (b)
and (c)(1) shall apply to underpayments attributable to
transactions entered into after the date of the enactment of
this Act.
(3) Understatements.--The amendments made by subsection
(c)(2) shall apply to understatements attributable to
transactions entered into after the date of the enactment of
this Act.
(4) Refunds and credits.--The amendment made by subsection
(d) shall apply to refunds and credits attributable to
transactions entered into after the date of the enactment of
this Act.
SEC. 563. CERTAIN LARGE OR PUBLICLY TRADED PERSONS MADE SUBJECT TO A
MORE LIKELY THAN NOT STANDARD FOR AVOIDING PENALTIES ON
UNDERPAYMENTS.
(a) In General.--Subsection (c) of section 6664 of the Internal
Revenue Code of 1986, as amended by section 562, is amended--
(1) by redesignating paragraphs (3) and (4) as paragraphs
(4) and (5), respectively,
(2) by striking ``paragraph (3)'' in paragraph (4)(A), as
so redesignated, and inserting ``paragraph (4)'', and
(3) by inserting after paragraph (2) the following new
paragraph:
``(3) Special rule for certain large or publicly traded
persons.--
``(A) In general.--In the case of any specified
person, paragraph (1) shall apply to the portion of an
underpayment which is attributable to any item only if
such person has a reasonable belief that the tax
treatment of such item by such person is more likely
than not the proper tax treatment of such item.
``(B) Specified person.--For purposes of this
paragraph, the term `specified person' means--
``(i) any person required to file periodic
or other reports under section 13 of the
Securities Exchange Act of 1934, and
``(ii) any corporation with gross receipts
in excess of $100,000,000 for the taxable year
involved.
All persons treated as a single employer under section
52(a) shall be treated as one person for purposes of
clause (ii).''.
(b) Nonapplication of Substantial Authority and Reasonable Basis
Standards for Reducing Understatements.--Paragraph (2) of section
6662(d) of such Code is amended by adding at the end the following new
subparagraph:
``(D) Reduction not to apply to certain large or
publicly traded persons.--Subparagraph (B) shall not
apply to any specified person (as defined in section
6664(c)(3)(B)).''.
(c) Effective Date.--
(1) In general.--Except as provided in paragraph (2), the
amendments made by this section shall apply to underpayments
attributable to transactions entered into after the date of the
enactment of this Act.
(2) Nonapplication of understatement reduction.--The
amendment made by subsection (b) shall apply to understatements
attributable to transactions entered into after the date of the
enactment of this Act.
PART 3--PARITY IN HEALTH BENEFITS
SEC. 571. CERTAIN HEALTH RELATED BENEFITS APPLICABLE TO SPOUSES AND
DEPENDENTS EXTENDED TO ELIGIBLE BENEFICIARIES.
(a) Application of Accident and Health Plans to Eligible
Beneficiaries.--
(1) Exclusion of contributions.--Section 106 of the
Internal Revenue Code of 1986 (relating to contributions by
employer to accident and health plans), as amended by section
531, is amended by adding at the end the following new
subsection:
``(g) Coverage Provided for Eligible Beneficiaries of Employees.--
``(1) In general.--Subsection (a) shall apply with respect
to any eligible beneficiary of the employee.
``(2) Eligible beneficiary.--For purposes of this
subsection, the term `eligible beneficiary' means any
individual who is eligible to receive benefits or coverage
under an accident or health plan.''.
(2) Exclusion of amounts expended for medical care.--The
first sentence of section 105(b) of such Code (relating to
amounts expended for medical care) is amended--
(A) by striking ``and his dependents'' and
inserting ``his dependents'', and
(B) by inserting before the period the following:
``and any eligible beneficiary (within the meaning of
section 106(g)) with respect to the taxpayer''.
(3) Payroll taxes.--
(A) Section 3121(a)(2) of such Code is amended--
(i) by striking ``or any of his
dependents'' in the matter preceding
subparagraph (A) and inserting ``, any of his
dependents, or any eligible beneficiary (within
the meaning of section 106(g)) with respect to
the employee'',
(ii) by striking ``or any of his
dependents,'' in subparagraph (A) and inserting
``, any of his dependents, or any eligible
beneficiary (within the meaning of section
106(g)) with respect to the employee,'', and
(iii) by striking ``and their dependents''
both places it appears and inserting ``and such
employees' dependents and eligible
beneficiaries (within the meaning of section
106(g))''.
(B) Section 3231(e)(1) of such Code is amended--
(i) by striking ``or any of his
dependents'' and inserting ``, any of his
dependents, or any eligible beneficiary (within
the meaning of section 106(g)) with respect to
the employee,'', and
(ii) by striking ``and their dependents''
both places it appears and inserting ``and such
employees' dependents and eligible
beneficiaries (within the meaning of section
106(g))''.
(C) Section 3306(b)(2) of such Code is amended--
(i) by striking ``or any of his
dependents'' in the matter preceding
subparagraph (A) and inserting ``, any of his
dependents, or any eligible beneficiary (within
the meaning of section 106(g)) with respect to
the employee,'',
(ii) by striking ``or any of his
dependents'' in subparagraph (A) and inserting
``, any of his dependents, or any eligible
beneficiary (within the meaning of section
106(g)) with respect to the employee'', and
(iii) by striking ``and their dependents''
both places it appears and inserting ``and such
employees' dependents and eligible
beneficiaries (within the meaning of section
106(g))''.
(D) Section 3401(a) of such Code is amended by
striking ``or'' at the end of paragraph (22), by
striking the period at the end of paragraph (23) and
inserting ``; or'', and by inserting after paragraph
(23) the following new paragraph:
``(24) for any payment made to or for the benefit of an
employee or any eligible beneficiary (within the meaning of
section 106(g)) if at the time of such payment it is reasonable
to believe that the employee will be able to exclude such
payment from income under section 106 or under section 105 by
reference in section 105(b) to section 106(g).''.
(b) Expansion of Dependency for Purposes of Deduction for Health
Insurance Costs of Self-employed Individuals.--
(1) In general.--Paragraph (1) of section 162(l) of the
Internal Revenue Code of 1986 (relating to special rules for
health insurance costs of self-employed individuals) is amended
to read as follows:
``(1) Allowance of deduction.--In the case of a taxpayer
who is an employee within the meaning of section 401(c)(1),
there shall be allowed as a deduction under this section an
amount equal to the amount paid during the taxable year for
insurance which constitutes medical care for--
``(A) the taxpayer,
``(B) the taxpayer's spouse,
``(C) the taxpayer's dependents,
``(D) any individual who--
``(i) satisfies the age requirements of
section 152(c)(3)(A),
``(ii) bears a relationship to the taxpayer
described in section 152(d)(2)(H), and
``(iii) meets the requirements of section
152(d)(1)(C), and
``(E) one individual who--
``(i) does not satisfy the age requirements
of section 152(c)(3)(A),
``(ii) bears a relationship to the taxpayer
described in section 152(d)(2)(H),
``(iii) meets the requirements of section
152(d)(1)(D), and
``(iv) is not the spouse of the taxpayer
and does not bear any relationship to the
taxpayer described in subparagraphs (A) through
(G) of section 152(d)(2).''.
(2) Conforming amendment.--Subparagraph (B) of section
162(l)(2) of such Code is amended by inserting ``, any
dependent, or individual described in subparagraph (D) or (E)
of paragraph (1) with respect to'' after ``spouse''.
(c) Extension to Eligible Beneficiaries of Sick and Accident
Benefits Provided to Members of a Voluntary Employees' Beneficiary
Association and Their Dependents.--Section 501(c)(9) of the Internal
Revenue Code of 1986 (relating to list of exempt organizations) is
amended by adding at the end the following new sentence: ``For purposes
of providing for the payment of sick and accident benefits to members
of such an association and their dependents, the term `dependents'
shall include any individual who is an eligible beneficiary (within the
meaning of section 106(g)), as determined under the terms of a medical
benefit, health insurance, or other program under which members and
their dependents are entitled to sick and accident benefits.''.
(d) Flexible Spending Arrangements and Health Reimbursement
Arrangements.--The Secretary of Treasury shall issue guidance of
general applicability providing that medical expenses that otherwise
qualify--
(1) for reimbursement from a flexible spending arrangement
under regulations in effect on the date of the enactment of
this Act may be reimbursed from an employee's flexible spending
arrangement, notwithstanding the fact that such expenses are
attributable to any individual who is not the employee's spouse
or dependent (within the meaning of section 105(b) of the
Internal Revenue Code of 1986) but is an eligible beneficiary
(within the meaning of section 106(g) of such Code) under the
flexible spending arrangement with respect to the employee, and
(2) for reimbursement from a health reimbursement
arrangement under regulations in effect on the date of the
enactment of this Act may be reimbursed from an employee's
health reimbursement arrangement, notwithstanding the fact that
such expenses are attributable to an individual who is not a
spouse or dependent (within the meaning of section 105(b) of
such Code) but is an eligible beneficiary (within the meaning
of section 106(g) of such Code) under the health reimbursement
arrangement with respect to the employee.
(e) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2009.
DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS
SEC. 1001. TABLE OF CONTENTS OF DIVISION.
The table of contents of this division is as follows:
Sec. 1001. Table of contents of division.
TITLE I--IMPROVING HEALTH CARE VALUE
Subtitle A--Provisions Related to Medicare Part A
Part 1--Market Basket Updates
Sec. 1101. Skilled nursing facility payment update.
Sec. 1102. Inpatient rehabilitation facility payment update.
Sec. 1103. Incorporating productivity improvements into market basket
updates that do not already incorporate
such improvements.
Part 2--Other Medicare Part A Provisions
Sec. 1111. Payments to skilled nursing facilities.
Sec. 1112. Medicare DSH report and payment adjustments in response to
coverage expansion.
Sec. 1113. Extension of hospice regulation moratorium.
Sec. 1114. Permitting physician assistants to order post-hospital
extended care services and to provide for
recognition of attending physician
assistants as attending physicians to serve
hospice patients.
Subtitle B--Provisions Related to Part B
Part 1--Physicians' Services
Sec. 1121. Resource-based feedback program for physicians in Medicare.
Sec. 1122. Misvalued codes under the physician fee schedule.
Sec. 1123. Payments for efficient areas.
Sec. 1124. Modifications to the Physician Quality Reporting Initiative
(PQRI).
Sec. 1125. Adjustment to Medicare payment localities.
Part 2--Market Basket Updates
Sec. 1131. Incorporating productivity improvements into market basket
updates that do not already incorporate
such improvements.
Part 3--Other Provisions
Sec. 1141. Rental and purchase of power-driven wheelchairs.
Sec. 1141A. Election to take ownership, or to decline ownership, of a
certain item of complex durable medical
equipment after the 13-month capped rental
period ends.
Sec. 1142. Extension of payment rule for brachytherapy.
Sec. 1143. Home infusion therapy report to Congress.
Sec. 1144. Require ambulatory surgical centers (ASCs) to submit cost
data and other data.
Sec. 1145. Treatment of certain cancer hospitals.
Sec. 1146. Payment for imaging services.
Sec. 1147. Durable medical equipment program improvements.
Sec. 1148. MedPAC study and report on bone mass measurement.
Sec. 1149. Timely access to post-mastectomy items.
Sec. 1149A. Payment for biosimilar biological products.
Sec. 1149B. Study and report on DME competitive bidding process.
Subtitle C--Provisions Related to Medicare Parts A and B
Sec. 1151. Reducing potentially preventable hospital readmissions.
Sec. 1152. Post acute care services payment reform plan and bundling
pilot program.
Sec. 1153. Home health payment update for 2010.
Sec. 1154. Payment adjustments for home health care.
Sec. 1155. Incorporating productivity improvements into market basket
update for home health services.
Sec. 1155A. MedPAC study on variation in home health margins.
Sec. 1155B. Permitting home health agencies to assign the most
appropriate skilled service to make the
initial assessment visit under a Medicare
home health plan of care for rehabilitation
cases.
Sec. 1156. Limitation on Medicare exceptions to the prohibition on
certain physician referrals made to
hospitals.
Sec. 1157. Institute of Medicine study of geographic adjustment factors
under Medicare.
Sec. 1158. Revision of medicare payment systems to address geographic
inequities.
Sec. 1159. Institute of Medicine study of geographic variation in
health care spending and promoting high-
value health care.
Sec. 1160. Implementation, and Congressional review, of proposal to
revise Medicare payments to promote high
value health care.
Subtitle D--Medicare Advantage Reforms
Part 1--Payment and Administration
Sec. 1161. Phase-in of payment based on fee-for-service costs; quality
bonus payments.
Sec. 1162. Authority for Secretarial coding intensity adjustment
authority.
Sec. 1163. Simplification of annual beneficiary election periods.
Sec. 1164. Extension of reasonable cost contracts.
Sec. 1165. Limitation of waiver authority for employer group plans.
Sec. 1166. Improving risk adjustment for payments.
Sec. 1167. Elimination of MA Regional Plan Stabilization Fund.
Sec. 1168. Study regarding the effects of calculating Medicare
Advantage payment rates on a regional
average of Medicare fee for service rates.
Part 2--Beneficiary Protections and Anti-Fraud
Sec. 1171. Limitation on cost-sharing for individual health services.
Sec. 1172. Continuous open enrollment for enrollees in plans with
enrollment suspension.
Sec. 1173. Information for beneficiaries on MA plan administrative
costs.
Sec. 1174. Strengthening audit authority.
Sec. 1175. Authority to deny plan bids.
Sec. 1175A. State authority to enforce standardized marketing
requirements.
Part 3--Treatment of Special Needs Plans
Sec. 1176. Limitation on enrollment outside open enrollment period of
individuals into chronic care specialized
MA plans for special needs individuals.
Sec. 1177. Extension of authority of special needs plans to restrict
enrollment; service area moratorium for
certain SNPs.
Sec. 1178. Extension of Medicare senior housing plans.
Subtitle E--Improvements to Medicare Part D
Sec. 1181. Elimination of coverage gap.
Sec. 1182. Discounts for certain part D drugs in original coverage gap.
Sec. 1183. Repeal of provision relating to submission of claims by
pharmacies located in or contracting with
long-term care facilities.
Sec. 1184. 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. 1185. No mid-year formulary changes permitted.
Sec. 1186. Negotiation of lower covered part D drug prices on behalf of
Medicare beneficiaries.
Sec. 1187. Accurate dispensing in long-term care facilities.
Sec. 1188. Free generic fill.
Sec. 1189. State certification prior to waiver of licensure
requirements under Medicare prescription
drug program.
Subtitle F--Medicare Rural Access Protections
Sec. 1191. Telehealth expansion and enhancements.
Sec. 1192. Extension of outpatient hold harmless provision.
Sec. 1193. Extension of section 508 hospital reclassifications.
Sec. 1194. Extension of geographic floor for work.
Sec. 1195. Extension of payment for technical component of certain
physician pathology services.
Sec. 1196. Extension of ambulance add-ons.
TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A--Improving and Simplifying Financial Assistance for Low
Income Medicare Beneficiaries
Sec. 1201. Improving assets tests for Medicare Savings Program and low-
income subsidy program.
Sec. 1202. Elimination of part D cost-sharing for certain non-
institutionalized full-benefit dual
eligible individuals.
Sec. 1203. Eliminating barriers to enrollment.
Sec. 1204. Enhanced oversight relating to reimbursements for
retroactive low income subsidy enrollment.
Sec. 1205. Intelligent assignment in enrollment.
Sec. 1206. Special enrollment period and automatic enrollment process
for certain subsidy eligible individuals.
Sec. 1207. Application of MA premiums prior to rebate and quality bonus
payments in calculation of low income
subsidy benchmark.
Subtitle B--Reducing Health Disparities
Sec. 1221. Ensuring effective communication in Medicare.
Sec. 1222. Demonstration to promote access for Medicare beneficiaries
with limited English proficiency by
providing reimbursement for culturally and
linguistically appropriate services.
Sec. 1223. IOM report on impact of language access services.
Sec. 1224. Definitions.
Subtitle C--Miscellaneous Improvements
Sec. 1231. Extension of therapy caps exceptions process.
Sec. 1232. Extended months of coverage of immunosuppressive drugs for
kidney transplant patients and other renal
dialysis provisions.
Sec. 1233. Voluntary advance care planning consultation.
Sec. 1234. Part B special enrollment period and waiver of limited
enrollment penalty for TRICARE
beneficiaries.
Sec. 1235. Exception for use of more recent tax year in case of gains
from sale of primary residence in computing
part B income-related premium.
Sec. 1236. Demonstration program on use of patient decisions aids.
TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND
COORDINATED CARE
Sec. 1301. Accountable Care Organization pilot program.
Sec. 1302. Medical home pilot program.
Sec. 1303. Payment incentive for selected primary care services.
Sec. 1304. Increased reimbursement rate for certified nurse-midwives.
Sec. 1305. Coverage and waiver of cost-sharing for preventive services.
Sec. 1306. Waiver of deductible for colorectal cancer screening tests
regardless of coding, subsequent diagnosis,
or ancillary tissue removal.
Sec. 1307. Excluding clinical social worker services from coverage
under the medicare skilled nursing facility
prospective payment system and consolidated
payment.
Sec. 1308. Coverage of marriage and family therapist services and
mental health counselor services.
Sec. 1309. Extension of physician fee schedule mental health add-on.
Sec. 1310. Expanding access to vaccines.
Sec. 1311. Expansion of Medicare-Covered Preventive Services at
Federally Qualified Health Centers.
Sec. 1312. Independence at home demonstration program.
Sec. 1313. Recognition of certified diabetes educators as certified
providers for purposes of Medicare diabetes
outpatient self-management training
services.
TITLE IV--QUALITY
Subtitle A--Comparative Effectiveness Research
Sec. 1401. Comparative effectiveness research.
Subtitle B--Nursing Home Transparency
Part 1--Improving Transparency of Information on Skilled Nursing
Facilities, Nursing Facilities, and Other Long-term Care Facilities
Sec. 1411. Required disclosure of ownership and additional disclosable
parties information.
Sec. 1412. Accountability requirements.
Sec. 1413. Nursing home compare Medicare website.
Sec. 1414. Reporting of expenditures.
Sec. 1415. Standardized complaint form.
Sec. 1416. Ensuring staffing accountability.
Sec. 1417. Nationwide program for national and State background checks
on direct patient access employees of long-
term care facilities and providers.
Part 2--Targeting Enforcement
Sec. 1421. Civil money penalties.
Sec. 1422. National independent monitor pilot program.
Sec. 1423. Notification of facility closure.
Part 3--Improving Staff Training
Sec. 1431. Dementia and abuse prevention training.
Sec. 1432. Study and report on training required for certified nurse
aides and supervisory staff.
Sec. 1433. Qualification of director of food services of a skilled
nursing facility or nursing facility.
Subtitle C--Quality Measurements
Sec. 1441. Establishment of national priorities for quality
improvement.
Sec. 1442. Development of new quality measures; GAO evaluation of data
collection process for quality measurement.
Sec. 1443. Multi-stakeholder pre-rulemaking input into selection of
quality measures.
Sec. 1444. Application of quality measures.
Sec. 1445. Consensus-based entity funding.
Subtitle D--Physician Payments Sunshine Provision
Sec. 1451. Reports on financial relationships between manufacturers and
distributors of covered drugs, devices,
biologicals, or medical supplies under
Medicare, Medicaid, or CHIP and physicians
and other health care entities and between
physicians and other health care entities.
Subtitle E--Public Reporting on Health Care-Associated Infections
Sec. 1461. Requirement for public reporting by hospitals and ambulatory
surgical centers on health care-associated
infections.
TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION
Sec. 1501. Distribution of unused residency positions.
Sec. 1502. Increasing training in nonprovider settings.
Sec. 1503. Rules for counting resident time for didactic and scholarly
activities and other activities.
Sec. 1504. Preservation of resident cap positions from closed
hospitals.
Sec. 1505. Improving accountability for approved medical residency
training.
TITLE VI--PROGRAM INTEGRITY
Subtitle A--Increased Funding to Fight Waste, Fraud, and Abuse
Sec. 1601. Increased funding and flexibility to fight fraud and abuse.
Subtitle B--Enhanced Penalties for Fraud and Abuse
Sec. 1611. Enhanced penalties for false statements on provider or
supplier enrollment applications.
Sec. 1612. Enhanced penalties for submission of false statements
material to a false claim.
Sec. 1613. Enhanced penalties for delaying inspections.
Sec. 1614. Enhanced hospice program safeguards.
Sec. 1615. Enhanced penalties for individuals excluded from program
participation.
Sec. 1616. Enhanced penalties for provision of false information by
Medicare Advantage and part D plans.
Sec. 1617. Enhanced penalties for Medicare Advantage and part D
marketing violations.
Sec. 1618. Enhanced penalties for obstruction of program audits.
Sec. 1619. Exclusion of certain individuals and entities from
participation in Medicare and State health
care programs.
Sec. 1620. OIG authority to exclude from Federal health care programs
officers and owners of entities convicted
of fraud.
Sec. 1621. Self-referral disclosure protocol.
Subtitle C--Enhanced Program and Provider Protections
Sec. 1631. Enhanced CMS program protection authority.
Sec. 1632. Enhanced Medicare, Medicaid, and CHIP program disclosure
requirements relating to previous
affiliations.
Sec. 1633. Required inclusion of payment modifier for certain
evaluation and management services.
Sec. 1634. Evaluations and reports required under Medicare Integrity
Program.
Sec. 1635. Require providers and suppliers to adopt programs to reduce
waste, fraud, and abuse.
Sec. 1636. Maximum period for submission of Medicare claims reduced to
not more than 12 months.
Sec. 1637. Physicians who order durable medical equipment or home
health services required to be Medicare
enrolled physicians or eligible
professionals.
Sec. 1638. Requirement for physicians to provide documentation on
referrals to programs at high risk of waste
and abuse.
Sec. 1639. Face-to-face encounter with patient required before
eligibility certifications for home health
services or durable medical equipment.
Sec. 1640. Extension of testimonial subpoena authority to program
exclusion investigations.
Sec. 1641. Required repayments of Medicare and Medicaid overpayments.
Sec. 1642. Expanded application of hardship waivers for OIG exclusions
to beneficiaries of any Federal health care
program.
Sec. 1643. Access to certain information on renal dialysis facilities.
Sec. 1644. Billing agents, clearinghouses, or other alternate payees
required to register under Medicare.
Sec. 1645. Conforming civil monetary penalties to False Claims Act
amendments.
Sec. 1646. Requiring provider and supplier payments under Medicare to
be made through direct deposit or
electronic funds transfer (EFT) at insured
depository institutions.
Sec. 1647. Inspector General for the Health Choices Administration.
Subtitle D--Access to Information Needed to Prevent Fraud, Waste, and
Abuse
Sec. 1651. Access to Information Necessary to Identify Fraud, Waste,
and Abuse.
Sec. 1652. Elimination of duplication between the Healthcare Integrity
and Protection Data Bank and the National
Practitioner Data Bank.
Sec. 1653. Compliance with HIPAA privacy and security standards.
TITLE VII--MEDICAID AND CHIP
Sec. 1. Table of contents [Temporary].
Subtitle A--Medicaid and Health Reform
Sec. 1701. Eligibility for individuals with income below 150 percent of
the Federal poverty level.
Sec. 1702. Requirements and special rules for certain Medicaid
eligible individuals.
Sec. 1703. CHIP and Medicaid maintenance of eligibility.
Sec. 1704. Reduction in Medicaid DSH.
Sec. 1705. Expanded outstationing.
Subtitle B--Prevention
Sec. 1711. Required coverage of preventive services.
Sec. 1712. Tobacco cessation.
Sec. 1713. Optional coverage of nurse home visitation services.
Sec. 1714. State eligibility option for family planning services.
Subtitle C--Access
Sec. 1721. Payments to primary care practitioners.
Sec. 1722. Medical home pilot program.
Sec. 1723. Translation or interpretation services.
Sec. 1724. Optional coverage for freestanding birth center services.
Sec. 1725. Inclusion of public health clinics under the vaccines for
children program.
Sec. 1726. Requiring coverage of services of podiatrists.
Sec. 1726A. Requiring coverage of services of optometrists.
Sec. 1727. Therapeutic foster care.
Sec. 1728. Assuring adequate payment levels for services.
Sec. 1729. Preserving Medicaid coverage for youths upon release from
public institutions.
Sec. 1730. Quality measures for maternity and adult health services
under Medicaid and CHIP.
Sec. 1730A. Accountable care organization pilot program.
Sec. 1730B. FQHC coverage.
Subtitle D--Coverage
Sec. 1731. Optional Medicaid coverage of low-income HIV-infected
individuals.
Sec. 1732. Extending transitional Medicaid Assistance (TMA).
Sec. 1733. Requirement of 12-month continuous coverage under certain
CHIP programs.
Sec. 1734. Preventing the application under CHIP of coverage waiting
periods for certain children.
Sec. 1735. Adult day health care services.
Sec. 1736. Medicaid coverage for citizens of Freely Associated States.
Sec. 1737. Continuing requirement of Medicaid coverage of nonemergency
transportation to medically necessary
services.
Sec. 1738. State option to disregard certain income in providing
continued Medicaid coverage for certain
individuals with extremely high
prescription costs.
Sec. 1739. Provisions relating to community living assistance services
and supports (CLASS).
Subtitle E--Financing
Sec. 1741. Payments to pharmacists.
Sec. 1742. Prescription drug rebates.
Sec. 1743. Extension of prescription drug discounts to enrollees of
Medicaid managed care organizations.
Sec. 1744. Payments for graduate medical education.
Sec. 1745. Nursing Facility Supplemental Payment Program.
Sec. 1746. Report on Medicaid payments.
Sec. 1747. Reviews of Medicaid.
Sec. 1748. Extension of delay in managed care organization provider tax
elimination.
Sec. 1749. Extension of ARRA increase in FMAP.
Subtitle F--Waste, Fraud, and Abuse
Sec. 1751. Health care acquired conditions.
Sec. 1752. Evaluations and reports required under Medicaid Integrity
Program.
Sec. 1753. Require providers and suppliers to adopt programs to reduce
waste, fraud, and abuse.
Sec. 1754. Overpayments.
Sec. 1755. Managed care organizations.
Sec. 1756. Termination of provider participation under Medicaid and
CHIP if terminated under Medicare or other
State plan or child health plan.
Sec. 1757. Medicaid and CHIP exclusion from participation relating to
certain ownership, control, and management
affiliations.
Sec. 1758. Requirement to report expanded set of data elements under
MMIS to detect fraud and abuse.
Sec. 1759. Billing agents, clearinghouses, or other alternate payees
required to register under Medicaid.
Sec. 1760. Denial of payments for litigation-related misconduct.
Sec. 1761. Mandatory State use of national correct coding initiative.
Subtitle G--Payments to the Territories
Sec. 1771. Payment to territories.
Subtitle H--Miscellaneous
Sec. 1781. Technical corrections.
Sec. 1782. Extension of QI program.
Sec. 1783. Assuring transparency of information.
Sec. 1784. Medicaid and CHIP Payment and Access Commission.
Sec. 1785. Outreach and enrollment of Medicaid and CHIP eligible
individuals.
Sec. 1786. Prohibitions on Federal Medicaid and CHIP payment for
undocumented aliens.
Sec. 1787. Demonstration project for stabilization of emergency medical
conditions by institutions for mental
diseases.
Sec. 1788. Application of Medicaid Improvement Fund.
Sec. 1789. Treatment of certain Medicaid brokers.
Sec. 1790. Rule for changes requiring State legislation.
TITLE VIII--REVENUE-RELATED PROVISIONS
Sec. 1801. Disclosures to facilitate identification of individuals
likely to be ineligible for the low-income
assistance under the Medicare prescription
drug program to assist Social Security
Administration's outreach to eligible
individuals.
Sec. 1802. Comparative Effectiveness Research Trust Fund; financing for
Trust Fund.
TITLE IX--MISCELLANEOUS PROVISIONS
Sec. 1901. Repeal of trigger provision.
Sec. 1902. Repeal of comparative cost adjustment (CCA) program.
Sec. 1903. Extension of gainsharing demonstration.
Sec. 1904. Grants to States for quality home visitation programs for
families with young children and families
expecting children.
Sec. 1905. Improved coordination and protection for dual eligibles.
Sec. 1906. Assessment of medicare cost-intensive diseases and
conditions.
Sec. 1907. Establishment of Center for Medicare and Medicaid Innovation
within CMS.
Sec. 1908. Application of emergency services laws.
Sec. 1909. Disregard under the Supplemental Security Income program of
compensation for participation in clinical
trials for rare diseases or conditions.
TITLE I--IMPROVING HEALTH CARE VALUE
Subtitle A--Provisions Related to Medicare Part A
PART 1--MARKET BASKET UPDATES
SEC. 1101. SKILLED NURSING FACILITY PAYMENT UPDATE.
(a) In General.--Section 1888(e)(4)(E)(ii) of the Social Security
Act (42 U.S.C. 1395yy(e)(4)(E)(ii)) is amended--
(1) in subclause (III), by striking ``and'' at the end;
(2) by redesignating subclause (IV) as subclause (VI); and
(3) by inserting after subclause (III) the following new
subclauses:
``(IV) for each of fiscal years
2004 through 2009, the rate computed
for the previous fiscal year increased
by the skilled nursing facility market
basket percentage change for the fiscal
year involved;
``(V) for fiscal year 2010, the
rate computed for the previous fiscal
year; and''.
(b) Delayed Effective Date.--Section 1888(e)(4)(E)(ii)(V) of the
Social Security Act, as inserted by subsection (a)(3), shall not apply
to payment for days before January 1, 2010.
SEC. 1102. INPATIENT REHABILITATION FACILITY PAYMENT UPDATE.
(a) In General.--Section 1886(j)(3)(C) of the Social Security Act
(42 U.S.C. 1395ww(j)(3)(C)) is amended by striking ``and 2009'' and
inserting ``through 2010''.
(b) Delayed Effective Date.--The amendment made by subsection (a)
shall not apply to payment units occurring before January 1, 2010.
SEC. 1103. INCORPORATING 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)) is amended--
(1) in clause (iii)--
(A) by striking ``(iii) For purposes of this
subparagraph,'' and inserting ``(iii)(I) For purposes
of this subparagraph, subject to the productivity
adjustment described in subclause (II),''; and
(B) by adding at the end the following new
subclause:
``(II) The productivity adjustment described in this subclause,
with respect to an increase or change for a fiscal year or year or cost
reporting period, or other annual period, is a productivity offset in
the form of a reduction in such increase or change equal to the
percentage change in the 10-year moving average of annual economy-wide
private nonfarm business multi-factor productivity (as recently
published in final form before the promulgation or publication of such
increase for the year or period involved). Except as otherwise
provided, any reference to the increase described in this clause shall
be a reference to the percentage increase described in subclause (I)
minus the percentage change under this subclause.'';
(2) in the first sentence of clause (viii)(I), by inserting
``(but not below zero)'' after ``shall be reduced''; and
(3) in the first sentence of clause (ix)(I)--
(A) by inserting ``(determined without regard to
clause (iii)(II))'' after ``clause (i)'' the second
time it appears; and
(B) by inserting ``(but not below zero)'' after
``reduced''.
(b) Skilled Nursing Facilities.--Section 1888(e)(5)(B) of such Act
(42 U.S.C. 1395yy(e)(5)(B)) is amended by inserting ``subject to the
productivity adjustment described in section 1886(b)(3)(B)(iii)(II)''
after ``as calculated by the Secretary''.
(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 paragraph:
``(3) Productivity adjustment.--In implementing the system
described in paragraph (1) for discharges occurring on or after
January 1, 2010, during the rate year ending in 2010 or any
subsequent rate year for a hospital, to the extent that an
annual percentage increase factor applies to a standard Federal
rate for such discharges for the hospital, such factor shall be
subject to the productivity adjustment described in subsection
(b)(3)(B)(iii)(II).''.
(d) Inpatient Rehabilitation Facilities.--The second sentence of
section 1886(j)(3)(C) of the Social Security Act (42 U.S.C.
1395ww(j)(3)(C)) is amended by inserting ``(subject to the productivity
adjustment described in subsection (b)(3)(B)(iii)(II))'' after
``appropriate percentage increase''.
(e) Psychiatric Hospitals.--Section 1886 of the Social Security Act
(42 U.S.C. 1395ww) is amended by adding at the end the following new
subsection:
``(o) 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) Productivity adjustment.--In implementing the system
described in paragraph (1) for days occurring during the rate
year ending in 2011 or any subsequent rate year for a
psychiatric hospital or unit described in such paragraph, to
the extent that an annual percentage increase factor applies to
a base rate for such days for the hospital or unit,
respectively, such factor shall be subject to the productivity
adjustment described in subsection (b)(3)(B)(iii)(II).''.
(f) Hospice Care.--Subclause (VII) of section 1814(i)(1)(C)(ii) of
the Social Security Act (42 U.S.C. 1395f(i)(1)(C)(ii)) is amended by
inserting after ``the market basket percentage increase'' the
following: ``(which is subject to the productivity adjustment described
in section 1886(b)(3)(B)(iii)(II))''.
(g) Effective Dates.--
(1) IPPS.--The amendments made by subsection (a) shall
apply to annual increases effected for fiscal years beginning
with fiscal year 2010, but only with respect to discharges
occurring on or after January 1, 2010.
(2) SNF and irf.--The amendments made by subsections (b)
and (d) shall apply to annual increases effected for fiscal
years beginning with fiscal year 2011.
(3) Hospice care.--The amendment made by subsection (f)
shall apply to annual increases effected for fiscal years
beginning with fiscal year 2010, but only with respect to days
of care occurring on or after January 1, 2010.
PART 2--OTHER MEDICARE PART A PROVISIONS
SEC. 1111. PAYMENTS TO SKILLED NURSING FACILITIES.
(a) Change in Recalibration Factor.--
(1) Analysis.--The Secretary of Health and Human Services
shall conduct, using calendar year 2006 claims data, an initial
analysis comparing total payments under title XVIII of the
Social Security Act for skilled nursing facility services under
the RUG-53 and under the RUG-44 classification systems.
(2) Adjustment in recalibration factor.--Based on the
initial analysis under paragraph (1), the Secretary shall
adjust the case mix indexes under section 1888(e)(4)(G)(i) of
the Social Security Act (42 U.S.C. 1395yy(e)(4)(G)(i)) for
fiscal year 2010 by the appropriate recalibration factor as
proposed in the proposed rule for Medicare skilled nursing
facilities issued by such Secretary on May 12, 2009 (74 Federal
Register 22214 et seq.).
(b) Change in Payment for Nontherapy Ancillary (NTA) Services and
Therapy Services.--
(1) Changes under current snf classification system.--
(A) In general.--Subject to subparagraph (B), the
Secretary of Health and Human Services shall, under the
system for payment of skilled nursing facility services
under section 1888(e) of the Social Security Act (42
U.S.C. 1395yy(e)), increase payment by 10 percent for
non-therapy ancillary services (as specified by the
Secretary in the notice issued on November 27, 1998 (63
Federal Register 65561 et seq.)) and shall decrease
payment for the therapy case mix component of such
rates by 5.5 percent.
(B) Effective date.--The changes in payment
described in subparagraph (A) shall apply for days on
or after January 1, 2010, and until the Secretary
implements an alternative case mix classification
system for payment of skilled nursing facility services
under section 1888(e) of the Social Security Act (42
U.S.C. 1395yy(e)).
(C) Implementation.--Notwithstanding any other
provision of law, the Secretary may implement by
program instruction or otherwise the provisions of this
paragraph.
(2) Changes under a future snf case mix classification
system.--
(A) Analysis.--
(i) In general.--The Secretary of Health
and Human Services shall analyze payments for
non-therapy ancillary services under a future
skilled nursing facility classification system
to ensure the accuracy of payment for non-
therapy ancillary services. Such analysis shall
consider use of appropriate predictors which
may include age, physical and mental status,
ability to perform activities of daily living,
prior nursing home stay, diagnoses, broad RUG
category, and a proxy for length of stay.
(ii) Application.--Such analysis shall be
conducted in a manner such that the future
skilled nursing facility classification system
is implemented to apply to services furnished
during a fiscal year beginning with fiscal year
2011.
(B) Consultation.--In conducting the analysis under
subparagraph (A), the Secretary shall consult with
interested parties, including the Medicare Payment
Advisory Commission and other interested stakeholders,
to identify appropriate predictors of nontherapy
ancillary costs.
(C) Rulemaking.--The Secretary shall include the
result of the analysis under subparagraph (A) in the
fiscal year 2011 rulemaking cycle for purposes of
implementation beginning for such fiscal year.
(D) Implementation.--Subject to subparagraph (E)
and consistent with subparagraph (A)(ii), the Secretary
shall implement changes to payments for non-therapy
ancillary services (which shall include a separate rate
component for non-therapy ancillary services and may
include use of a model that predicts payment amounts
applicable for non-therapy ancillary services) under
such future skilled nursing facility services
classification system as the Secretary determines
appropriate based on the analysis conducted pursuant to
subparagraph (A).
(E) Budget neutrality.--The Secretary shall
implement changes described in subparagraph (D) in a
manner such that the estimated expenditures under such
future skilled nursing facility services classification
system for a fiscal year beginning with fiscal year
2011 with such changes would be equal to the estimated
expenditures that would otherwise occur under title
XVIII of the Social Security Act under such future
skilled nursing facility services classification system
for such year without such changes.
(c) Outlier Policy for NTA and Therapy.--Section 1888(e) of the
Social Security Act (42 U.S.C. 1395yy(e)) is amended by adding at the
end the following new paragraph:
``(13) Outliers for nta and therapy.--
``(A) In general.--With respect to outliers because
of unusual variations in the type or amount of
medically necessary care, beginning with October 1,
2010, the Secretary--
``(i) shall provide for an addition or
adjustment to the payment amount otherwise made
under this section with respect to non-therapy
ancillary services in the case of such
outliers; and
``(ii) may provide for such an addition or
adjustment to the payment amount otherwise made
under this section with respect to therapy
services in the case of such outliers.
``(B) Outliers based on aggregate costs.--Outlier
adjustments or additional payments described in
subparagraph (A) shall be based on aggregate costs
during a stay in a skilled nursing facility and not on
the number of days in such stay.
``(C) Budget neutrality.--The Secretary shall
reduce estimated payments that would otherwise be made
under the prospective payment system under this
subsection with respect to a fiscal year by 2 percent.
The total amount of the additional payments or payment
adjustments for outliers made under this paragraph with
respect to a fiscal year may not exceed 2 percent of
the total payments projected or estimated to be made
based on the prospective payment system under this
subsection for the fiscal year.''.
(d) Conforming Amendments.--Section 1888(e)(8) of such Act (42
U.S.C. 1395yy(e)(8)) is amended--
(1) in subparagraph (A)--
(A) by striking ``and'' before ``adjustments''; and
(B) by inserting ``, and adjustment under section
1111(b) of the Affordable Health Care for America Act''
before the semicolon at the end;
(2) in subparagraph (B), by striking ``and'';
(3) in subparagraph (C), by striking the period and
inserting ``; and''; and
(4) by adding at the end the following new subparagraph:
``(D) the establishment of outliers under paragraph
(13).''.
SEC. 1112. MEDICARE DSH REPORT AND PAYMENT ADJUSTMENTS IN RESPONSE TO
COVERAGE EXPANSION.
(a) DSH Report.--
(1) In general.--Not later than January 1, 2016, the
Secretary of Health and Human Services shall submit to Congress
a report on Medicare DSH taking into account the impact of the
health care reforms carried out under division A in reducing
the number of uninsured individuals. The report shall include
recommendations relating to the following:
(A) The appropriate amount, targeting, and
distribution of Medicare DSH to compensate for higher
Medicare costs associated with serving low-income
beneficiaries (taking into account variations in the
empirical justification for Medicare DSH attributable
to hospital characteristics, including bed size),
consistent with the original intent of Medicare DSH.
(B) The appropriate amount, targeting, and
distribution of Medicare DSH to hospitals given their
continued uncompensated care costs, to the extent such
costs remain.
(2) Coordination with medicaid dsh report.--The Secretary
shall coordinate the report under this subsection with the
report on Medicaid DSH under section 1704(a).
(b) Payment Adjustments in Response to Coverage Expansion.--
(1) In general.--If there is a significant decrease in the
national rate of uninsurance as a result of this Act (as
determined under paragraph (2)(A)), then the Secretary of
Health and Human Services shall, beginning in fiscal year 2017,
implement the following adjustments to Medicare DSH:
(A) In lieu of the amount of Medicare DSH payment
that would otherwise be made under section
1886(d)(5)(F) of the Social Security Act, the amount of
Medicare DSH payment shall be an amount based on the
recommendations of the report under subsection
(a)(1)(A) and shall take into account variations in the
empirical justification for Medicare DSH attributable
to hospital characteristics, including bed size.
(B) Subject to paragraph (3), make an additional
payment to a hospital by an amount that is estimated
based on the amount of uncompensated care provided by
the hospital based on criteria for uncompensated care
as determined by the Secretary, which shall exclude bad
debt.
(2) Significant decrease in national rate of uninsurance as
a result of this act.--For purposes of this subsection--
(A) In general.--There is a ``significant decrease
in the national rate of uninsurance as a result of this
Act'' if there is a decrease in the national rate of
uninsurance (as defined in subparagraph (B)) from 2012
to 2014 that exceeds 8 percentage points.
(B) National rate of uninsurance defined.--The term
``national rate of uninsurance'' means, for a year,
such rate for the under-65 population for the year as
determined and published by the Bureau of the Census in
its Current Population Survey in or about September of
the succeeding year.
(3) Uncompensated care increase.--
(A) Computation of dsh savings.--For each fiscal
year (beginning with fiscal year 2017), the Secretary
shall estimate the aggregate reduction in the amount of
Medicare DSH payment that would be expected to result
from the adjustment under paragraph (1)(A).
(B) Structure of payment increase.--The Secretary
shall compute the additional payment to a hospital as
described in paragraph (1)(B) for a fiscal year in
accordance with a formula established by the Secretary
that provides that--
(i) the estimated aggregate amount of such
increase for the fiscal year does not exceed 50
percent of the aggregate reduction in Medicare
DSH estimated by the Secretary for such fiscal
year; and
(ii) hospitals with higher levels of
uncompensated care receive a greater increase.
(c) Medicare DSH.--In this section, the term ``Medicare DSH'' means
adjustments in payments under section 1886(d)(5)(F) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(F)) for inpatient hospital
services furnished by disproportionate share hospitals.
SEC. 1113. EXTENSION OF HOSPICE REGULATION MORATORIUM.
Section 4301(a) of division B of the American Recovery and
Reinvestment Act of 2009 (Public Law 111-5) is amended--
(1) by striking ``October 1, 2009'' and inserting ``October
1, 2010''; and
(2) by striking ``for fiscal year 2009'' and inserting
``for fiscal years 2009 and 2010''.
SEC. 1114. PERMITTING PHYSICIAN ASSISTANTS TO ORDER POST-HOSPITAL
EXTENDED CARE SERVICES AND TO PROVIDE FOR RECOGNITION OF
ATTENDING PHYSICIAN ASSISTANTS AS ATTENDING PHYSICIANS TO
SERVE HOSPICE PATIENTS.
(a) Ordering Post-hospital Extended Care Services.--Section 1814(a)
of the Social Security Act (42 U.S.C. 1395f(a)) is amended--
(1) in paragraph (2) in the matter preceding subparagraph
(A), is amended by striking ``nurse practitioner or clinical
nurse specialist'' and inserting ``nurse practitioner, a
clinical nurse specialist, or a physician assistant''.
(2) in the second sentence, by striking ``or clinical nurse
specialist'' and inserting ``clinical nurse specialist, or
physician assistant''.
(b) Recognition of Attending Physician Assistants as Attending
Physicians to Serve Hospice Patients.--
(1) In general.--Section 1861(dd)(3)(B) of such Act (42
U.S.C. 1395x(dd)(3)(B)) is amended--
(A) by striking ``or nurse'' and inserting ``, the
nurse''; and
(B) by inserting ``or the physician assistant (as
defined in such subsection),'' after ``subsection
(aa)(5)),''.
(2) Conforming amendment.--Section 1814(a)(7)(A)(i)(I) of
such Act (42 U.S.C. 1395f(a)(7)(A)(i)(I)) is amended by
inserting ``or a physician assistant'' after ``a nurse
practitioner''.
(3) Construction.--Nothing in the amendments made by this
subsection shall be construed as changing the requirements of
section 1842(b)(6)(C) of the Social Security Act (42 U.S.C.
1395u(b)(6)(C)) with respect to payment for services of
physician assistants under part B of title XVIII of such Act.
(c) Effective Date.--The amendments made by this section shall
apply to items and services furnished on or after January 1, 2010.
Subtitle B--Provisions Related to Part B
PART 1--PHYSICIANS' SERVICES
SEC. 1121. RESOURCE-BASED FEEDBACK PROGRAM FOR PHYSICIANS IN MEDICARE.
Section 1848(n) of the Social Security Act (42 U.S.C. 1395w-4(n))
is amended by adding at the end the following new paragraph:
``(9) Feedback implementation plan.--
``(A) Timeline for feedback program.--
``(i) Evaluation.--During 2011 the
Secretary shall conduct the evaluation
specified in subparagraph (E)(i).
``(ii) Expansion.--The Secretary shall
expand the Program under this subsection as
specified in subparagraph (E)(ii).
``(B) Establishment of nature of reports.--
``(i) In general.--The Secretary shall
develop and specify the nature of the reports
that will be disseminated under this
subsection, based on results and findings from
the Program under this subsection as in
existence before the date of the enactment of
this paragraph. Such reports may be based on a
per capita basis, an episode basis that
combines separate but clinically related
physicians' services and other items and
services furnished or ordered by a physician
into an episode of care, as appropriate, or
both.
``(ii) Timeline for development.--The
nature of the reports described in clause (i)
shall be developed by not later than January 1,
2012.
``(iii) Public availability.--The Secretary
shall make the details of the nature of the
reports developed under clause (i) available to
the public.
``(C) Analysis of data.--The Secretary shall, for
purposes of preparing reports under this subsection,
establish methodologies as appropriate such as to--
``(i) attribute items and services, in
whole or in part, to physicians;
``(ii) identify appropriate physicians for
purposes of comparison under subparagraph
(B)(i); and
``(iii) aggregate items and services
attributed to a physician under clause (i) into
a composite measure per individual.
``(D) Feedback program.--The Secretary shall engage
in efforts to disseminate reports under this
subsection. In disseminating such reports, the
Secretary shall consider the following:
``(i) Direct meetings between contracted
physicians, facilitated by the Secretary, to
discuss the contents of reports under this
subsection, including any reasons for
divergence from local or national averages.
``(ii) Contract with local, non-profit
entities engaged in quality improvement efforts
at the community level. Such entities shall use
the reports under this subsection, or such
equivalent tool as specified by the Secretary.
Any exchange of data under this paragraph shall
be protected by appropriate privacy safeguards.
``(iii) Mailings or other methods of
communication that facilitate large-scale
dissemination.
``(iv) Other methods specified by the
Secretary.
``(E) Evaluation and expansion.--
``(i) Evaluation.--The Secretary shall
evaluate the methods specified in subparagraph
(D) with regard to their efficacy in changing
practice patterns to improve quality and
decrease costs.
``(ii) Expansion.--Taking into account the
cost of each method specified in subparagraph
(D), the Secretary shall develop a plan to
disseminate reports under this subsection in a
significant manner in the regions and cities of
the country with the highest utilization of
services under this title. To the extent
practicable, reports under this subsection
shall be disseminated to increasing numbers of
physicians each year, such that during 2014 and
subsequent years, reports are disseminated at
least to physicians with utilization rates
among the highest 5 percent of the nation,
subject the authority to focus under paragraph
(4).
``(F) Administration.--
``(i) Chapter 35 of title 44, United States
Code shall not apply to this paragraph.
``(ii) Notwithstanding any other provision
of law, the Secretary may implement the
provisions of this paragraph by program
instruction or otherwise.''.
SEC. 1122. 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 three 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 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) Funding.--For purposes of carrying out the provisions
of subparagraphs (K) and (L) of 1848(c)(2) of the Social
Security Act, as added by subsection (a), in addition to funds
otherwise available, out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the Secretary
of Health and Human Services for the Center for Medicare &
Medicaid Services Program Management Account $20,000,000 for
fiscal year 2010 and each subsequent fiscal year. Amounts
appropriated under this paragraph for a fiscal year shall be
available until expended.
(2) 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.
(3) Focusing cms resources on potentially overvalued
codes.--Section 1868(a) of the Social Security Act (42
1395ee(a)) is repealed.
SEC. 1123. PAYMENTS FOR EFFICIENT AREAS.
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 Efficient Areas.--
``(1) In general.--In the case of services furnished under
the physician fee schedule under section 1848 on or after
January 1, 2011, and before January 1, 2013, by a supplier that
is paid under such fee schedule in an efficient area (as
identified under paragraph (2)), 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 5 percent of the payment amount for
the services under this part.
``(2) Identification of efficient areas.--
``(A) In general.--Based upon available data, the
Secretary shall identify those counties or equivalent
areas in the United States in the lowest fifth
percentile of utilization based on per capita spending
under this part and part A for services provided in the
most recent year for which data are available as of the
date of the enactment of this subsection, as
standardized to eliminate the effect of geographic
adjustments in payment rates.
``(B) Identification of counties where service is
furnished..--For purposes of paying the additional
amount specified in paragraph (1), if the Secretary
uses the 5-digit postal ZIP Code where the service is
furnished, the dominant county of the postal ZIP Code
(as determined by the United States Postal Service, or
otherwise) shall be used to determine whether the
postal ZIP Code is in a county described in
subparagraph (A).
``(C) Limitation on review.--There shall be no
administrative or judicial review under section 1869,
1878, or otherwise, respecting--
``(i) the identification of a county or
other area under subparagraph (A); or
``(ii) the assignment of a postal ZIP Code
to a county or other area under subparagraph
(B).
``(D) Publication of list of counties; posting on
website.--With respect to a year for which a county or
area is identified under this paragraph, the Secretary
shall identify such counties or areas as part of the
proposed and final rule to implement the physician fee
schedule under section 1848 for the applicable year.
The Secretary shall post the list of counties
identified under this paragraph on the Internet website
of the Centers for Medicare & Medicaid Services.''.
SEC. 1124. MODIFICATIONS TO THE PHYSICIAN QUALITY REPORTING INITIATIVE
(PQRI).
(a) 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.''.
(b) Appeals.--Such section is further amended--
(1) in subparagraph (E), by striking ``There shall be'' and
inserting ``Except as provided in subparagraph (I), there shall
be''; and
(2) by adding at the end the following new subparagraph:
``(I) Informal appeals process.--By not later than
January 1, 2011, the Secretary shall 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.''.
(c) Integration of Physician Quality Reporting and EHR Reporting.--
Section 1848(m) of such Act 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 clinical 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 development of measures, the reporting of
which would both demonstrate--
``(i) meaningful use of an electronic
health record for purposes of subsection (o);
and
``(ii) clinical quality of care furnished
to an individual.
``(B) The collection of health data to identify
deficiencies in the quality and coordination of care
for individuals eligible for benefits under this part.
``(C) Such other activities as specified by the
Secretary.''.
(d) Extension of Incentive Payments.--Section 1848(m)(1) of such
Act (42 U.S.C. 1395w-4(m)(1)) is amended--
(1) in subparagraph (A), by striking ``2010'' and inserting
``2012''; and
(2) in subparagraph (B)(ii), by striking ``2009 and 2010''
and inserting ``for each of the years 2009 through 2012''.
SEC. 1125. ADJUSTMENT TO MEDICARE PAYMENT LOCALITIES.
(a) In General.--Section 1848(e) of the Social Security Act (42
U.S.C.1395w-4(e)) is amended by adding at the end the following new
paragraph:
``(6) Transition to use of msas as fee schedule areas in
california.--
``(A) In general.--
``(i) Revision.--Subject to clause (ii) and
notwithstanding the previous provisions of this
subsection, for services furnished on or after
January 1, 2011, the Secretary shall revise the
fee schedule areas used for payment under this
section applicable to the State of California
using the Metropolitan Statistical Area (MSA)
iterative Geographic Adjustment Factor
methodology as follows:
``(I) The Secretary shall configure
the physician fee schedule areas using
the Metropolitan Statistical Areas
(each in this paragraph referred to as
an `MSA'), as defined by the Director
of the Office of Management and Budget
and published in the Federal Register,
using the most recent available
decennial population data as of the
date of the enactment of the Affordable
Health Care for America Act, as the
basis for the fee schedule areas.
``(II) For purposes of this clause,
the Secretary shall treat all areas not
included in an MSA as a single rest of
the State MSA.
``(III) The Secretary shall list
all MSAs within the State by Geographic
Adjustment Factor described in
paragraph (2) (in this paragraph
referred to as a `GAF') in descending
order.
``(IV) In the first iteration, the
Secretary shall compare the GAF of the
highest cost MSA in the State to the
weighted-average GAF of all the
remaining MSAs in the State (including
the rest of State MSA described in
subclause (II)). If the ratio of the
GAF of the highest cost MSA to the
weighted-average of the GAF of
remaining lower cost MSAs is 1.05 or
greater, the highest cost MSA shall be
a separate fee schedule area.
``(V) In the next iteration, the
Secretary shall compare the GAF of the
MSA with the second-highest GAF to the
weighted-average GAF of the all the
remaining MSAs (excluding MSAs that
become separate fee schedule areas). If
the ratio of the second-highest MSA's
GAF to the weighted-average of the
remaining lower cost MSAs is 1.05 or
greater, the second-highest MSA shall
be a separate fee schedule area. ``(VI)
The iterative process shall continue
until the ratio of the GAF of the MSA
with highest remaining GAF to the
weighted-average of the remaining MSAs
with lower GAFS is less than 1.05, and
the remaining group of MSAs with lower
GAFS shall be treated as a single fee
schedule area.
``(VI) For purposes of the
iterative process described in this
clause, if two MSAs have identical
GAFs, they shall be combined.
``(ii) Transition.--For services furnished
on or after January 1, 2011, and before January
1, 2016, in the State of California, after
calculating the work, practice expense, and
malpractice geographic indices that would
otherwise be determined under clauses (i),
(ii), and (iii) of paragraph (1)(A) for a fee
schedule area determined under clause (i), if
the index for a county within a fee schedule
area is less than the index in effect for such
county on December 31, 2010, the Secretary
shall instead apply the index in effect for
such county on such date.
``(B) Subsequent revisions.--After the transition
described in subparagraph (A)(ii), not less than every
3 years the Secretary shall review and update the fee
schedule areas using the methodology described in
subparagraph (A)(i) and any updated MSAs as defined by
the Director of the Office of Management and Budget and
published in the Federal Register. The Secretary shall
review and make any changes pursuant to such reviews
concurrent with the application of the periodic review
of the adjustment factors required under paragraph
(1)(C) for California.
``(C) References to fee schedule areas.--Effective
for services furnished on or after January 1, 2011, for
the State of California, any reference in this section
to a fee schedule area shall be deemed a reference to
an MSA in the State (including the single rest of state
MSA described in subparagraph (A)(i)(II)).''.
(b) Conforming Amendment to Definition of Fee Schedule Area.--
Section 1848(j)(2) of the Social Security Act (42 U.S.C. 1395w(j)(2))
is amended by striking ``The term'' and inserting ``Except as provided
in subsection (e)(6)(C), the term''.
PART 2--MARKET BASKET UPDATES
SEC. 1131. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO MARKET BASKET
UPDATES THAT DO NOT ALREADY INCORPORATE SUCH
IMPROVEMENTS.
(a) Outpatient Hospitals.--
(1) In general.--Section 1833(t)(3)(C)(iv) of the Social
Security Act (42 U.S.C. 1395l(t)(3)(C)(iv)) is amended----
(A) in the first sentence--
(i) by inserting ``(which is subject to the
productivity adjustment described in subclause
(II) of such section)'' after
``1886(b)(3)(B)(iii)''; and
(ii) by inserting ``(but not below 0)''
after ``reduced''; and
(B) in the second sentence, by inserting ``and
which is subject, beginning with 2010, to the
productivity adjustment described in section
1886(b)(3)(B)(iii)(II)''.
(2) Effective date.--The amendments made by this subsection
shall apply to increase factors for services furnished in years
beginning with 2010.
(b) Ambulance Services.--Section 1834(l)(3)(B) of such Act (42
U.S.C. 1395m(l)(3)(B))) is amended by inserting before the period at
the end the following: ``and, in the case of years beginning with 2010,
subject to the productivity adjustment described in section
1886(b)(3)(B)(iii)(II)''.
(c) Ambulatory Surgical Center Services.--Section 1833(i)(2)(D) of
such 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
services furnished during 2010 or any subsequent year, to the extent
that an annual percentage change factor applies, such factor shall be
subject to the productivity adjustment described in section
1886(b)(3)(B)(iii)(II).''.
(d) Laboratory Services.--Section 1833(h)(2)(A) of such Act (42
U.S.C. 1395l(h)(2)(A)) is amended--
(1) in clause (i), by striking ``for each of the years 2009
through 2013'' and inserting ``for 2009''; and
(2) clause (ii)--
(A) by striking ``and'' at the end of subclause
(III);
(B) by striking the period at the end of subclause
(IV) and inserting ``; and''; and
(C) by adding at the end the following new
subclause:
``(V) the annual adjustment in the fee schedules determined
under clause (i) for years beginning with 2010 shall be subject
to the productivity adjustment described in section
1886(b)(3)(B)(iii)(II).''.
(e) Certain Durable Medical Equipment.--Section 1834(a)(14) of such
Act (42 U.S.C. 1395m(a)(14)) is amended--
(1) in subparagraph (K), by inserting before the semicolon
at the end the following: ``, subject to the productivity
adjustment described in section 1886(b)(3)(B)(iii)(II)'';
(2) in subparagraph (L)(i), by inserting after ``June
2013,'' the following: ``subject to the productivity adjustment
described in section 1886(b)(3)(B)(iii)(II),'';
(3) in subparagraph (L)(ii), by inserting after ``June
2013'' the following: ``, subject to the productivity
adjustment described in section 1886(b)(3)(B)(iii)(II)''; and
(4) in subparagraph (M), by inserting before the period at
the end the following: ``, subject to the productivity
adjustment described in section 1886(b)(3)(B)(iii)(II)''.
PART 3--OTHER PROVISIONS
SEC. 1141. RENTAL AND PURCHASE OF POWER-DRIVEN WHEELCHAIRS.
(a) In General.--Section 1834(a)(7)(A)(iii) of the Social Security
Act (42 U.S.C. 1395m(a)(7)(A)(iii)) is amended--
(1) in the heading, by inserting ``certain complex
rehabilitative'' after ``option for''; and
(2) by striking ``power-driven wheelchair'' and inserting
``complex rehabilitative power-driven wheelchair recognized by
the Secretary as classified within group 3 or higher''.
(b) Effective Date.--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. Such amendments shall not
apply to contracts entered into under section 1847 of the Social
Security Act (42 U.S.C. 1395w-3) pursuant to a bid submitted under such
section before October 1, 2010, under subsection (a)(1)(B)(i)(I) of
such section.
SEC. 1141A. ELECTION TO TAKE OWNERSHIP, OR TO DECLINE OWNERSHIP, OF A
CERTAIN ITEM OF COMPLEX DURABLE MEDICAL EQUIPMENT AFTER
THE 13-MONTH CAPPED RENTAL PERIOD ENDS.
(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 (ii)--
(A) by striking ``rental.--On'' and inserting
``rental.--
``(I) In general.--Except as
provided in subclause (II), on''; and
(B) by adding at the end the following new
subclause:
``(II) Option to accept or reject
transfer of title to group 3 support
surface.--
``(aa) In general.--During
the 10th continuous month
during which payment is made
for the rental of a Group 3
Support Surface under clause
(i), the supplier of such item
shall offer the individual the
option to accept or reject
transfer of title to a Group 3
Support Surface after the 13th
continuous month during which
payment is made for the rental
of the Group 3 Support Surface
under clause (i). Such title
shall be transferred to the
individual only if the
individual notifies the
supplier not later than 1 month
after the supplier makes such
offer that the individual
agrees to accept transfer of
the title to the Group 3
Support Surface. Unless the
individual accepts transfer of
title to the Group 3 Support
Surface in the manner set forth
in this subclause, the
individual shall be deemed to
have rejected transfer of
title. If the individual agrees
to accept the transfer of the
title to the Group 3 Support
Surface, the supplier shall
transfer such title to the
individual on the first day
that begins after the 13th
continuous month during which
payment is made for the rental
of the Group 3 Support Surface
under clause (i).
``(bb) Special rule.--If,
on the effective date of this
subclause, an individual's
rental period for a Group 3
Support Surface has exceeded 10
continuous months, but the
first day that begins after the
13th continuous month during
which payment is made for the
rental under clause (i) has not
been reached, the supplier
shall, within 1 month following
such effective date, offer the
individual the option to accept
or reject transfer of title to
a Group 3 Support Surface. Such
title shall be transferred to
the individual only if the
individual notifies the
supplier not later than 1 month
after the supplier makes such
offer that the individual
agrees to accept transfer of
title to the Group 3 Support
Surface. Unless the individual
accepts transfer of title to
the Group 3 Support Surface in
the manner set forth in this
subclause, the individual shall
be deemed to have rejected
transfer of title. If the
individual agrees to accept the
transfer of the title to the
Group 3 Support Surface, the
supplier shall transfer such
title to the individual on the
first day that begins after the
13th continuous month during
which payment is made for the
rental of the Group 3 Support
Surface under clause (i) unless
that day has passed, in which
case the supplier shall
transfer such title to the
individual not later than 1
month after notification that
the individual accepts transfer
of title.
``(cc) Treatment of
subsequent resupply within
period of reasonable useful
lifetime of group 3 support
surface in case of need.--If an
individual rejects transfer of
title to a Group 3 Support
Surface under this subclause
and the individual requires
such Support Surface at any
subsequent time during the
period of the reasonable useful
lifetime of such equipment (as
defined by the Secretary)
beginning with the first month
for which payment is made for
the rental of such equipment
under clause (i), the supplier
shall supply the equipment
without charge to the
individual or the program under
this title during the remainder
of such period, other than
payment for maintenance and
servicing during such period
which would otherwise have been
paid if the individual had
accepted title to such
equipment. The previous
sentence shall not affect the
payment of amounts under this
part for such equipment after
the end of such period of the
reasonable useful lifetime of
the equipment.
``(dd) Payments.--
Maintenance and servicing
payments shall be made in
accordance with clause (iv), in
the case of a supplier that
transfers title to the Group 3
Support Surface under this
subclause, after such transfer
and, in the case of an
individual who rejects transfer
of title under this subclause,
after the end of the period of
medical need during which
payment is made under clause
(i).''; and
(2) in clause (iv), by inserting ``or, in the case of an
individual who rejects transfer of title to a Group 3 Support
Surface under clause (ii), after the end of the period of
medical need during which payment is made under clause (i),''
after ``under clause (ii)''.
(b) Effective Date.--The amendments made by this section shall
apply with respect to durable medical equipment not later than January
1, 2011.
SEC. 1142. EXTENSION OF PAYMENT RULE FOR BRACHYTHERAPY.
Section 1833(t)(16)(C) of the Social Security Act (42 U.S.C.
1395l(t)(16)(C)), as amended by section 142 of the Medicare
Improvements for Patients and Providers Act of 2008 (Public Law 110-
275), is amended by striking, the first place it appears, ``January 1,
2010'' and inserting ``January 1, 2012''.
SEC. 1143. HOME INFUSION THERAPY REPORT TO CONGRESS.
Not later than July 1, 2011, the Medicare Payment Advisory
Commission shall submit to Congress a report on the following:
(1) The scope of coverage for home infusion therapy in the
fee-for-service Medicare program under title XVIII of the
Social Security Act, Medicare Advantage under part C of such
title, the veteran's health care program under chapter 17 of
title 38, United States Code, and among private payers,
including an analysis of the scope of services provided by home
infusion therapy providers to their patients in such programs.
(2) The benefits and costs of providing such coverage under
the Medicare program, including a calculation of the potential
savings achieved through avoided or shortened hospital and
nursing home stays as a result of Medicare coverage of home
infusion therapy.
(3) An assessment of sources of data on the costs of home
infusion therapy that might be used to construct payment
mechanisms in the Medicare program.
(4) Recommendations, if any, on the structure of a payment
system under the Medicare program for home infusion therapy,
including an analysis of the payment methodologies used under
Medicare Advantage plans and private health plans for the
provision of home infusion therapy and their applicability to
the Medicare program.
SEC. 1144. REQUIRE AMBULATORY SURGICAL CENTERS (ASCS) TO SUBMIT COST
DATA AND OTHER DATA.
(a) Cost Reporting.--
(1) In general.--Section 1833(i) of the Social Security Act
(42 U.S.C. 1395l(i)) is amended by adding at the end the
following new paragraph:
``(8) The Secretary shall require, as a condition of the agreement
described in section 1832(a)(2)(F)(i), the submission of such cost
report as the Secretary may specify, taking into account the
requirements for such reports under section 1815 in the case of a
hospital.''.
(2) Development of cost report.--Not later than 3 years
after the date of the enactment of this Act, the Secretary of
Health and Human Services shall develop a cost report form for
use under section 1833(i)(8) of the Social Security Act, as
added by paragraph (1).
(3) Audit requirement.--The Secretary shall provide for
periodic auditing of cost reports submitted under section
1833(i)(8) of the Social Security Act, as added by paragraph
(1).
(4) Effective date.--The amendment made by paragraph (1)
shall apply to agreements applicable to cost reporting periods
beginning 18 months after the date the Secretary develops the
cost report form under paragraph (2).
(b) Additional Data on Quality.--
(1) In general.--Section 1833(i)(7) of such Act (42 U.S.C.
1395l(i)(7)) is amended--
(A) in subparagraph (B), by inserting ``subject to
subparagraph (C),'' after ``may otherwise provide,'';
and
(B) by adding at the end the following new
subparagraph:
``(C) Under subparagraph (B) the Secretary shall require the
reporting of such additional data relating to quality of services
furnished in an ambulatory surgical facility, including data on health
care associated infections, as the Secretary may specify.''.
(2) Effective date.--The amendment made by paragraph (1)
shall to reporting for years beginning with 2012.
SEC. 1145. 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).
``(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. 1146. PAYMENT FOR IMAGING SERVICES.
(a) Adjustment in Practice Expense to Reflect a Presumed Level of
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 a
presumed level of 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, 2011, the Secretary
shall adjust such number of units so it reflects a
presumed rate of utilization of imaging equipment of 75
percent.''; and
(2) in subsection (c)(2)(B)(v)), by adding at the end the
following new subclause:
``(III) Change in presumed
utilization level of certain advanced
diagnostic imaging services.--Effective
for fee schedules established beginning
with 2011, reduced expenditures
attributable to the presumed
utilization of 75 percent under
subsection (b)(4)(C) instead of a
presumed utilization of imaging
equipment of 50 percent.''.
(b) Adjustment in Technical Component ``discount'' on Single-
session Imaging to Consecutive Body Parts.--Section 1848 of such Act
(42 U.S.C. 1395w-4) is further 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 January 1,
2011, the Secretary shall increase the reduction in
expenditures 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:
``(III) Additional reduced payment
for multiple imaging procedures.--
Effective for fee schedules established
beginning with 2011, reduced
expenditures attributable to the
increase in the multiple procedure
payment reduction from 25 percent to 50
percent as described in subsection
(b)(4)(D).''.
SEC. 1147. DURABLE MEDICAL EQUIPMENT PROGRAM IMPROVEMENTS.
(a) Waiver of Surety Bond Requirement.--Section 1834(a)(16) of the
Social Security Act (42 U.S.C. 1395m(a)(16)) is amended by adding at
the end the following sentence: ``The requirement for a surety bond
described in subparagraph (B) shall not apply in the case of a pharmacy
or supplier that exclusively furnishes eyeglasses or contact lenses
described in section 1861(s)(8) if the pharmacy or supply has been
enrolled under section 1866(j) as a supplier of durable medical
equipment, prosthetics, orthotics, and supplies and has been issued
(which may include renewal of) a supplier number (as described in the
first sentence of this paragraph) for at least 5 years, and if a final
adverse action (as defined in section 424.57(a) of title 42, Code of
Federal Regulations) has never been imposed for such pharmacy or
supplier.''.
(b) Ensuring Supply of Oxygen Equipment .--
(1) In general.--Section 1834(a)(5)(F) of the Social
Security Act (42 U.S.C. 1395m(a)(5)(F)) is amended--
(A) in clause (ii), by striking ``After the'' and
inserting ``Except as provided in clause (iii), after
the''; and
(B) by adding at the end the following new clause:
``(iii) Continuation of supply.--In the
case of a supplier furnishing such equipment to
an individual under this subsection as of the
27th month of the 36 months described in clause
(i), the supplier furnishing such equipment as
of such month shall continue to furnish such
equipment to such individual (either directly
or though arrangements with other suppliers of
such equipment) during any subsequent period of
medical need for the remainder of the
reasonable useful lifetime of the equipment, as
determined by the Secretary, regardless of the
location of the individual, unless another
supplier has accepted responsibility for
continuing to furnish such equipment during the
remainder of such period.''.
(2) Effective date.--The amendments made by paragraph (1)
shall take effect as of the date of the enactment of this Act
and shall apply to the furnishing of equipment to individuals
for whom the 27th month of a continuous period of use of oxygen
equipment described in section 1834(a)(5)(F) of the Social
Security Act occurs on or after July 1, 2010.
(c) Treatment of Current Accreditation Applications.--Section
1834(a)(20)(F) of such Act (42 U.S.C. 1395m(a)(20)(F)) is amended--
(1) in clause (i)--
(A) by striking ``clause (ii)'' and inserting
``clauses (ii) and (iii)''; and
(B) by striking ``and'' at the end;
(2) by striking the period at the end of clause (ii)(II)
and by inserting a semicolon;
(3) by inserting after clause (ii) the following new
clauses:
``(iii) the requirement for accreditation
described in clause (i) shall not apply for
purposes of supplying diabetic testing
supplies, canes, and crutches in the case of a
pharmacy that is enrolled under section 1866(j)
as a supplier of durable medical equipment,
prosthetics, orthotics, and supplies; and
``(iv) a supplier that has submitted an
application for accreditation before August 1,
2009, shall retain the supplier's provider or
supplier number until an independent
accreditation organization determines if such
supplier complies with requirements under this
paragraph.''; and
(4) by adding at the end the following new sentence:
``Nothing in clauses (iii) and (iv) shall be construed as
affecting the application of an accreditation requirement for
suppliers to qualify for bidding in a competitive acquisition
area under section 1847,''.
(d) Restoring 36-month Oxygen Rental Period in Case of Supplier
Bankruptcy for Certain Individuals.--Section 1834(a)(5)(F) of such Act
(42 U.S.C. 1395m(a)(5)(F)), as amended by subsection (b), is further
amended by adding at the end the following new clause:
``(iv) Exception for bankruptcy.--If a
supplier who furnishes oxygen and oxygen
equipment to an individual is declared bankrupt
and its assets are liquidated and at the time
of such declaration and liquidation more than
24 months of rental payments have been made,
such individual may begin a new 36-month rental
period under this subparagraph with another
supplier of oxygen.''.
SEC. 1148. MEDPAC STUDY AND REPORT ON BONE MASS MEASUREMENT.
(a) In General.--The Medicare Payment Advisory Commission shall
conduct a study regarding bone mass measurement, including computed
tomography, duel-energy x-ray absorptriometry, and vertebral fracture
assessment. The study shall focus on the following:
(1) An assessment of the adequacy of Medicare payment rates
for such services, taking into account costs of acquiring the
necessary equipment, professional work time, and practice
expense costs.
(2) The impact of Medicare payment changes since 2006 on
beneficiary access to bone mass measurement benefits in general
and in rural and minority communities specifically.
(3) A review of the clinically appropriate and recommended
use among Medicare beneficiaries and how usage rates among such
beneficiaries compares to such recommendations.
(4) In conjunction with the findings under (3),
recommendations, if necessary, regarding methods for reaching
appropriate use of bone mass measurement studies among Medicare
beneficiaries.
(b) Report.--The Commission shall submit a report to the Congress,
not later than 9 months after the date of the enactment of this Act,
containing a description of the results of the study conducted under
subsection (a) and the conclusions and recommendations, if any,
regarding each of the issues described in paragraphs (1), (2) (3) and
(4) of such subsection.
SEC. 1149. TIMELY ACCESS TO POST-MASTECTOMY ITEMS.
(a) In General.--Section 1834(h)(1) of the Social Security Act (42
U.S.C. 1395m) is amended--
(1) by redesignating subparagraph (H) as subparagraph (I);
and
(2) by inserting after subparagraph (G) the following new
subparagraph:
``(H) Special payment rule for post-mastectomy
external breast prosthesis garments.--Payment for post-
mastectomy external breast prosthesis garments shall be
made regardless of whether such items are supplied to
the beneficiary prior to or after the mastectomy
procedure or other breast cancer surgical procedure.
The Secretary shall develop policies to ensure
appropriate beneficiary access and utilization
safeguards for such items supplied to a beneficiary
prior to the mastectomy or other breast cancer surgical
procedure.''
(b) Effective Date.--This amendment shall apply not later than
January 1, 2011.
SEC. 1149A. 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)(1)--
(A) in subparagraph (A), by striking ``or'' at the
end;
(B) in subparagraph (B), by striking the period at
the end and inserting ``; or''; and
(C) by adding at the end the following new
subparagraph:
``(C) in the case of one or more interchangeable
biological products (as defined in subsection
(c)(6)(I)) and their reference biological product (as
defined in subsection (c)(6)(J)), which shall be
included in the same billing and payment code, the sum
of--
``(i) the average sales price as determined
using the methodology described in paragraph
(6) applied to such interchangeable and
reference products for all National Drug Codes
assigned to such products in the same manner as
such paragraph (6) is applied to multiple
source drugs; and
``(ii) 6 percent of the amount determined
under clause (i);
``(D) in the case of a biosimilar biological
product (as defined in subsection (c)(6)(H)), the sum
of--
``(i) the average sales price as determined
using the methodology described in paragraph
(4) applied to such biosimilar biological
product for all National Drug Codes assigned to
such product in the same manner as such
paragraph (4) is applied to a single source
drug; and
``(ii) 6 percent of the amount determined
under paragraph (4) or the amount determined
under subparagraph (C)(ii), as the case may be,
for the reference biological product (as
defined in subsection (c)(6)(J)); or
``(E) in the case of a reference biological product
for both an interchangeable biological product and a
biosimilar product, the amount determined in
subparagraph (C).''; and
(2) in subsection (c)(6)--
(A) by amending subparagraph (D)(i) to read as
follows:
``(i) a biological, including a reference
biological product for a biosimilar product,
but excluding--
``(I) a biosimilar biological
product;
``(II) an interchangeable
biological product;
``(III) a reference biological
product for an interchangeable
biological product; and
``(IV) a reference biological
product for both an interchangeable
biological product and a biosimilar
product; or''; and
(B) by adding at the end the following new
subparagraphs:
``(H) Biosimilar biological product.--The term
`biosimilar biological product' means a biological
product licensed as a biosimilar biological product
under section 351(k) of the Public Health Service Act.
``(I) Interchangeable biological product.--The term
`interchangeable biological product' means a biological
product licensed as an interchangeable biological
product under section 351(k) of the Public Health
Service Act
``(J) Reference biological product.--The term
`reference biological product' means the biological
product that is referred to in the application for a
biosimilar or interchangeable biological product
licensed under section 351(k) of the Public Health
Service Act.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to payments for biosimilar biological products, interchangeable
biological products, and reference biological products beginning with
the first day of the second calendar quarter after the date of the
enactment of this Act.
SEC. 1149B. STUDY AND REPORT ON DME COMPETITIVE BIDDING PROCESS.
(a) Study.--The Comptroller General of the United States shall
conduct a study to evaluate the potential establishment of a program
under Medicare under title XVIII of the Social Security Act to acquire
durable medical equipment and supplies through a competitive bidding
process among manufacturers of such equipment and supplies. Such study
shall address the following:
(1) Identification of types of durable medical equipment
and supplies that would be appropriate for bidding under such a
program.
(2) Recommendations on how to structure such an acquisition
program in order to promote fiscal responsibility while also
ensuring beneficiary access to high quality equipment and
supplies.
(3) Recommendations on how such a program could be phased-
in and on what geographic level would bidding be most
appropriate.
(4) In addition to price, recommendations on criteria that
could be factored into the bidding process.
(5) Recommendations on how suppliers could be compensated
for furnishing and servicing equipment and supplies acquired
under such a program.
(6) Comparison of such a program to the current competitive
bidding program under Medicare for durable medical equipment,
as well as any other similar Federal acquisition programs, such
as the General Services Administration's vehicle purchasing
program.
(7) Any other consideration relevant to the acquisition,
supply, and service of durable medical equipment and supplies
that is deemed appropriate by the Comptroller General.
(b) Report.--Not later than 12 months after the date of the
enactment of this Act, the Comptroller General of the United States
shall submit to Congress a report on the findings of the study under
subsection (a).
Subtitle C--Provisions Related to Medicare Parts A and B
SEC. 1151. REDUCING POTENTIALLY PREVENTABLE HOSPITAL READMISSIONS.
(a) Hospitals.--
(1) In general.--Section 1886 of the Social Security Act
(42 U.S.C. 1395ww), as amended by section 1103(a), is amended
by adding at the end the following new subsection:
``(p) Adjustment to Hospital Payments for Excess Readmissions.--
``(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,
2011, 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.--
``(A) In general.--Except as provided in
subparagraph (B), for purposes of this subsection, the
term `base operating DRG payment amount' means, with
respect to a hospital for a fiscal year, the payment
amount that would otherwise be made under subsection
(d) for a discharge if this subsection did not apply,
reduced by any portion of such amount that is
attributable to payments under subparagraphs (B) and
(F) of paragraph (5).
``(B) Adjustments.--For purposes of subparagraph
(A), 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.
``(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 2012 is 0.99;
``(ii) fiscal year 2013 is 0.98;
``(iii) fiscal year 2014 is 0.97; or
``(iv) a subsequent fiscal year is 0.95.
``(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 a fiscal year, 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 fiscal year for such
condition;
``(ii) the number of admissions for such
condition for such hospital for such fiscal
year; and
``(iii) the excess readmissions ratio (as
defined in subparagraph (C)) for such hospital
for the applicable period for such fiscal year
minus 1.
``(B) Aggregate payments for all discharges.--The
term `aggregate payments for all discharges' means, for
a hospital for a fiscal year, the sum of the base
operating DRG payment amounts for all discharges for
all conditions from such hospital for such fiscal year.
``(C) Excess readmission ratio.--
``(i) In general.--Subject to clauses (ii)
and (iii), 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 the 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.
``(iii) Adjustment.--In order to promote a
reduction over time in the overall rate of
readmissions for applicable conditions, the
Secretary may provide, beginning with
discharges for fiscal year 2014, for the
determination of the excess readmissions ratio
under subparagraph (C) to be based on a ranking
of hospitals by readmission ratios (from lower
to higher readmission ratios) normalized to a
benchmark that is lower than the 50th
percentile.
``(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
appropriate 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 2013, the Secretary shall
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 so identified by the Medicare
Payment Advisory Commission in its report to Congress
in June 2007 and to other conditions and procedures
which may include an all-condition measure of
readmissions, 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.
``(C) Applicable hospital.--The term `applicable
hospital' means a subsection (d) hospital or a hospital
that is paid under section 1814(b)(3).
``(D) Applicable period.--The term `applicable
period' means, with respect to a fiscal year, such
period as the Secretary shall specify for purposes of
determining excess readmissions.
``(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) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of--
``(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); and
``(D) the determination of a targeted hospital
under paragraph (8)(B)(i), the increase in payment
under paragraph (8)(B)(ii), the aggregate cap under
paragraph (8)(C)(i), the hospital-specific limit under
paragraph (8)(C)(ii), and the form of payment made by
the Secretary under paragraph (8)(D).
``(7) Monitoring inappropriate changes in admissions
practices.--The Secretary shall monitor the activities of
applicable hospitals to determine if such hospitals have taken
steps to avoid patients at risk in order to reduce the
likelihood of increasing readmissions for applicable conditions
or taken other inappropriate steps involving readmissions or
transfers. If the Secretary determines that such a hospital has
taken such a step, after notice to the hospital and opportunity
for the hospital to undertake action to alleviate such steps,
the Secretary may impose an appropriate sanction.
``(8) Assistance to certain hospitals.--
``(A) In general.--For purposes of providing funds
to applicable hospitals to take steps described in
subparagraph (E) to address factors that may impact
readmissions of individuals who are discharged from
such a hospital, for fiscal years beginning on or after
October 1, 2011, the Secretary shall make a payment
adjustment for a hospital described in subparagraph
(B), with respect to each such fiscal year, by a
percent estimated by the Secretary to be consistent
with subparagraph (C). The Secretary shall provide
priority to hospitals that serve Medicare beneficiaries
at highest risk for readmission or for a poor
transition from such a hospital to a post-hospital site
of care.
``(B) Targeted hospitals.--Subparagraph (A) shall
apply to an applicable hospital that--
``(i) had (or, in the case of an 1814(b)(3)
hospital, otherwise would have had) a
disproportionate patient percentage (as defined
in section 1886(d)(5)(F)) of at least 30
percent, using the latest available data as
estimated by the Secretary; and
``(ii) provides assurances satisfactory to
the Secretary that the increase in payment
under this paragraph shall be used for purposes
described in subparagraph (E).
``(C) Caps.--
``(i) Aggregate cap.--The aggregate amount
of the payment adjustment under this paragraph
for a fiscal year shall not exceed 5 percent of
the estimated difference in the spending that
would occur for such fiscal year with and
without application of the adjustment factor
described in paragraph (3) and applied pursuant
to paragraph (1).
``(ii) Hospital-specific limit.--The
aggregate amount of the payment adjustment for
a hospital under this paragraph shall not
exceed the estimated difference in spending
that would occur for such fiscal year for such
hospital with and without application of the
adjustment factor described in paragraph (3)
and applied pursuant to paragraph (1).
``(D) Form of payment.--The Secretary may make the
additional payments under this paragraph on a lump sum
basis, a periodic basis, a claim by claim basis, or
otherwise.
``(E) Use of additional payment.--
``(i) In general.--Funding under this
paragraph shall be used by targeted hospitals
for activities designed to address the patient
noncompliance issues that result in higher than
normal readmission rates, including
transitional care services described in clause
(ii) and any or all of the other activities
described in clause (iii).
``(ii) Transitional care services.--The
transitional care services described in this
clause are transitional care services furnished
by a qualified transitional care provider, such
as a nurse or other health professional, who
meets relevant experience and training
requirements as specified by the Secretary that
support a beneficiary under this section
beginning on the date of an individual's
admission to a hospital for inpatient hospital
services and ending at the latest on the last
day of the 90-day period beginning on the date
of the individual's discharge from the
applicable hospital. The Secretary shall
determine and update services to be included in
transitional care services under this clause as
appropriate, based on evidence of their
effectiveness in reducing hospital readmissions
and improving health outcomes. Such services
shall include the following:
``(I) Conduct of an assessment
prior to discharge, which assessment
may include an assessment of the
individual's physical and mental
condition, cognitive and functional
capacities, medication regimen and
adherence, social and environmental
needs, and primary caregiver needs and
resources.
``(II) Development of a evidence-
based plan of transitional care for the
individual developed after consultation
with the individual and the
individual's primary caregiver and
other health team members, as
appropriate. Such plan shall include a
list of current therapies prescribed,
treatment goals and may include other
items or elements as determined by the
Secretary, such as identifying list of
potential health risks and future
services for both the individual and
any primary caregiver.
``(iii) Other activities.--The other
activities described in this clause are the
following:
``(I) Providing other care
coordination services not described
under clause (ii).
``(II) Hiring translators and
interpreters.
``(III) Increasing services offered
by discharge planners.
``(IV) Ensuring that individuals
receive a summary of care and
medication orders upon discharge.
``(V) Developing a quality
improvement plan to assess and remedy
preventable readmission rates.
``(VI) Assigning appropriate
follow-up care for discharged
individuals.
``(VII) Doing other activities as
determined appropriate by the
Secretary.
``(F) GAO report on use of funds.--Not later than 3
years after the date on which funds are first made
available under this paragraph, the Comptroller General
of the United States shall submit to Congress a report
on the use of such funds. Such report shall consider
information on the effective uses of such funds, how
the uses of such funds affected hospital readmission
rates (including at 6 months post-discharge), health
outcomes and quality, reductions in expenditures under
this title and the experiences of beneficiaries,
primary caregivers, and providers, as well as any
appropriate recommendations.''.
(b) Application to Critical Access Hospitals.--Section 1814(l) of
the Social Security Act (42 U.S.C. 1395f(l)) is amended--
(1) in paragraph (5)--
(A) by striking ``and'' at the end of subparagraph
(C);
(B) by striking the period at the end of
subparagraph (D) and inserting ``; and'';
(C) by inserting at the end the following new
subparagraph:
``(E) the methodology for determining the adjustment factor
under paragraph (5), including the determination of aggregate
payments for actual and expected readmissions, applicable
periods, applicable conditions and measures of readmissions.'';
and
(D) by redesignating such paragraph as paragraph
(6); and
(2) by inserting after paragraph (4) the following new
paragraph:
``(5) The adjustment factor described in section 1886(p)(3) shall
apply to payments with respect to a critical access hospital with
respect to a cost reporting period beginning in fiscal year 2012 and
each subsequent fiscal year (after application of paragraph (4) of this
subsection) in a manner similar to the manner in which such section
applies with respect to a fiscal year to an applicable hospital as
described in section 1886(p)(2).''.
(c) Post Acute Care Providers.--
(1) Interim policy.--
(A) In general.--With respect to a readmission to
an applicable hospital or a critical access hospital
(as described in section 1814(l) of the Social Security
Act) from a post acute care provider (as defined in
paragraph (3)) and such a readmission is not governed
by section 412.531 of title 42, Code of Federal
Regulations, if the claim submitted by such a post-
acute care provider under title XVIII of the Social
Security Act indicates that the individual was
readmitted to a hospital from such a post-acute care
provider or admitted from home and under the care of a
home health agency within 30 days of an initial
discharge from an applicable hospital or critical
access hospital, the payment under such title on such
claim shall be the applicable percent specified in
subparagraph (B) of the payment that would otherwise be
made under the respective payment system under such
title for such post-acute care provider if this
subsection did not apply. In applying the previous
sentence, the Secretary shall exclude a period of 1 day
from the date the individual is first admitted to or
under the care of the post-acute care provider.
(B) Applicable percent defined.--For purposes of
subparagraph (A), the applicable percent is--
(i) for fiscal or rate year 2012 is 0.996;
(ii) for fiscal or rate year 2013 is 0.993;
and
(iii) for fiscal or rate year 2014 is 0.99.
(C) Effective date.--Subparagraph (1) shall apply
to discharges or services furnished (as the case may be
with respect to the applicable post acute care
provider) on or after the first day of the fiscal year
or rate year, beginning on or after October 1, 2011,
with respect to the applicable post acute care
provider.
(2) Development and application of performance measures.--
(A) In general.--The Secretary of Health and Human
Services shall develop appropriate measures of
readmission rates for post acute care providers. The
Secretary shall seek endorsement of such measures by
the entity with a contract under section 1890(a) of the
Social Security Act but may adopt and apply such
measures under this paragraph without such an
endorsement. The Secretary shall expand such measures
in a manner similar to the manner in which applicable
conditions are expanded under paragraph (5)(B) of
section 1886(p) of the Social Security Act, as added by
subsection (a).
(B) Implementation.--The Secretary shall apply, on
or after October 1, 2014, with respect to post acute
care providers, policies similar to the policies
applied with respect to applicable hospitals and
critical access hospitals under the amendments made by
subsection (a). The provisions of paragraph (1) shall
apply with respect to any period on or after October 1,
2014, and before such application date described in the
previous sentence in the same manner as such provisions
apply with respect to fiscal or rate year 2014.
(C) Monitoring and penalties.--The provisions of
paragraph (7) of such section 1886(p) shall apply to
providers under this paragraph in the same manner as
they apply to hospitals under such section.
(3) Definitions.--For purposes of this subsection:
(A) Post acute care provider.--The term ``post
acute care provider'' means--
(i) a skilled nursing facility (as defined
in section 1819(a) of the Social Security Act);
(ii) an inpatient rehabilitation facility
(described in section 1886(h)(1)(A) of such
Act);
(iii) a home health agency (as defined in
section 1861(o) of such Act); and
(iv) a long term care hospital (as defined
in section 1861(ccc) of such Act).
(B) Other terms .--The terms ``applicable
condition'', ``applicable hospital'', and
``readmission'' have the meanings given such terms in
section 1886(p)(5) of the Social Security Act, as added
by subsection (a)(1).
(d) Physicians.--
(1) Study.--The Secretary of Health and Human Services
shall conduct a study to determine how the readmissions policy
described in the previous subsections could be applied to
physicians.
(2) Considerations.--In conducting the study, the Secretary
shall consider approaches such as--
(A) creating a new code (or codes) and payment
amount (or amounts) under the fee schedule in section
1848 of the Social Security Act (in a budget neutral
manner) for services furnished by an appropriate
physician who sees an individual within the first week
after discharge from a hospital or critical access
hospital;
(B) developing measures of rates of readmission for
individuals treated by physicians;
(C) applying a payment reduction for physicians who
treat the patient during the initial admission that
results in a readmission; and
(D) methods for attributing payments or payment
reductions to the appropriate physician or physicians.
(3) Report.--The Secretary shall issue a public report on
such study not later than the date that is one year after the
date of the enactment of this Act.
(e) Funding.--For purposes of carrying out the provisions of this
section, in addition to funds otherwise available, out of any funds in
the Treasury not otherwise appropriated, there are appropriated to the
Secretary of Health and Human Services for the Center for Medicare &
Medicaid Services Program Management Account $25,000,000 for each
fiscal year beginning with 2010. Amounts appropriated under this
subsection for a fiscal year shall be available until expended.
SEC. 1152. POST ACUTE CARE SERVICES PAYMENT REFORM PLAN AND BUNDLING
PILOT PROGRAM.
(a) Plan.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
develop a detailed plan to reform payment for post acute care
(PAC) services under the Medicare program under title XVIII of
the Social Security Act (in this section referred to as the
``Medicare program)''. The goals of such payment reform are
to--
(A) improve the coordination, quality, and
efficiency of such services; and
(B) improve outcomes for individuals such as
reducing the need for readmission to hospitals from
providers of such services.
(2) Bundling post acute services.--The plan described in
paragraph (1) shall include detailed specifications for a
bundled payment for post acute services (in this section
referred to as the ``post acute care bundle''), and may include
other approaches determined appropriate by the Secretary.
(3) Post acute services.--For purposes of this section, the
term ``post acute services'' means services for which payment
may be made under the Medicare program that are furnished by
skilled nursing facilities, inpatient rehabilitation
facilities, long term care hospitals, hospital based outpatient
rehabilitation facilities and home health agencies to an
individual after discharge of such individual from a hospital,
and such other services determined appropriate by the
Secretary.
(b) Details.--The plan described in subsection (a)(1) shall include
consideration of the following issues:
(1) The nature of payments under a post acute care bundle,
including the type of provider or entity to whom payment should
be made, the scope of activities and services included in the
bundle, whether payment for physicians' services should be
included in the bundle, and the period covered by the bundle.
(2) Whether the payment should be consolidated with the
payment under the inpatient prospective system under section
1886 of the Social Security Act (in this section referred to as
MS-DRGs) or a separate payment should be established for such
bundle, and if a separate payment is established, whether it
should be made only upon use of post acute care services or for
every discharge.
(3) Whether the bundle should be applied across all
categories of providers of inpatient services (including
critical access hospitals) and post acute care services or
whether it should be limited to certain categories of
providers, services, or discharges, such as high volume or high
cost MS-DRGs.
(4) The extent to which payment rates could be established
to achieve offsets for efficiencies that could be expected to
be achieved with a bundle payment, whether such rates should be
established on a national basis or for different geographic
areas, should vary according to discharge, case mix, outliers,
and geographic differences in wages or other appropriate
adjustments, and how to update such rates.
(5) The nature of protections needed for individuals under
a system of bundled payments to ensure that individuals receive
quality care, are furnished the level and amount of services
needed as determined by an appropriate assessment instrument,
are offered choice of provider, and the extent to which
transitional care services would improve quality of care for
individuals and the functioning of a bundled post-acute system.
(6) The nature of relationships that may be required
between hospitals and providers of post acute care services to
facilitate bundled payments, including the application of
gainsharing, anti-referral, anti-kickback, and anti-trust laws.
(7) Quality measures that would be appropriate for
reporting by hospitals and post acute providers (such as
measures that assess changes in functional status and quality
measures appropriate for each type of post acute services
provider including how the reporting of such quality measures
could be coordinated with other reporting of such quality
measures by such providers otherwise required).
(8) How cost-sharing for a post acute care bundle should be
treated relative to current rules for cost-sharing for
inpatient hospital, home health, skilled nursing facility, and
other services.
(9) How other programmatic issues should be treated in a
post acute care bundle, including rules specific to various
types of post-acute providers such as the post-acute transfer
policy, three-day hospital stay to qualify for services
furnished by skilled nursing facilities, and the coordination
of payments and care under the Medicare program and the
Medicaid program.
(10) Such other issues as the Secretary deems appropriate.
(c) Consultations and Analysis.--
(1) Consultation with stakeholders.--In developing the plan
under subsection (a)(1), the Secretary shall consult with
relevant stakeholders and shall consider experience with such
research studies and demonstrations that the Secretary
determines appropriate.
(2) Analysis and data collection.--In developing such plan,
the Secretary shall--
(A) analyze the issues described in subsection (b)
and other issues that the Secretary determines
appropriate;
(B) analyze the impacts (including geographic
impacts) of post acute service reform approaches,
including bundling of such services on individuals,
hospitals, post acute care providers, and physicians;
(C) use existing data (such as data submitted on
claims) and collect such data as the Secretary
determines are appropriate to develop such plan
required in this section; and
(D) if patient functional status measures are
appropriate for the analysis, to the extent practical,
build upon the CARE tool being developed pursuant to
section 5008 of the Deficit Reduction Act of 2005.
(d) Administration.--
(1) Funding.--For purposes of carrying out the provisions
of this section, in addition to funds otherwise available, out
of any funds in the Treasury not otherwise appropriated, there
are appropriated to the Secretary for the Center for Medicare &
Medicaid Services Program Management Account $15,000,000 for
each of the fiscal years 2010 through 2012. Amounts
appropriated under this paragraph for a fiscal year shall be
available until expended.
(2) Expedited data collection.--Chapter 35 of title 44,
United States Code shall not apply to this section.
(e) Public Reports.--
(1) Interim reports.--The Secretary shall issue interim
public reports on a periodic basis on the plan described in
subsection (a)(1), the issues described in subsection (b), and
impact analyses as the Secretary determines appropriate.
(2) Final report.--Not later than the date that is 3 years
after the date of the enactment of this Act, the Secretary
shall issue a final public report on such plan, including
analysis of issues described in subsection (b) and impact
analyses.
(f) Conversion of Acute Care Episode Demonstration to Pilot Program
and Expansion to Include Post Acute Services.--
(1) In general.--Part E of title XVIII of the Social
Security Act is amended by inserting after section 1866C the
following new section:
``conversion of acute care episode demonstration to pilot program and
expansion to include post acute services
``Sec. 1866D. (a) Conversion and Expansion.--
``(1) In general.--By not later than January 1, 2011, the
Secretary shall, for the purpose of promoting the use of
bundled payments to promote efficient, coordinated, and high
quality delivery of care--
``(A) convert the acute care episode demonstration
program conducted under section 1866C to a pilot
program; and
``(B) subject to subsection (c), expand such
program as so converted to include post acute services
and such other services the Secretary determines to be
appropriate, which may include transitional services.
``(2) Bundled payment structures.--
``(A) In general.--In carrying out paragraph (1),
the Secretary may apply bundled payments with respect
to--
``(i) hospitals and physicians;
``(ii) hospitals and post-acute care
providers;
``(iii) hospitals, physicians, and post-
acute care providers; or
``(iv) combinations of post-acute
providers.
``(B) Further application.--
``(i) In general.--In carrying out
paragraph (1), the Secretary shall apply
bundled payments in a manner so as to include
collaborative care networks and continuing care
hospitals.
``(ii) Collaborative care network
defined.--For purposes of this subparagraph,
the term `collaborative care network' means a
consortium of health care providers that
provides a comprehensive range of coordinated
and integrated health care services to low-
income patient populations (including the
uninsured) which may include coordinated and
comprehensive care by safety net providers to
reduce any unnecessary use of items and
services furnished in emergency departments,
manage chronic conditions, improve quality and
efficiency of care, increase preventive
services, and promote adherence to post-acute
and follow-up care plans.
``(iii) Continuing care hospital defined.--
For purposes of this subparagraph, 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) Scope.--The Secretary shall set specific goals for the number
of acute and post-acute bundling test sites under the pilot program to
ensure that over time the pilot program is of sufficient size and scope
to--
``(1) test the approaches under the pilot program in a
variety of settings, including urban, rural, and underserved
areas;
``(2) include geographic areas and additional conditions
that account for significant program spending, as defined by
the Secretary; and
``(3) subject to subsection (d), disseminate the pilot
program rapidly on a national basis.
To the extent that the Secretary finds inpatient and post acute care
bundling to be successful in improving quality and reducing costs, the
Secretary shall implement such mechanisms and reforms under the pilot
program on as large a geographic scale as practical and economical,
consistent with subsection (e). Nothing in this subsection shall be
construed as limiting the number of hospital and physician groups or
the number of hospital and post-acute provider groups that may
participate in the pilot program.
``(c) Limitation.--The Secretary shall only expand the pilot
program under subsection (a) if the Secretary finds that--
``(1) the demonstration program under section 1866C and
pilot program under this section maintain or increase the
quality of care received by individuals enrolled under this
title; and
``(2) such demonstration program and pilot program reduce
program expenditures and, based on the certification under
subsection (d), that the expansion of such pilot program would
result in estimated spending that would be less than what
spending would otherwise be in the absence of this section.
``(d) Certification.--For purposes of subsection (c), the Chief
Actuary of the Centers for Medicare & Medicaid Services shall certify
whether expansion of the pilot program under this section would result
in estimated spending that would be less than what spending would
otherwise be in the absence of this section.
``(e) Voluntary Participation.--Nothing in this paragraph shall be
construed as requiring the participation of an entity in the pilot
program under this section.
``(f) Evaluation on Cost and Quality of Care.--The Secretary shall
conduct an evaluation of the pilot program under subsection (a) to
study the effect of such program on costs and quality of care. The
findings of such evaluation shall be included in the final report
required under section 1152(e)(2) of the Affordable Health Care for
America Act.
``(g) Study of Additional Bundling and Episode-based Payment for
Physicians' Services.--
``(1) In general.--The Secretary shall provide for a study
of and development of a plan for testing additional ways to
increase bundling of payments for physicians in connection with
an episode of care, such as in connection with outpatient
hospital services or services rendered in physicians' offices,
other than those provided under the pilot program.
``(2) Application.--The Secretary may implement such a plan
through a demonstration program.''.
(2) Conforming amendment.--Section 1866C(b) of the Social
Security Act (42 U.S.C. 1395cc-3(b)) is amended by striking
``The Secretary'' and inserting ``Subject to section 1866D, the
Secretary''.
SEC. 1153. HOME HEALTH PAYMENT UPDATE FOR 2010.
Section 1895(b)(3)(B)(ii) of the Social Security Act (42 U.S.C.
1395fff(b)(3)(B)(ii)) is amended--
(1) in subclause (IV), by striking ``and'';
(2) by redesignating subclause (V) as subclause (VII); and
(3) by inserting after subclause (IV) the following new
subclauses:
``(V) 2007, 2008, and 2009, subject
to clause (v), the home health market
basket percentage increase;
``(VI) 2010, subject to clause (v),
0 percent; and''.
SEC. 1154. PAYMENT ADJUSTMENTS FOR HOME HEALTH CARE.
(a) Acceleration of Adjustment for Case Mix Changes.--Section
1895(b)(3)(B) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(B))
is amended--
(1) in clause (iv), by striking ``Insofar as'' and
inserting ``Subject to clause (vi), insofar as''; and
(2) by adding at the end the following new clause:
``(vi) Special rule for case mix changes
for 2011.--
``(I) In general.--With respect to
the case mix adjustments established in
section 484.220(a) of title 42, Code of
Federal Regulations, the Secretary
shall apply, in 2010, the adjustment
established in paragraph (3) of such
section for 2011, in addition to
applying the adjustment established in
paragraph (2) for 2010.
``(II) Construction.--Nothing in
this clause shall be construed as
limiting the amount of adjustment for
case mix for 2010 or 2011 if more
recent data indicate an appropriate
adjustment that is greater than the
amount established in the section
described in subclause (I).''.
(b) Rebasing Home Health Prospective Payment Amount.--Section
1895(b)(3)(A) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(A))
is amended--
(1) in clause (i)--
(A) in subclause (III), by inserting ``and before
2011'' after ``after the period described in subclause
(II)''; and
(B) by inserting after subclause (III) the
following new subclauses:
``(IV) Subject to clause (iii)(I),
for 2011, such amount (or amounts)
shall be adjusted by a uniform
percentage determined to be appropriate
by the Secretary based on analysis of
factors such as changes in the average
number and types of visits in an
episode, the change in intensity of
visits in an episode, growth in cost
per episode, and other factors that the
Secretary considers to be relevant.
``(V) Subject to clause (iii)(II),
for a year after 2011, such a amount
(or amounts) shall be equal to the
amount (or amounts) determined under
this clause for the previous year,
updated under subparagraph (B).''; and
(2) by adding at the end the following new clause:
``(iii) Special rule in case of inability
to effect timely rebasing.--
``(I) Application of proxy amount
for 2011.--If the Secretary is not able
to compute the amount (or amounts)
under clause (i)(IV) so as to permit,
on a timely basis, the application of
such clause for 2011, the Secretary
shall substitute for such amount (or
amounts) 95 percent of the amount (or
amounts) that would otherwise be
specified under clause (i)(III) if it
applied for 2011.
``(II) Adjustment for subsequent
years based on data.--If the Secretary
applies subclause (I), the Secretary
before July 1, 2011, shall compare the
amount (or amounts) applied under such
subclause with the amount (or amounts)
that should have been applied under
clause (i)(IV). The Secretary shall
decrease or increase the prospective
payment amount (or amounts) under
clause (i)(V) for 2012 (or, at the
Secretary's discretion, over a period
of several years beginning with 2012)
by the amount (if any) by which the
amount (or amounts) applied under
subclause (I) is greater or less,
respectively, than the amount (or
amounts) that should have been applied
under clause (i)(IV).''.
SEC. 1155. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO MARKET BASKET
UPDATE FOR HOME HEALTH SERVICES.
(a) In General.--Section 1895(b)(3)(B) of the Social Security Act
(42 U.S.C. 1395fff(b)(3)(B)) is amended--
(1) in clause (iii), by inserting ``(including being
subject to the productivity adjustment described in section
1886(b)(3)(B)(iii)(II))'' after ``in the same manner''; and
(2) in clause (v)(I), by inserting ``(but not below 0)''
after ``reduced''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to home health market basket percentage increases for years
beginning with 2011.
SEC. 1155A. MEDPAC STUDY ON VARIATION IN HOME HEALTH MARGINS.
(a) In General.--The Medicare Payment Advisory Commission shall
conduct a study regarding variation in performance of home health
agencies in an effort to explain variation in Medicare margins for such
agencies. Such study shall include an examination of at least the
following issues:
(1) The demographic characteristics of individuals served
and the geographic distribution associated with transportation
costs.
(2) The characteristics of such agencies, such as whether
such agencies operate 24 hours each day, provide charity care,
or are part of an integrated health system.
(3) The socio-economic status of individuals served, such
as the proportion of such individuals who are dually eligible
for Medicare and Medicaid benefits.
(4) The presence of severe and or chronic disease or
disability in individuals served, as evidenced by multiple
discontinuous home health episodes with a high number of visits
per episode.
(5) The differences in services provided, such as therapy
and non-therapy services.
(b) Report.--Not later than June 1, 2011, the Commission shall
submit a report to the Congress on the results of the study conducted
under subsection (a) and shall include in the report the Commission's
conclusions and recommendations, if appropriate, regarding each of the
issues described in paragraphs (1), (2) and (3) of such subsection.
SEC. 1155B. PERMITTING HOME HEALTH AGENCIES TO ASSIGN THE MOST
APPROPRIATE SKILLED SERVICE TO MAKE THE INITIAL
ASSESSMENT VISIT UNDER A MEDICARE HOME HEALTH PLAN OF
CARE FOR REHABILITATION CASES.
(a) In General.--Notwithstanding section 484.55(a)(2) of title 42
of the Code of Federal Regulations or any other provision of law, a
home health agency may determine the most appropriate skilled therapist
to make the initial assessment visit for an individual who is referred
(and may be eligible) for home health services under title XVIII of the
Social Security Act but who does not require skilled nursing care as
long as the skilled service (for which that therapist is qualified to
provide the service) is included as part of the plan of care for home
health services for such individual.
(b) Rule of Construction.--Nothing in subsection (a) shall be
construed to provide for initial eligibility for coverage of home
health services under title XVIII of the Social Security Act on the
basis of a need for occupational therapy.
SEC. 1156. LIMITATION ON MEDICARE EXCEPTIONS TO THE PROHIBITION ON
CERTAIN PHYSICIAN REFERRALS MADE TO 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).'';
(3) by amending subsection (f) to read as follows:
``(f) Reporting and Disclosure Requirements.--
``(1) In general.--Each entity providing covered items or
services for which payment may be made under this title shall
provide the Secretary with the information concerning the
entity's ownership, investment, and compensation arrangements,
including--
``(A) the covered items and services provided by
the entity, and
``(B) the names and unique physician identification
numbers of all physicians with an ownership or
investment interest (as described in subsection
(a)(2)(A)), or with a compensation arrangement (as
described in subsection (a)(2)(B)), in the entity, or
whose immediate relatives have such an ownership or
investment interest or who have such a compensation
relationship with the entity.
Such information shall be provided in such form, manner, and at
such times as the Secretary shall specify. The requirement of
this subsection shall not apply to designated health services
provided outside the United States or to entities which the
Secretary determines provide services for which payment may be
made under this title very infrequently.
``(2) Requirements for hospitals with physician ownership
or investment.--In the case of a hospital that meets the
requirements described in subsection (i)(1), the hospital
shall--
``(A) submit to the Secretary an initial report,
and periodic updates at a frequency determined by the
Secretary, containing a detailed description of the
identity of each physician owner and physician investor
and any other owners or investors of the hospital;
``(B) require that any referring physician owner or
investor discloses to the individual being referred, by
a time that permits the individual to make a meaningful
decision regarding the receipt of services, as
determined by the Secretary, the ownership or
investment interest, as applicable, of such referring
physician in the hospital; and
``(C) disclose the fact that the hospital is
partially or wholly owned by one or more physicians or
has one or more physician investors--
``(i) on any public website for the
hospital; and
``(ii) in any public advertising for the
hospital.
The information to be reported or disclosed under this
paragraph shall be provided in such form, manner, and at such
times as the Secretary shall specify. The requirements of this
paragraph shall not apply to designated health services
furnished outside the United States or to entities which the
Secretary determines provide services for which payment may be
made under this title very infrequently.
``(3) Publication of information.--The Secretary shall
publish, and periodically update, the information submitted by
hospitals under paragraph (2)(A) on the public Internet website
of the Centers for Medicare & Medicaid Services.'';
(4) by amending subsection (g)(5) to read as follows:
``(5) Failure to report or disclose information.--
``(A) Reporting.--Any person who is required, but
fails, to meet a reporting requirement of paragraphs
(1) and (2)(A) of subsection (f) is subject to a civil
money penalty of not more than $10,000 for each day for
which reporting is required to have been made.
``(B) Disclosure.--Any physician who is required,
but fails, to meet a disclosure requirement of
subsection (f)(2)(B) or a hospital that is required,
but fails, to meet a disclosure requirement of
subsection (f)(2)(C) is subject to a civil money
penalty of not more than $10,000 for each case in which
disclosure is required to have been made.
``(C) Application.--The provisions of section 1128A
(other than the first sentence of subsection (a) and
other than subsection (b)) shall apply to a civil money
penalty under subparagraphs (A) and (B) in the same
manner as such provisions apply to a penalty or
proceeding under section 1128A(a).''; and
(5) by adding at the end the following new subsection:
``(i) Requirements to Qualify for Rural Provider and Hospital
Ownership Exceptions to Self-referral Prohibition.--
``(1) Requirements described.--For purposes of subsection
(d)(3)(D), the requirements described in this paragraph are as
follows:
``(A) Provider agreement.--The hospital had--
``(i) physician ownership or investment on
January 1, 2009; and
``(ii) a provider agreement under section
1866 in effect on such date.
``(B) Prohibition on physician ownership or
investment.--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.
``(C) Prohibition on expansion of facility
capacity.--Except as provided in paragraph (2), the
number of operating rooms, procedure rooms, or beds of
the hospital at any time on or after the date of the
enactment of this subsection are no greater than the
number of operating rooms, procedure rooms, or beds,
respectively, as of such date.
``(D) Ensuring bona fide ownership and
investment.--
``(i) Any ownership or investment interests
that the hospital offers to a physician are not
offered on more favorable terms than the terms
offered to a person who is not in a position to
refer patients or otherwise generate business
for the hospital.
``(ii) The hospital (or any investors in
the hospital) does not directly or indirectly
provide loans or financing for any physician
owner or investor in the hospital.
``(iii) The hospital (or any investors in
the hospital) does not directly or indirectly
guarantee a loan, make a payment toward a loan,
or otherwise subsidize a loan, for any
physician owner or investor or group of
physician owners or investors that is related
to acquiring any ownership or investment
interest in the hospital.
``(iv) 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.
``(v) The investment interest of the owner
or investor is directly proportional to the
owner's or investor's capital contributions
made at the time the ownership or investment
interest is obtained.
``(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 a person that
is not a physician owner or investor.
``(viii) 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.
``(E) Patient safety.--In the case of a hospital
that does not offer emergency services, the hospital
has the capacity to--
``(i) provide assessment and initial
treatment for medical emergencies; and
``(ii) if the hospital lacks additional
capabilities required to treat the emergency
involved, refer and transfer the patient with
the medical emergency to a hospital with the
required capability.
``(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) Exception to prohibition on expansion of facility
capacity.--
``(A) Process.--
``(i) Establishment.--The Secretary shall
establish and implement a process under which a
hospital may apply for an exception from the
requirement under paragraph (1)(C).
``(ii) Opportunity for community input.--
The process under clause (i) shall provide
persons and entities in the community in which
the 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 the date that is one month after
the promulgation of regulations described in
clause (iv).
``(iv) Regulations.--Not later than the
first day of the month beginning 18 months
after the date of the enactment of this
subsection, the Secretary shall promulgate
regulations to carry out the process under
clause (i). The Secretary may issue such
regulations as interim final regulations.
``(B) Frequency.--The process described in
subparagraph (A) shall permit a 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), a hospital granted an
exception under the process described in
subparagraph (A) may increase the number of
operating rooms, procedure rooms, or beds of
the hospital above the baseline number of
operating rooms, procedure rooms, or beds,
respectively, of the hospital (or, if the
hospital has been granted a previous exception
under this paragraph, above the number of
operating rooms, procedure rooms, or beds,
respectively, of the hospital 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,
or beds of a hospital under clause (i) to the
extent such increase would result in the number
of operating rooms, procedure rooms, or beds of
the hospital exceeding 200 percent of the
baseline number of operating rooms, procedure
rooms, or beds of the hospital.
``(iii) Baseline number of operating rooms,
procedure rooms, or beds.--In this paragraph,
the term `baseline number of operating rooms,
procedure rooms, or beds' means the number of
operating rooms, procedure rooms, or beds of a
hospital 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, or beds of a hospital
pursuant to this paragraph may only occur in facilities
on the main campus of the hospital.
``(E) Conditions for approval of an increase in
facility capacity.--The Secretary may grant an
exception under the process described in subparagraph
(A) only to a hospital--
``(i) that is located in a county in which
the percentage increase in the population
during the most recent 5-year period for which
data are available is estimated to be 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 and available
to the Secretary;
``(ii) whose annual percent of total
inpatient admissions that represent inpatient
admissions under the program under title XIX is
estimated to be 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
estimated to be less than the national average
bed capacity;
``(v) that has an average bed occupancy
rate that is estimated to be greater than the
average bed occupancy rate in the State in
which the hospital is located; and
``(vi) that meets other conditions as
determined by the Secretary.
``(F) Procedure rooms.--In this subsection, the
term `procedure rooms' includes rooms in which
catheterizations, angiographies, angiograms, and
endoscopies are furnished, but such term shall not
include emergency rooms or departments (except for
rooms in which catheterizations, angiographies,
angiograms, and endoscopies are furnished).
``(G) Publication of final decisions.--Not later
than 120 days after receiving a complete application
under this paragraph, the Secretary shall publish on
the public Internet website of the Centers for Medicare
& Medicaid Services 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 exception process
under this paragraph, including the establishment of
such process, and any determination made under such
process.
``(3) Physician owner or investor defined.--For purposes of
this subsection and subsection (f)(2), 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.
``(4) Patient safety requirement.--In the case of a
hospital to which the requirements of paragraph (1) apply,
insofar as the hospital admits a patient and does not have any
physician available on the premises 24 hours per day, 7 days
per week, before admitting the patient--
``(A) the hospital shall disclose such fact to the
patient; and
``(B) following such disclosure, the hospital shall
receive from the patient a signed acknowledgment that
the patient understands such fact.
``(5) Clarification.--Nothing in this subsection shall be
construed as preventing the Secretary from terminating a
hospital's provider agreement if the hospital is not in
compliance with regulations pursuant to section 1866.''.
(b) Verifying Compliance.--The Secretary of Health and Human
Services shall establish policies and procedures to verify compliance
with the requirements described in subsections (i)(1) and (i)(4) of
section 1877 of the Social Security Act, as added by subsection (a)(5).
The Secretary may use unannounced site reviews of hospitals and audits
to verify compliance with such requirements.
(c) Implementation.--
(1) Funding.--For purposes of carrying out the amendments
made by subsection (a) and the provisions of subsection (b), in
addition to funds otherwise available, out of any funds in the
Treasury not otherwise appropriated there are appropriated to
the Secretary of Health and Human Services for the Centers for
Medicare & Medicaid Services Program Management Account
$5,000,000 for each fiscal year beginning with fiscal year
2010. Amounts appropriated under this paragraph for a fiscal
year shall be available until expended.
(2) Administration.--Chapter 35 of title 44, United States
Code, shall not apply to the amendments made by subsection (a)
and the provisions of subsection (b).
SEC. 1157. INSTITUTE OF MEDICINE STUDY OF GEOGRAPHIC ADJUSTMENT FACTORS
UNDER MEDICARE.
(a) In General.--The Secretary of Health and Human Services shall
enter into a contract with the Institute of Medicine of the National
Academy of Science to conduct a comprehensive empirical study, and
provide recommendations as appropriate, on the accuracy of the
geographic adjustment factors established under sections 1848(e) and
1886(d)(3)(E) of the Social Security Act (42 U.S.C. 1395w-4(e),
1395ww(d)(3)(E)).
(b) Matters Included.--Such study shall include an evaluation and
assessment of the following with respect to such adjustment factors:
(1) Empirical validity of the adjustment factors.
(2) Methodology used to determine the adjustment factors.
(3) Measures used for the adjustment factors, taking into
account--
(A) timeliness of data and frequency of revisions
to such data;
(B) sources of data and the degree to which such
data are representative of costs; and
(C) operational costs of providers who participate
in Medicare.
(c) Evaluation.--Such study shall, within the context of the United
States health care marketplace, evaluate and consider the following:
(1) The effect of the adjustment factors on the level and
distribution of the health care workforce and resources,
including--
(A) recruitment and retention that takes into
account workforce mobility between urban and rural
areas;
(B) ability of hospitals and other facilities to
maintain an adequate and skilled workforce; and
(C) patient access to providers and needed medical
technologies.
(2) The effect of the adjustment factors on population
health and quality of care.
(3) The effect of the adjustment factors on the ability of
providers to furnish efficient, high value care.
(d) Report.--The contract under subsection (a) shall provide for
the Institute of Medicine to submit, not later than 1 year after the
date of the enactment of this Act, to the Secretary and the Congress a
report containing results and recommendations of the study conducted
under this section.
(e) Funding.--There are authorized to be appropriated to carry out
this section such sums as may be necessary.
SEC. 1158. REVISION OF MEDICARE PAYMENT SYSTEMS TO ADDRESS GEOGRAPHIC
INEQUITIES.
(a) Revision of Medicare Payment Systems.--Taking into account the
recommendations described in the report under section 1157, and
notwithstanding the geographic adjustments that would otherwise apply
under section 1848(e) and section 1886(d)(3)(E) of the Social Security
Act (42 U.S.C. 1395w-4(e), 1395ww(d)(3)(E)), the Secretary of Health
and Human Services shall include in proposed rules applicable to the
rulemaking cycle for payment systems for physicians' services and
inpatient hospital services under sections 1848 and section 1886(d) of
such Act, respectively, proposals (as the Secretary determines to be
appropriate) to revise the geographic adjustment factors used in such
systems. Such proposals' rules shall be contained in the next
rulemaking cycle following the submission to the Secretary of the
report described in section 1157.
(b) Payment Adjustments.--
(1) Funding for improvements.--For years before 2014, the
Secretary shall ensure that the additional expenditures
resulting from the implementation of the provisions of this
section, as estimated by the Secretary, do not exceed
$8,000,000,000, and do not exceed half of such amount in any
payment year.
(2) Hold harmless.--In carrying out this subsection--
(A) for payment years before 2014, the Secretary
shall not reduce the geographic adjustment below the
factor that applied for such payment system in the
payment year before such changes; and
(B) for payment years beginning with 2014, the
Secretary shall implement the geographic adjustment in
a manner that does not result in any net change in
aggregate expenditures under title XVIII of the Social
Security Act from the amount of such expenditures that
the Secretary estimates would have occurred if no
geographic adjustment had occurred under this section.
(c) Medicare Improvement Fund.--
(1) Amounts in the Medicare Improvement Fund under section
1898 of the Social Security Act, as amended by paragraph (2),
shall be available to the Secretary to make changes to the
geographic adjustments factors as described in subsections (a)
and (b) with respect to services furnished before January 1,
2014. No more than one-half of such amounts shall be
available with respect to services furnished in any one payment
year.
(2) Section 1898(b) of the Social Security Act (42 U.S.C.
1395iii(b)) is amended--
(A) by amending paragraph (1)(A) to read as
follows:
``(A) the period beginning with fiscal year 2011
and ending with fiscal year 2019, $8,000,000,000;
and''; and
(B) by adding at the end the following new
paragraph:
``(5) Adjustment for underfunding.--For fiscal year 2014 or
a subsequent fiscal year specified by the Secretary, the amount
available to the fund under subsection (a) shall be increased
by the Secretary's estimate of the amount (based on data on
actual expenditures) by which--
``(A) the additional expenditures resulting from
the implementation of subsection (a) of section 1158 of
the Affordable Health Care for America Act for the
period before fiscal year 2014, is less than
``(B) the maximum amount of funds available under
subsection (a) of such section for funding for such
expenditures.''.
SEC. 1159. INSTITUTE OF MEDICINE STUDY OF GEOGRAPHIC VARIATION IN
HEALTH CARE SPENDING AND PROMOTING HIGH-VALUE HEALTH
CARE.
(a) In General.--The Secretary of Health and Human Services (in
this section and the succeeding section referred to as the
``Secretary'') shall enter into an agreement with the Institute of
Medicine of the National Academies (referred to in this section as the
``Institute'') to conduct a study on geographic variation and growth in
volume and intensity of services in per capita health care spending
among the Medicare, Medicaid, privately insured and uninsured
populations. Such study may draw on recent relevant reports of the
Institute and shall include each of the following:
(1) An evaluation of the extent and range of such variation
using various units of geographic measurement, including micro
areas within larger areas.
(2) An evaluation of the extent to which geographic
variation can be attributed to differences in input prices;
health status; practice patterns; access to medical services;
supply of medical services; socio-economic factors, including
race, ethnicity, gender, age, income and educational status;
and provider and payer organizational models.
(3) An evaluation of the extent to which variations in
spending are correlated with patient access to care, insurance
status, distribution of health care resources, health care
outcomes, and consensus-based measures of health care quality.
(4) An evaluation of the extent to which variation can be
attributed to physician and practitioner discretion in making
treatment decisions, and the degree to which discretionary
treatment decisions are made that could be characterized as
different from the best available medical evidence.
(5) An evaluation of the extent to which variation can be
attributed to patient preferences and patient compliance with
treatment protocols.
(6) An assessment of the degree to which variation cannot
be explained by empirical evidence.
(7) For Medicare beneficiaries, An evaluation of the extent
to which variations in spending are correlated with insurance
status prior to enrollment in the Medicare program under title
XVIII of the Social Security Act, and institutionalization
status; whether beneficiaries are dually eligible for the
Medicare program and Medicaid under title XIX of such Act; and
whether beneficiaries are enrolled in fee-for-service Medicare
or Medicare Advantage.
(8) An evaluation of such other factors as the Institute
deems appropriate.
The Institute shall conduct public hearings and provide an opportunity
for comments prior to completion of the reports under subsection (e).
(b) Recommendations.--Taking into account the findings under
subsection (a) and the changes to the payment systems made by this Act,
the Institute shall recommend changes to payment for items and services
under parts A and B of title XVIII of the Social Security Act, for
addressing variation in Medicare per capita spending for items and
services (not including add-ons for graduate medical education,
disproportionate share payments, and health information technology, as
specified in sections 1886(d)(5)(F), 1886(d)(5)(B), 1886(h), 1848(o),
and 1886(n), respectively, of such Act) by promoting high-value care
(as defined in subsection (f)), with particular attention to high-
volume, high-cost conditions. In making such recommendations, the
Institute shall consider each of the following:
(1) Measurement and reporting on quality and population
health.
(2) Reducing fragmented and duplicative care.
(3) Promoting the practice of evidence-based medicine.
(4) Empowering patients to make value-based care decisions.
(5) Leveraging the use of health information technology.
(6) The role of financial and other incentives affecting
provision of care.
(7) Variation in input costs.
(8) The characteristics of the patient population,
including socio-economic factors (including race, ethnicity,
gender, age, income and educational status), and whether the
beneficiaries are dually eligible for the Medicare program
under title XVIII of the Social Security Act and Medicaid under
title XIX of such Act.
(9) Other topics the Institute deems appropriate.
In making such recommendations, the Institute shall consider an
appropriate phase-in that takes into account the impact of payment
changes on providers and facilities and preserves access to care for
Medicare beneficiaries.
(c) Specific Considerations.--In making the recommendations under
subsection (b), the Institute shall specifically address whether
payment systems under title XVIII of the Social Security Act for
physicians and hospitals should be further modified to incentivize
high-value care. In so doing, the Institute shall consider the adoption
of a value index based on a composite of appropriate measures of
quality and cost that would adjust provider payments on a regional or
provider-level basis. If the Institute finds that application of such a
value index would significantly incentivize providers to furnish high-
value care, it shall make specific recommendations on how such an index
would be designed and implemented. In so doing, it should identify
specific measures of quality and cost appropriate for use in such an
index, and include a thorough analysis (including on a geographic
basis) of how payments and spending under such title would be affected
by such an index.
(d) Additional Considerations.--The Institute shall consider the
experience of governmental and community-based programs that promote
high-value care.
(e) Reports.--
(1) Not later than April 15, 2011, the Institute shall
submit to the Secretary and each House of Congress a report
containing findings and recommendations of the study conducted
under this section.
(2) Following submission of the report under paragraph (1),
the Institute shall use the data collected and analyzed in this
section to issue a subsequent report, or series of reports, on
how best to address geographic variation or efforts to promote
high-value care for items and services reimbursed by private
insurance or other programs. Such reports shall include a
comparison to the Institute's findings and recommendations
regarding the Medicare program. Such reports, and any
recommendations, would not be subject to the procedures
outlined in section 1160.
(f) High-value Care Defined.--For purposes of this section, the
term ``high-value care'' means the efficient delivery of high quality,
evidence-based, patient-centered care.
(g) Appropriations.--There is appropriated from amounts in the
general fund of the Treasury not otherwise appropriated $10,000,000 to
carry out this section. Such sums are authorized to remain available
until expended.
SEC. 1160. IMPLEMENTATION, AND CONGRESSIONAL REVIEW, OF PROPOSAL TO
REVISE MEDICARE PAYMENTS TO PROMOTE HIGH VALUE HEALTH
CARE.
(a) Preparation and Submission of Implementation Plans.--
(1) Final implementation plan.--Not later than 240 days
after the date of receipt by the Secretary and each House of
Congress of the report under section 1159(e)(1), the Secretary
shall submit to each House of Congress a final implementation
plan describing proposed changes to payment for items and
services under parts A and B of title XVIII of the Social
Security Act (which may include payment for inpatient and
outpatient hospital services for services furnished in PPS and
PPS-exempt hospitals, physicians' services, dialysis facility
services, skilled nursing facility services, home health
services, hospice care, clinical laboratory services, durable
medical equipment, and other items and services, but which
shall exclude add-on payments for graduate medical education,
disproportionate share payments, and health information
technology, as specified in sections 1886(d)(5)(F),
1886(d)(5)(B), 1886(h), 1848(o), and 1886(n), respectively, of
the Social Security Act) taking into consideration, as
appropriate, the recommendations of the report submitted under
section 1159(e)(1) and the changes to the payment systems made
by this Act. To the extent such implementation plan requires a
substantial change to the payment system, it shall include a
transition phase-in that takes into consideration possible
disruption to provider participation in the Medicare program
under title XVIII of the Social Security Act and preserves
access to care for Medicare beneficiaries.
(2) Preliminary implementation plan.--Not later than 90
days after the date the Institute of Medicine submits to each
House of Congress the report under section 1159(e)(1), the
Secretary shall submit to each House of Congress a preliminary
version of the implementation plan provided for under paragraph
(1)(A).
(3) No increase in budget expenditures.--The Secretary
shall include with the submission of the final implementation
plan under paragraph (1) a certification by the Chief Actuary
of the Centers for Medicare & Medicaid Services that over the
initial 10-year period in which the plan is implemented, the
aggregate level of net expenditures under the Medicare program
under title XVIII of the Social Security Act will not exceed
the aggregate level of such expenditures that would have
occurred if the plan were not implemented.
(4) Waivers required.--To the extent the final
implementation plan under paragraph (1) proposes changes that
are not otherwise permitted under title XVIII of the Social
Security Act, the Secretary shall specify in the plan the
specific waivers required under such title to implement such
changes. Except as provided in subsection (c), the Secretary is
authorized to waive the requirements so specified in order to
implement such changes.
(5) Assessment of impact.--In addition, both the
preliminary and final implementation plans under this
subsection shall include a detailed assessment of the effects
of the proposed payment changes by provider or supplier type
and State relative to the payments that would otherwise apply.
(b) Review by MedPAC and GAO.--Not later than 45 days after the
date the preliminary implementation plan is received by each House of
Congress under subsection (a)(2), the Medicare Payment Advisory
Committee and the Comptroller General of the United States shall each
evaluate such plan and submit to each House of Congress a report
containing its analysis and recommendations regarding implementation of
the plan, including an analysis of the effects of the proposed changes
in the plan on payments and projected spending.
(c) Implementation.--
(1) In general.--The Secretary shall include, in applicable
proposed rules for the next rulemaking cycle beginning after
the Congressional action deadline, appropriate proposals to
revise payments under title XVIII of the Social Security Act in
accordance with the final implementation plan submitted under
subsection (a)(1), and the waivers specified in subsection
(a)(4) to the extent required to carry out such plan are
effective, unless a joint resolution (described in subsection
(d)(5)(A)) with respect to such plan is enacted by not later
than such deadline. If such a joint resolution is enacted, the
Secretary is not authorized to implement such plan and the
waiver authority provided under subsection (a)(4) shall no
longer be effective.
(2) Congressional action deadline.--For purposes of this
section, the term ``Congressional action deadline'' means, with
respect to a final implementation plan under subsection (a)(1),
May 31, 2012, or, if later, the date that is 145 days after the
date of receipt of such plan by each House of Congress under
subsection (a).
(d) Congressional Procedures.--
(1) Introduction.--On the day on which the final
implementation plan is received by the House of Representatives
and the Senate under subsection (a), a joint resolution
specified in paragraph (5)(A) shall be introduced in the House
of Representatives by the majority leader and minority leader
of the House of Representatives and in the Senate by the
majority leader and minority leader of the Senate. If either
House is not in session on the day on which such a plan is
received, the joint resolution with respect to such plan shall
be introduced in that House, as provided in the preceding
sentence, on the first day thereafter on which that House is in
session.
(2) Consideration in the house of representatives.--
(A) Reporting and discharge.--Any committee of the
House of Representatives to which a joint resolution
introduced under paragraph (1) is referred shall report
such joint resolution to the House not later than 50
legislative days after the applicable date of
introduction of the joint resolution. If a committee
fails to report such joint resolution within that
period, a motion to discharge the committee from
further consideration of the joint resolution shall be
in order. Such a motion shall be in order only at a
time designated by the Speaker in the legislative
schedule within two legislative days after the day on
which the proponent announces an intention to offer the
motion. Notice may not be given on an anticipatory
basis. Such a motion shall not be in order after the
last committee authorized to consider the joint
resolution reports it to the House or after the House
has disposed of a motion to discharge the joint
resolution. The previous question shall be considered
as ordered on the motion to its adoption without
intervening motion except 20 minutes of debate equally
divided and controlled by the proponent and an
opponent. A motion to reconsider the vote by which the
motion is disposed of shall not be in order.
(B) Proceeding to consideration.--After each
committee authorized to consider a joint resolution
reports such joint resolution to the House of
Representatives or has been discharged from its
consideration, a motion to proceed to consider such
joint resolution shall be in order. Such a motion shall
be in order only at a time designated by the Speaker in
the legislative schedule within two legislative days
after the day on which the proponent announces an
intention to offer the motion. Notice may not be given
on an anticipatory basis. Such a motion shall not be in
order after the House of Representatives has disposed
of a motion to proceed on the joint resolution. The
previous question shall be considered as ordered on the
motion to its adoption without intervening motion. A
motion to reconsider the vote by which the motion is
disposed of shall not be in order.
(C) Consideration.--The joint resolution shall be
considered in the House and shall be considered as
read. All points of order against a joint resolution
and against its consideration are waived. The previous
question shall be considered as ordered on the joint
resolution to its passage without intervening motion
except two hours of debate equally divided and
controlled by the proponent and an opponent. A motion
to reconsider the vote on passage of a joint resolution
shall not be in order.
(3) Consideration in the senate.--
(A) Reporting and discharge.--Any committee of the
Senate to which a joint resolution introduced under
paragraph (1) is referred shall report such joint
resolution to the Senate within 50 legislative days. If
a committee fails to report such joint resolution at
the close of the 15th legislative day after its receipt
by the Senate, such committee shall be automatically
discharged from further consideration of such joint
resolution and such joint resolution or joint
resolutions shall be placed on the calendar. A vote on
final passage of such joint resolution shall be taken
in the Senate on or before the close of the second
legislative day after such joint resolution is reported
by the committee or committees of the Senate to which
it was referred, or after such committee or committees
have been discharged from further consideration of such
joint resolution.
(B) Proceeding to consideration.--A motion in the
Senate to proceed to the consideration of a joint
resolution shall be privileged and not debatable. An
amendment to such a motion shall not be in order, nor
shall it be in order to move to reconsider the vote by
which such a motion is agreed to or disagreed to.
(C) Consideration.--
(i) Debate in the Senate on a joint
resolution, and all debatable motions and
appeals in connection therewith, shall be
limited to not more than 20 hours. The time
shall be equally divided between, and
controlled by, the majority leader and the
minority leader or their designees.
(ii) Debate in the Senate on any debatable
motion or appeal in connection with a joint
resolution shall be limited to not more than 1
hour, to be equally divided between, and
controlled by, the mover and the manager of the
resolution, except that in the event the
manager of the joint resolution is in favor of
any such motion or appeal, the time in
opposition thereto shall be controlled by the
minority leader or a designee. Such leaders, or
either of them, may, from time under their
control on the passage of a joint resolution,
allot additional time to any Senator during the
consideration of any debatable motion or
appeal.
(iii) A motion in the Senate to further
limit debate is not debatable. A motion to
recommit a joint resolution is not in order.
(4) Rules relating to senate and house of
representatives.--
(A) Coordination with action by other house.--If,
before the passage by one House of a joint resolution
of that House, that House receives from the other House
a joint resolution, 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 the joint resolution
of the House receiving the resolution, the
procedure in that House shall be the same as if
no such joint resolution had been received from
the other House; but the vote on passage shall
be on the joint resolution of the other House.
(B) Treatment of companion measures.--If, following
passage of a joint resolution in the Senate, the Senate
then receives the companion measure from the House of
Representatives, the companion measure shall not be
debatable.
(C) Rules of house of representatives and senate.--
This paragraph and the preceding paragraphs are enacted
by Congress--
(i) as an exercise of the rulemaking power
of the Senate and House of Representatives,
respectively, and as such it is deemed a 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 a
joint resolution, and it supersedes other rules
only to the extent that it is inconsistent with
such rules; and
(ii) with full recognition of the
constitutional right of either House to change
the rules (so far as relating 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.
(5) Definitions.--In this section:
(A) Joint resolution.--The term ``joint
resolution'' means only a joint resolution--
(i) which does not have a preamble;
(ii) the title of which is as follows:
``Joint resolution disapproving a Medicare
final implementation plan of the Secretary of
Health and Human Services submitted under
section 1160(a) of the Affordable Health Care
for America Act''; and
(iii) the sole matter after the resolving
clause of which is as follows: ``That the
Congress disapproves the final implementation
plan of the Secretary of Health and Human
Services transmitted to the Congress on--------
--.'', the blank space being filled with the
appropriate date.
(B) Legislative day.--The term ``legislative day''
means any calendar day excluding any day on which that
House was not in session.
(6) Budgetary treatment.--For the purposes of consideration
of a joint resolution, the Chairmen of the House of
Representatives and Senate Committees on the Budget shall
exclude from the evaluation of the budgetary effects of the
measure, any such effects that are directly attributable to
disapproving a Medicare final implementation plan of the
Secretary submitted under subsection (a).
Subtitle D--Medicare Advantage Reforms
PART 1--PAYMENT AND ADMINISTRATION
SEC. 1161. PHASE-IN OF PAYMENT BASED ON FEE-FOR-SERVICE COSTS; QUALITY
BONUS PAYMENTS.
(a) Phase-in of Payment Based on Fee-for-service Costs.--Section
1853 of the Social Security Act (42 U.S.C. 1395w-23) is amended--
(1) in subsection (j)(1)(A)--
(A) by striking ``beginning with 2007'' and
inserting ``for 2007, 2008, 2009, and 2010''; and
(B) by inserting after ``(k)(1)'' the following:
``, or, beginning with 2011, \1/12\ of the blended
benchmark amount determined under subsection (n)(1)'';
and
(2) by adding at the end the following new subsection:
``(n) Determination of Blended Benchmark Amount.--
``(1) In general.--For purposes of subsection (j), subject
to paragraphs (3) and (4), the term `blended benchmark amount'
means for an area--
``(A) for 2011 the sum of--
``(i) \2/3\ of the applicable amount (as
defined in subsection (k)) for the area and
year; and
``(ii) \1/3\ of the amount specified in
paragraph (2) for the area and year;
``(B) for 2012 the sum of--
``(i) \1/3\ of the applicable amount for
the area and year; and
``(ii) \2/3\ of the amount specified in
paragraph (2) for the area and year; and
``(C) for a subsequent year the amount specified in
paragraph (2) for the area and year.
``(2) Specified amount.--The amount specified in this
paragraph for an area and year is the amount specified in
subsection (c)(1)(D)(i) for the area and year adjusted (in a
manner specified by the Secretary) to take into account the
phase-out in the indirect costs of medical education from
capitation rates described in subsection (k)(4).
``(3) Fee-for-service payment floor.--In no case shall the
blended benchmark amount for an area and year be less than the
amount specified in paragraph (2).
``(4) Exception for pace plans.--This subsection shall not
apply to payments to a PACE program under section 1894.''.
(b) Quality Bonus Payments.--Section 1853 of the Social Security
Act (42 U.S.C. 1395w-23), as amended by subsection (a), is amended--
(1) in subsection (j), by inserting ``subject to subsection
(o),'' after ``For purposes of this part,''; and
(2) by adding at the end the following new subsection:
``(o) Quality Based Payment Adjustment.--
``(1) In general.--In the case of a qualifying plan in a
qualifying county with respect to a year beginning with 2011,
the blended benchmark amount under subsection (n)(1) shall be
increased--
``(A) for 2011, by 1.5 percent;
``(B) for 2012, by 3.0 percent; and
``(C) for a subsequent year, by 5.0 percent.
``(2) Qualifying plan and qualifying county defined.--For
purposes of this subsection:
``(A) Qualifying plan.--The term `qualifying plan'
means, for a year and subject to paragraph (4), a plan
that, in a preceding year specified by the Secretary,
had a quality ranking (based on the quality ranking
system established by the Centers for Medicare &
Medicaid Services for Medicare Advantage plans) of 4
stars or higher.
``(B) Qualifying county.--The term `qualifying
county' means, for a year, a county--
``(i) that ranked within the lowest third
of counties in the amount specified in
subsection (n)(2) for a year specified by the
Secretary; and
``(ii) for which, as of June of a year
specified by the Secretary, of the Medicare
Advantage eligible individuals residing in the
county at least 20 percent of such individuals
were enrolled in Medicare Advantage plans.
``(3) Determinations of quality.--
``(A) Quality performance.--The Secretary shall
provide for the computation of a quality performance
score for each Medicare Advantage plan to be applied
for each year.
``(B) Computation of score.--
``(i) Quality performance sore.--For years
before a year specified by the Secretary, the
quality performance score for a Medicare
Advantage plan shall be computed based on a
blend (as designated by the Secretary) of the
plan's performance on--
``(I) HEDIS effectiveness of care
quality measures;
``(II) CAHPS quality measures; and
``(III) such other measures of
clinical quality as the Secretary may
specify.
Such measures shall be risk-adjusted as the
Secretary deems appropriate.
``(ii) Establishment of outcome-based
measures.--By not later than for a year
specified by the Secretary, the Secretary shall
implement reporting requirements for quality
under this section on measures selected under
clause (iii) that reflect the outcomes of care
experienced by individuals enrolled in Medicare
Advantage plans (in addition to measures
described in clause (i)). Such measures may
include--
``(I) measures of rates of
admission and readmission to a
hospital;
``(II) measures of prevention
quality, such as those established by
the Agency for Healthcare Research and
Quality (that include hospital
admission rates for specified
conditions);
``(III) measures of patient
mortality and morbidity following
surgery;
``(IV) measures of health
functioning (such as limitations on
activities of daily living) and
survival for patients with chronic
diseases;
``(V) measures of patient safety;
and
``(VI) other measure of outcomes
and patient quality of life as
determined by the Secretary.
Such measures shall be risk-adjusted as the
Secretary deems appropriate. In determining the
quality measures to be used under this clause,
the Secretary shall take into consideration the
recommendations of the Medicare Payment
Advisory Commission in its report to Congress
under section 168 of the Medicare Improvements
for Patients and Providers Act of 2008 (Public
Law 110-275) and shall provide preference to
measures collected on and comparable to
measures used in measuring quality under parts
A and B.
``(iii) Rules for selection of measures.--
The Secretary shall select measures for
purposes of clause (ii) consistent with the
following:
``(I) The Secretary shall provide
preference to clinical quality measures
that have been endorsed by the entity
with a contract with the Secretary
under section 1890(a).
``(II) Prior to any measure being
selected under this clause, the
Secretary shall publish in the Federal
Register such measure and provide for a
period of public comment on such
measure.
``(iv) Transitional use of blend.--For
payments for years specified by the Secretary,
the Secretary may compute the quality
performance score for a Medicare Advantage plan
based on a blend of the measures specified in
clause (i) and the measures described in clause
(ii) and selected under clause (iii).
``(v) Use of quality outcomes measures.--
For payments beginning with a year specified by
the Secretary (beginning after the years
specified for section (iv)), the preponderance
of measures used under this paragraph shall be
quality outcomes measures described in clause
(ii) and selected under clause (iii).
``(C) Reporting of data.--Each Medicare Advantage
organization shall provide for the reporting to the
Secretary of quality performance data described in this
paragraph (in order to determine a quality performance
score under this paragraph) in such time and manner as
the Secretary shall specify.
``(4) Notification.--The Secretary, in the annual
announcement required under subsection (b)(1)(B) in 2010 and
each succeeding year, shall notify the Medicare Advantage
organization that is offering a qualifying plan in a qualifying
county of such identification for the year. The Secretary shall
provide for publication on the website for the Medicare program
of the information described in the previous sentence.
``(5) Authority to disqualify deficient plans.--The
Secretary may determine that a Medicare Advantage plan is not a
qualifying plan if the Secretary has identified deficiencies in
the plan's compliance with rules for Medicare Advantage plans
under this part.''.
SEC. 1162. AUTHORITY FOR SECRETARIAL CODING INTENSITY ADJUSTMENT
AUTHORITY.
Section 1853(a)(1)(C)(ii) of the Social Security Act (42 U.S.C.
1395w-23(a)(1)(C)(ii) is amended--
(1) in the matter before subclause (I), by striking
``through 2010'' and inserting ``and each subsequent year'';
and
(2) in subclause (II)--
(A) by inserting ``periodically'' before ``conduct
an analysis'';
(B) by inserting ``on a timely basis'' after ``are
incorporated''; and
(C) by striking ``only for 2008, 2009, and 2010''
and inserting ``for 2008 and subsequent years''.
SEC. 1163. SIMPLIFICATION OF ANNUAL BENEFICIARY ELECTION PERIODS.
(a) 2 Week Processing Period for Annual Enrollment Period (AEP).--
Paragraph (3)(B) of section 1851(e) of the Social Security Act (42
U.S.C. 1395w-21(e)) is amended--
(1) by striking ``and'' at the end of clause (iii);
(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 2011 and succeeding
years, the period beginning on November 1 and
ending on December 15 of the year before such
year.''.
(b) Elimination of 3-month Additional Open Enrollment Period
(OEP).--Effective for plan years beginning with 2011, paragraph (2) of
such section is amended by striking subparagraph (C).
SEC. 1164. EXTENSION OF REASONABLE COST CONTRACTS.
Section 1876(h)(5)(C) of the Social Security Act (42 U.S.C.
1395mm(h)(5)(C)) is amended--
(1) in clause (ii), by striking ``January 1, 2010'' and
inserting ``January 1, 2012''; and
(2) in clause (iii), by striking ``the service area for the
year'' and inserting ``the portion of the plan's service area
for the year that is within the service area of a reasonable
cost reimbursement contract''.
SEC. 1165. LIMITATION OF WAIVER AUTHORITY FOR EMPLOYER GROUP PLANS.
(a) In General.--The first sentence of each of paragraphs (1) and
(2) of section 1857(i) of the Social Security Act (42 U.S.C. 1395w-
27(i)) is amended by inserting before the period at the end the
following: ``, but only if 90 percent of the Medicare Advantage
eligible individuals enrolled under such plan reside in a county in
which the MA organization offers an MA local plan''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply for plan years beginning on or after January 1, 2011, and shall
not apply to plans which were in effect as of December 31, 2010.
SEC. 1166. IMPROVING RISK ADJUSTMENT FOR PAYMENTS.
(a) Report to Congress.--Not later than 1 year after the date of
the enactment of this Act, the Secretary of Health and Human Services
shall submit to Congress a report that evaluates the adequacy of the
risk adjustment system under section 1853(a)(1)(C) of the Social
Security Act (42 U.S.C. 1395-23(a)(1)(C)) in predicting costs for
beneficiaries with chronic or co-morbid conditions, beneficiaries
dually-eligible for Medicare and Medicaid, and non-Medicaid eligible
low-income beneficiaries; and the need and feasibility of including
further gradations of diseases or conditions and multiple years of
beneficiary data.
(b) Improvements to Risk Adjustment.--Not later than January 1,
2012, the Secretary shall implement necessary improvements to the risk
adjustment system under section 1853(a)(1)(C) of the Social Security
Act (42 U.S.C. 1395-23(a)(1)(C)), taking into account the evaluation
under subsection (a).
SEC. 1167. ELIMINATION OF MA REGIONAL PLAN STABILIZATION FUND.
(a) In General.--Section 1858 of the Social Security Act (42 U.S.C.
1395w-27a) is amended by striking subsection (e).
(b) 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. 1168. STUDY REGARDING THE EFFECTS OF CALCULATING MEDICARE
ADVANTAGE PAYMENT RATES ON A REGIONAL AVERAGE OF MEDICARE
FEE FOR SERVICE RATES.
(a) In General.--The Administrator of the Centers for Medicare and
Medicaid Services shall conduct a study to determine the potential
effects of calculating Medicare Advantage payment rates on a more
aggregated geographic basis (such as metropolitan statistical areas or
other regional delineations) rather than using county boundaries. In
conducting such study, the Administrator shall consider the effect of
such alternative geographic basis on the following:
(1) The quality of care received by Medicare Advantage
enrollees.
(2) The networks of Medicare Advantage plans, including any
implications for providers contracting with Medicare Advantage
plans.
(3) The predictability of benchmark amounts for Medicare
advantage plans.
(b) Consultations.--In conducting the study, the Administrator
shall consult with the following:
(1) Experts in health care financing.
(2) Representatives of foundations and other nonprofit
entities that have conducted or supported research on Medicare
financing issues.
(3) Representatives from Medicare Advantage plans.
(4) Such other entities or people as determined by the
Secretary.
(c) Report.--Not later than one year after the date of the
enactment of this Act, the Administrator shall transmit a report to the
Congress on the study conducted under this section. The report shall
contain a detailed statement of findings and conclusions of the study,
together with its recommendations for such legislation and
administrative actions as the Administrator considers appropriate.
PART 2--BENEFICIARY PROTECTIONS AND ANTI-FRAUD
SEC. 1171. LIMITATION ON COST-SHARING FOR INDIVIDUAL HEALTH SERVICES.
(a) In General.--Section 1852(a)(1) of the Social Security Act (42
U.S.C. 1395w-22(a)(1)) is amended--
(1) in subparagraph (A), by inserting before the period at
the end the following: ``with cost-sharing that is no greater
(and may be less) than the cost-sharing that would otherwise be
imposed under such program option'';
(2) in subparagraph (B)(i), by striking ``or an actuarially
equivalent level of cost-sharing as determined in this part'';
and
(3) by amending clause (ii) of subparagraph (B) to read as
follows:
``(ii) Permitting use of flat copayment or
per diem rate.--Nothing in clause (i) shall be
construed as prohibiting a Medicare Advantage
plan from using a flat copayment or per diem
rate, in lieu of the cost-sharing that would be
imposed under part A or B, so long as the
amount of the cost-sharing imposed does not
exceed the amount of the cost-sharing that
would be imposed under the respective part if
the individual were not enrolled in a plan
under this part.''.
(b) Limitation for Dual Eligibles and Qualified Medicare
Beneficiaries.--Section 1852(a)(7) of such Act is amended to read as
follows:
``(7) Limitation on cost-sharing for dual eligibles and
qualified medicare beneficiaries.--In the case of a individual
who is a full-benefit dual eligible individual (as defined in
section 1935(c)(6)) or a qualified medicare beneficiary (as
defined in section 1905(p)(1)) who is enrolled in a Medicare
Advantage plan, the plan may not impose cost-sharing that
exceeds the amount of cost-sharing that would be permitted with
respect to the individual under this title and title XIX if the
individual were not enrolled with such plan.''.
(c) Effective Dates.--
(1) The amendments made by subsection (a) shall apply to
plan years beginning on or after January 1, 2011.
(2) The amendments made by subsection (b) shall apply to
plan years beginning on or after January 1, 2011.
SEC. 1172. CONTINUOUS OPEN ENROLLMENT FOR ENROLLEES IN PLANS WITH
ENROLLMENT SUSPENSION.
Section 1851(e)(4) of the Social Security Act (42 U.S.C.
1395w(e)(4)) is amended--
(1) in subparagraph (C), by striking at the end ``or'';
(2) in subparagraph (D)--
(A) by inserting ``, taking into account the health
or well-being of the individual'' before the period;
and
(B) by redesignating such subparagraph as
subparagraph (E); and
(3) by inserting after subparagraph (C) the following new
subparagraph:
``(D) the individual is enrolled in an MA plan and
enrollment in the plan is suspended under paragraph
(2)(B) or (3)(C) of section 1857(g) because of a
failure of the plan to meet applicable requirements;
or''.
SEC. 1173. INFORMATION FOR BENEFICIARIES ON MA PLAN ADMINISTRATIVE
COSTS.
(a) Disclosure of Medical Loss Ratios and Other Expense Data.--
Section 1851 of the Social Security Act (42 U.S.C. 1395w-21), as
previously amended by this subtitle, is amended by adding at the end
the following new subsection:
``(p) Publication of Medical Loss Ratios and Other Cost-related
Information.--
``(1) In general.--The Secretary shall publish, not later
than November 1 of each year (beginning with 2011), for each MA
plan contract, the medical loss ratio of the plan in the
previous year.
``(2) Submission of data.--
``(A) In general.--Each MA organization shall
submit to the Secretary, in a form and manner specified
by the Secretary, data necessary for the Secretary to
publish the medical loss ratio on a timely basis.
``(B) Data for 2010 and 2011.--The data submitted
under subparagraph (A) for 2010 and for 2011 shall be
consistent in content with the data reported as part of
the MA plan bid in June 2009 for 2010.
``(C) Use of standardized elements and
definitions.--The data to be submitted under
subparagraph (A) relating to medical loss ratio for a
year, beginning with 2012, shall be submitted based on
the standardized elements and definitions developed
under paragraph (3).
``(3) Development of data reporting standards.--
``(A) In general.--The Secretary shall develop and
implement standardized data elements and definitions
for reporting under this subsection, for contract years
beginning with 2012, of data necessary for the
calculation of the medical loss ratio for MA plans. Not
later than December 31, 2010, the Secretary shall
publish a report describing the elements and
definitions so developed.
``(B) Consultation.--The Secretary shall consult
with the Health Choices Commissioner, representatives
of MA organizations, experts on health plan accounting
systems, and representatives of the National
Association of Insurance Commissioners, in the
development of such data elements and definitions.
``(4) Medical loss ratio to be defined.--For purposes of
this part, the term `medical loss ratio' has the meaning given
such term by the Secretary, taking into account the meaning
given such term by the Health Choices Commissioner under
section 116 of the Affordable Health Care for America Act.''.
(b) Minimum Medical Loss Ratio.--Section 1857(e) of the Social
Security Act (42 U.S.C. 1395w-27(e)) is amended by adding at the end
the following new paragraph:
``(4) Requirement for minimum medical loss ratio.--If the
Secretary determines for a contract year (beginning with 2014)
that an MA plan has failed to have a medical loss ratio (as
defined in section 1851(p)(4)) of at least .85--
``(A) the Secretary shall require the Medicare
Advantage organization offering the plan to give
enrollees a rebate (in the second succeeding contract
year) of premiums under this part (or part B or part D,
if applicable) by such amount as would provide for a
benefits ratio of at least .85;
``(B) for 3 consecutive contract years, the
Secretary shall not permit the enrollment of new
enrollees under the plan for coverage during the second
succeeding contract year; and
``(C) the Secretary shall terminate the plan
contract if the plan fails to have such a medical loss
ratio for 5 consecutive contract years.''.
SEC. 1174. STRENGTHENING AUDIT AUTHORITY.
(a) For Part C Payments Risk Adjustment.--Section 1857(d)(1) of the
Social Security Act (42 U.S.C. 1395w-27(d)(1)) is amended by inserting
after ``section 1858(c))'' the following: ``, and data submitted with
respect to risk adjustment under section 1853(a)(3)''.
(b) Enforcement of Audits and Deficiencies.--
(1) In general.--Section 1857(e) of such Act, as amended by
section 1173, is amended by adding at the end the following new
paragraph:
``(5) Enforcement of audits and deficiencies.--
``(A) Information in contract.--The Secretary shall
require that each contract with an MA organization
under this section shall include terms that inform the
organization of the provisions in subsection (d).
``(B) Enforcement authority.--The Secretary is
authorized, in connection with conducting audits and
other activities under subsection (d), to take such
actions, including pursuit of financial recoveries,
necessary to address deficiencies identified in such
audits or other activities.''.
(2) Application under part d.--For provision applying the
amendment made by paragraph (1) to prescription drug plans
under part D, see section 1860D-12(b)(3)(D) of the Social
Security Act.
(c) Effective Date.--The amendments made by this section shall take
effect on the date of the enactment of this Act and shall apply to
audits and activities conducted for contract years beginning on or
after January 1, 2011.
SEC. 1175. 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.--Nothing in this section
shall be construed as requiring the Secretary to accept
any or every bid by an MA organization under this
subsection.''.
(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 under this section in
the same manner as it applies to bids by an MA organization
under such section.''.
(c) Effective Date.--The amendments made by this section shall
apply to bids for contract years beginning on or after January 1, 2011.
SEC. 1175A. STATE AUTHORITY TO ENFORCE STANDARDIZED MARKETING
REQUIREMENTS.
Section 1856(b)(3) of the Social Security Act (42 U.S.C. 1395w-
26(b)(3)) is amended--
(1) by striking ``The standards'' and inserting ``(A) in
general.--The standards'' with appropriate indentation that is
the same as for the subparagraph (B) added by paragraph (2);
and
(2) by adding at the end the following new subparagraph:
``(B) Enforcement of federal standards permitted.--
``(i) In general.--Subject to the
subsequent provision of this subparagraph,
nothing in this title shall be construed to
prohibit a State from conducting a market
conduct examination or from imposing civil
monetary penalties, in accordance with laws and
procedures of the State, against Medicare
Advantage organizations, PDP sponsors, or
agents or brokers of such organizations or
sponsors for violations of the marketing
requirements under subsections (h)(4), (h)(6),
and (j) of section 1851 and section
1857(g)(1)(E).
``(ii) Additional remedies resulting from
federal-state cooperation.--
``(I) State recommendation.--A
State may recommend to the Secretary
the imposition of an intermediate
sanction not described in clause (i)
(such as those available under section
1857(g)) against a Medicare Advantage
organization, PDP sponsor, or agent or
broker of such an organization or
sponsor for a violation described in
such clause.
``(II) Response to
recommendation.--Not later than 30 days
after receipt of a recommendation under
subclause (I) from a State, with
respect to a violation described in
clause (i), the Secretary shall respond
in writing to the State indicating the
progress of any investigation involving
such violation, whether the Secretary
intends to pursue the recommendation
from the State, and in the case the
Secretary does not intend to pursue
such recommendation, the reason for
such decision.
``(iii) Non-duplication of penalties.--In
the case that an action has been initiated
against a Medicare Advantage organization, PDP
sponsor, or agent or broker of such an
organization or sponsor for a violation of a
marketing requirement under subsection (h)(4),
(h)(6), or (j) of section 1851 or section
1857(g)(1)(E)--
``(I) in the case such action has
been initiated by the Secretary, no
State may bring an action under such
applicable subsection or section
against such organization, sponsor,
agent, or broker with respect to such
violation during the pendency period of
the action initiated by the Secretary
and, if a penalty is imposed pursuant
to such action, after such period; and
``(II) in the case such action has
been initiated by a State, the
Secretary may not bring an action under
such applicable subsection or section
against such organization, sponsor,
agent, or broker with respect to such
violation during the pendency period of
the action initiated by the Secretary
and, if a penalty is imposed pursuant
to such action, after such period.
Nothing in this clause shall be construed as
limiting the ability of the Secretary to impose
any sanction other than a civil monetary
penalty under section 1857 against a Medicare
Advantage organization, PDP sponsor, or agent
or broker of such an organization or sponsor
for a violation described in clause (i).
``(iv) Construction.--Nothing in this
subparagraph shall be construed as affecting
any State authority to regulate brokers
described in this paragraph or any other
conduct of a Medicare Advantage organization or
PDP sponsor.''.
PART 3--TREATMENT OF SPECIAL NEEDS PLANS
SEC. 1176. LIMITATION ON ENROLLMENT OUTSIDE OPEN ENROLLMENT PERIOD OF
INDIVIDUALS INTO CHRONIC CARE SPECIALIZED MA PLANS FOR
SPECIAL NEEDS INDIVIDUALS.
Section 1859(f)(4) of the Social Security Act (42 U.S.C. 1395w-
28(f)(4)) is amended by adding at the end the following new
subparagraph:
``(C) The plan does not enroll an individual on or
after January 1, 2011, other than--
``(i) during an annual, coordinated open
enrollment period; or
``(ii) during a special election period
consisting of the period for which the
individual has a chronic condition that
qualifies the individual as an individual
described in subsection (b)(6)(B)(iii) for such
plan and ending on the date on which the
individual enrolls in such a plan on the basis
of such condition.
If an individual is enrolled in such a plan on the
basis of a chronic condition and becomes eligible for
another such plan on the basis of another chronic
condition, the other plan may enroll the individual on
the basis of such other chronic condition during a
special enrollment period described in clause (ii). An
individual is eligible to apply such clause only once
on the basis of any specific chronic condition.''.
SEC. 1177. EXTENSION OF AUTHORITY OF SPECIAL NEEDS PLANS TO RESTRICT
ENROLLMENT; SERVICE AREA MORATORIUM FOR CERTAIN SNPS.
(a) In General.--Section 1859(f)(1) of the Social Security Act (42
U.S.C. 1395w-28(f)(1)) is amended by striking ``January 1, 2011'' and
inserting ``January 1, 2013 (or January 1, 2016, in the case of a plan
described in section 1177(b)(1) of the Affordable Health Care for
America Act)''.
(b) Extension of Certain Plans.--
(1) Plans described.--For purposes of Section 1859(f)(1) of
the Social Security Act (42 U.S.C. 1395w-28(f)(1)), a plan
described in this paragraph is a Medicare Advantage dual
eligible special needs plan that--
(A) whose sponsoring Medicare Advantage
organization, as of the date enactment of the
Affordable Health Care for America Act, has a contract
with a State Medicaid Agency that participated in the
``Demonstrations Serving Those Dually-Eligible for
Medicare and Medicaid'' under the Medicare program; and
(B) that has been approved by the Centers for
Medicare & Medicaid Services as a dual eligible special
needs plan and that offers integrated Medicare and
Medicaid services under a contract with the State
Medicaid agency.
(2) Analysis; report.--
(A) Analysis.--The Secretary of Health and Human
Services shall provide, through a contract with an
independent health services evaluation organization,
for an analysis of the plans described in paragraph (1)
with regard to the impact of such plans on cost,
quality of care, patient satisfaction, and other
subjects specified by the Secretary. Such report also
will identify statutory changes needed to simplify
access to needed services, improve coordination of
benefits and services and ensure protection for dual
eligibles as appropriate.
(B) Report.--Not later than December 31, 2011, the
Secretary shall submit to the Congress a report on the
analysis under subparagraph (A) and shall include in
such report such recommendations with regard to the
treatment of such plans as the Secretary deems
appropriate.
(c) Extension of Service Area Moratorium for Certain SNPs.--Section
164(c)(2) of the Medicare Improvements for Patients and Providers Act
of 2008 is amended by striking ``December 31, 2010'' and inserting
``December 31, 2012''.
SEC. 1178. EXTENSION OF MEDICARE SENIOR HOUSING PLANS.
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.--Notwithstanding any other provision of
this part, in the case of a Medicare Advantage senior housing
facility plan described in paragraph (2) and for periods before
January 1, 2013--
``(A) the service area of such plan may be limited
to a senior housing facility in a geographic area;
``(B) the service area of such plan may not be
expanded; and
``(C) additional senior housing facilities may not
be serviced by such plan.
``(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)(i) 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));
``(ii) provides primary care services onsite and
has a ratio of accessible providers to beneficiaries
that the Secretary determines is adequate, taking into
consideration the number of residents onsite, the
health needs of those residents, and the accessibility
of providers offsite; and
``(iii) provides transportation services for
beneficiaries to providers outside of the facility; and
``(B) is offered by a Medicare Advantage
organization that has offered at least 1 plan described
in subparagraph (A) for at least 1 year prior to
January 1, 2010, under a demonstration project
established by the Secretary.''.
Subtitle E--Improvements to Medicare Part D
SEC. 1181. ELIMINATION OF COVERAGE GAP.
(a) 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 plan years beginning during
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.''.
(b) Additional Closure in Gap Beginning in 2011.--Section 1860D-
2(b) of such Act (42 U.S.C. 1395w-102(b)) as amended by subsection (a),
is further amended--
(1) in paragraph (3)(A), by striking ``and (7)'' and
inserting ``, (7), and (8)'' ;
(2) in paragraph (4)(B)(i), by inserting ``subject to
paragraph (8)'' after ``purposes of this part''; and
(3) by adding at the end the following new paragraph:
``(8) Phased-in elimination of coverage gap.--
``(A) In general.--For each year beginning with
2011, the Secretary shall consistent with this
paragraph progressively increase the initial coverage
limit (described in subsection (b)(3)) and decrease the
annual out-of-pocket threshold from the amounts
otherwise computed until, beginning in 2019, there is a
continuation of coverage from the initial coverage
limit for expenditures incurred through the total
amount of expenditures at which benefits are available
under paragraph (4).
``(B) Increase in initial coverage limit.--
``(i) In general.--For a year beginning
with 2011, subject to clause (ii), the initial
coverage limit otherwise computed without
regard to this paragraph shall be increased by
the cumulative ICL phase-in percentage (as
defined in clause (iii) for the year) times the
out-of-pocket gap amount (as defined in
subparagraph (D)) for the year.
``(ii) Maintenance of 2010 initial coverage
limit level.--If for a year the initial
coverage limit otherwise computed under this
paragraph would be less than the initial
coverage limit applied during 2010, taking into
account paragraph (7), the initial coverage
limit for that year shall be such initial
coverage limit as so applied during 2010.
``(iii) Cumulative phase-in percentage.--
``(I) In general.--For purposes of
this paragraph, subject to subclause
(II), the term `cumulative ICL phase-in
percentage' means for a year the sum of
the annual ICL phase-in percentage (as
defined in clause (iv)) for the year
and the annual ICL phase-in percentages
for each previous year beginning with
2011.
``(II) Limitation.--If the sum of
the cumulative ICL phase-in percentage
and the cumulative OPT phase-in
percentage (as defined in subparagraph
(C)(iii)) for a year would otherwise
exceed 100 percent, each such
percentage shall be reduced in a
proportional amount so the sum does not
exceed 100 percent.
``(iv) Annual icl phase-in percentage.--For
purposes of this paragraph, the term `annual
ICL phase-in percentage' means--
``(I) for 2011, 8.25 percent;
``(II) for 2012, 2013, and 2014,
4.5 percent;
``(III) for 2015 and 2016, 6
percent;
``(IV) for 2017, 7.5 percent;
``(V) for 2018, 8 percent; and
``(VI) for 2019, 8 percent, or such
other percent as may be necessary to
provide for a full continuation of
coverage as described in subparagraph
(A) in that year.
``(C) Decrease in annual out-of-pocket threshold.--
``(i) In general.--For a year beginning
with 2011, subject to clause (ii), the annual
out-of-pocket threshold otherwise computed
without regard to this paragraph shall be
decreased by the cumulative OPT phase-in
percentage (as defined in clause (iii) for the
year) of the out-of-pocket gap amount for the
year multiplied by 1.75.
``(ii) Maintenance.--The Secretary shall
adjust the annual out-of-pocket threshold for a
year to the extent necessary to ensure that the
sum of the initial coverage limit described in
subparagraph (A) and the out-of-pocket gap
amount (defined in subparagraph (D)), as
determined for the year pursuant to the
provisions of this paragraph for such year,
does not exceed such sum that would have
applied if this paragraph did not apply.
``(iii) Cumulative opt phase-in
percentage.--For purposes of this paragraph,
subject to subparagraph (B)(iii)(II), the term
`cumulative OPT phase-in percentage' means for
a year the sum of the annual OPT phase-in
percentage (as defined in clause (iv)) for the
year and the annual OPT phase-in percentages
for each previous year beginning with 2011.
``(iv) Annual opt phase-in percentage.--For
purposes of this paragraph, the term `annual
OPT phase-in percentage' means--
``(I) for 2011, 0 percent;
``(II) for 2012, 2013, and 2014,
4.5 percent;
``(III) for 2015 and 2016, 6
percent;
``(IV) for 2017, 7.5 percent; and
``(V) for 2018 and 2019, 8 percent.
``(D) Out-of-pocket gap amount.--For purposes of
this paragraph, the term `out-of-pocket gap amount'
means for a year the amount by which--
``(i) the annual out-of-pocket threshold
specified in paragraph (4)(B) for the year (as
determined as if this paragraph did not apply),
exceeds
``(ii) the sum of--
``(I) the annual deductible under
paragraph (1) for the year; and
``(II) \1/4\ of the amount by which
the initial coverage limit under
paragraph (3) for the year (as
determined as if this paragraph did not
apply) exceeds such annual deductible.
``(E) Relation to aahca transitional increase.--
Except as otherwise specifically provided, this
paragraph shall be applied as if no increase had been
made in the initial coverage limit under paragraph
(7).''.
(c) Requiring Drug Manufacturers to Provide Drug Rebates for Rebate
Eligible Individuals.--
(1) In general.--Section 1860D-2 of the Social Security Act
(42 U.S.C. 1395w-102) is amended--
(A) in subsection (e)(1), in the matter before
subparagraph (A), by inserting ``and subsection (f)''
after ``this subsection''; and
(B) by adding at the end the following new
subsection:
``(f) Prescription Drug Rebate Agreement for Rebate Eligible
Individuals.--
``(1) Requirement.--
``(A) In general.--For plan years beginning on or
after January 1, 2011, in this part, the term `covered
part D drug' does not include any drug or biological
product that is manufactured by a manufacturer that has
not entered into and have in effect a rebate agreement
described in paragraph (2).
``(B) 2010 plan year requirement.--Any drug or
biological product manufactured by a manufacturer that
declines to enter into a rebate agreement described in
paragraph (2) for the period beginning on January 1,
2010, and ending on December 31, 2010, shall not be
included as a `covered part D drug ` for the subsequent
plan year.
``(2) Rebate agreement.--A rebate agreement under this
subsection shall require the manufacturer to provide to the
Secretary a rebate for each rebate period (as defined in
paragraph (6)(B)) ending after December 31, 2009, in the amount
specified in paragraph (3) for any covered part D drug of the
manufacturer dispensed after December 31, 2009, to any rebate
eligible individual (as defined in paragraph (6)(A)) for which
payment was made by a PDP sponsor under part D or a MA
organization under part C for such period, including payments
passed through the low-income and reinsurance subsidies under
sections 1860D-14 and 1860D-15(b), respectively. Such rebate
shall be paid by the manufacturer to the Secretary not later
than 30 days after the date of receipt of the information
described in section 1860D-12(b)(7), including as such section
is applied under section 1857(f)(3), or 30 days after the
receipt of information under subparagraph (D) of paragraph (3),
as determined by the Secretary. Insofar as not inconsistent
with this subsection, the Secretary shall establish terms and
conditions of such agreement relating to compliance, penalties,
and program evaluations, investigations, and audits that are
similar to the terms and conditions for rebate agreements under
paragraphs (3) and (4) of section 1927(b).
``(3) Rebate for rebate eligible medicare drug plan
enrollees.--
``(A) In general.--The amount of the rebate
specified under this paragraph for a manufacturer for a
rebate period, with respect to each dosage form and
strength of any covered part D drug provided by such
manufacturer and dispensed to a rebate eligible
individual, shall be equal to the product of--
``(i) the total number of units of such
dosage form and strength of the drug so
provided and dispensed for which payment was
made by a PDP sponsor under part D or a MA
organization under part C for the rebate
period, including payments passed through the
low-income and reinsurance subsidies under
sections 1860D-14 and 1860D-15(b),
respectively; and
``(ii) the amount (if any) by which--
``(I) the Medicaid rebate amount
(as defined in subparagraph (B)) for
such form, strength, and period,
exceeds
``(II) the average Medicare drug
program rebate eligible rebate amount
(as defined in subparagraph (C)) for
such form, strength, and period.
``(B) Medicaid rebate amount.--For purposes of this
paragraph, the term `Medicaid rebate amount' means,
with respect to each dosage form and strength of a
covered part D drug provided by the manufacturer for a
rebate period--
``(i) in the case of a single source drug
or an innovator multiple source drug, the
amount specified in paragraph (1)(A)(ii) of
section 1927(c) plus the amount, if any,
specified in paragraph (2)(A)(ii) of such
section, for such form, strength, and period;
or
``(ii) in the case of any other covered
outpatient drug, the amount specified in
paragraph (3)(A)(i) of such section for such
form, strength, and period.
``(C) Average medicare drug program rebate eligible
rebate amount.--For purposes of this subsection, the
term `average Medicare drug program rebate eligible
rebate amount' means, with respect to each dosage form
and strength of a covered part D drug provided by a
manufacturer for a rebate period, the sum, for all PDP
sponsors under part D and MA organizations
administering a MA-PD plan under part C, of--
``(i) the product, for each such sponsor or
organization, of--
``(I) the sum of all rebates,
discounts, or other price concessions
(not taking into account any rebate
provided under paragraph (2) for such
dosage form and strength of the drug
dispensed, calculated on a per-unit
basis, but only to the extent that any
such rebate, discount, or other price
concession applies equally to drugs
dispensed to rebate eligible Medicare
drug plan enrollees and drugs dispensed
to PDP and MA-PD enrollees who are not
rebate eligible individuals; and
``(II) the number of the units of
such dosage and strength of the drug
dispensed during the rebate period to
rebate eligible individuals enrolled in
the prescription drug plans
administered by the PDP sponsor or the
MA-PD plans administered by the MA
organization; divided by
``(ii) the total number of units of such
dosage and strength of the drug dispensed
during the rebate period to rebate eligible
individuals enrolled in all prescription drug
plans administered by PDP sponsors and all MA-
PD plans administered by MA organizations.
``(D) Use of estimates.--The Secretary may
establish a methodology for estimating the average
Medicare drug program rebate eligible rebate amounts
for each rebate period based on bid and utilization
information under this part and may use these estimates
as the basis for determining the rebates under this
section. If the Secretary elects to estimate the
average Medicare drug program rebate eligible rebate
amounts, the Secretary shall establish a reconciliation
process for adjusting manufacturer rebate payments not
later than 3 months after the date that manufacturers
receive the information collected under section 1860D-
12(b)(7)(B).
``(4) Length of agreement.--The provisions of paragraph (4)
of section 1927(b) (other than clauses (iv) and (v) of
subparagraph (B)) shall apply to rebate agreements under this
subsection in the same manner as such paragraph applies to a
rebate agreement under such section.
``(5) Other terms and conditions.--The Secretary shall
establish other terms and conditions of the rebate agreement
under this subsection, including terms and conditions related
to compliance, that are consistent with this subsection.
``(6) Definitions.--In this subsection and section 1860D-
12(b)(7):
``(A) Rebate eligible individual.--The term `rebate
eligible individual'--
``(i) means a full-benefit dual eligible
individual (as defined in section 1935(c)(6));
and
``(ii) includes, for drugs dispensed after
December 31, 2014, a subsidy eligible
individual (as defined in section 1860D-
14(a)(3)(A)).
``(B) Rebate period.--The term `rebate period' has
the meaning given such term in section 1927(k)(8).
``(7) Waiver.--Chapter 35 of title 44, United States Code,
shall not apply to the requirements under this subsection for
the period beginning on January 1, 2010, and ending on December
31, 2010.''.
(2) Reporting requirement for the determination and payment
of rebates by manufactures related to rebate for rebate
eligible medicare drug plan enrollees.--
(A) Requirements for pdp sponsors.--Section 1860D-
12(b) of the Social Security Act (42 U.S.C. 1395w-
112(b)) is amended by adding at the end the following
new paragraph:
``(7) Reporting requirement for the determination and
payment of rebates by manufacturers related to rebate for
rebate eligible medicare drug plan enrollees.--
``(A) In general.--For purposes of the rebate under
section 1860D-2(f) for contract years beginning on or
after January 1, 2011, each contract entered into with
a PDP sponsor under this part with respect to a
prescription drug plan shall require that the sponsor
comply with subparagraphs (B) and (C).
``(B) Report form and contents.--Not later than a
date specified by the Secretary, a PDP sponsor of a
prescription drug plan under this part shall report to
each manufacturer--
``(i) information (by National Drug Code
number) on the total number of units of each
dosage, form, and strength of each drug of such
manufacturer dispensed to rebate eligible
Medicare drug plan enrollees under any
prescription drug plan operated by the PDP
sponsor during the rebate period;
``(ii) information on the price discounts,
price concessions, and rebates for such drugs
for such form, strength, and period;
``(iii) information on the extent to which
such price discounts, price concessions, and
rebates apply equally to rebate eligible
Medicare drug plan enrollees and PDP enrollees
who are not rebate eligible Medicare drug plan
enrollees; and
``(iv) any additional information that the
Secretary determines is necessary to enable the
Secretary to calculate the average Medicare
drug program rebate eligible rebate amount (as
defined in paragraph (3)(C) of such section),
and to determine the amount of the rebate
required under this section, for such form,
strength, and period.
Such report shall be in a form consistent with a
standard reporting format established by the Secretary.
``(C) Submission to secretary.--Each PDP sponsor
shall promptly transmit a copy of the information
reported under subparagraph (B) to the Secretary for
the purpose of audit oversight and evaluation.
``(D) Confidentiality of information.--The
provisions of subparagraph (D) of section 1927(b)(3),
relating to confidentiality of information, shall apply
to information reported by PDP sponsors under this
paragraph in the same manner that such provisions apply
to information disclosed by manufacturers or
wholesalers under such section, except--
``(i) that any reference to `this section'
in clause (i) of such subparagraph shall be
treated as being a reference to this section;
``(ii) the reference to the Director of the
Congressional Budget Office in clause (iii) of
such subparagraph shall be treated as including
a reference to the Medicare Payment Advisory
Commission; and
``(iii) clause (iv) of such subparagraph
shall not apply.
``(E) Oversight.--Information reported under this
paragraph may be used by the Inspector General of the
Department of Health and Human Services for the
statutorily authorized purposes of audit,
investigation, and evaluations.
``(F) Penalties for failure to provide timely
information and provision of false information.--In the
case of a PDP sponsor--
``(i) that fails to provide information
required under subparagraph (B) on a timely
basis, the sponsor is subject to a civil money
penalty in the amount of $10,000 for each day
in which such information has not been
provided; or
``(ii) that knowingly (as defined in
section 1128A(i)) provides false information
under such subparagraph, the sponsor is subject
to a civil money penalty in an amount not to
exceed $100,000 for each item of false
information.
Such civil money penalties are in addition to other
penalties as may be prescribed by law. The provisions
of section 1128A (other than subsections (a) and (b))
shall apply to a civil money penalty under this
subparagraph in the same manner as such provisions
apply to a penalty or proceeding under section
1128A(a).''.
(B) Application to ma organizations.--Section
1857(f)(3) of the Social Security Act (42 U.S.C. 1395w-
27(f)(3)) is amended by adding at the end the
following:
``(D) Reporting requirement related to rebate for
rebate eligible medicare drug plan enrollees.--Section
1860D-12(b)(7).''.
(3) Deposit of rebates into medicare prescription drug
account.--Section 1860D-16(c) of such Act (42 U.S.C. 1395w-
116(c)) is amended by adding at the end the following new
paragraph:
``(6) Rebate for rebate eligible medicare drug plan
enrollees.--Amounts paid under a rebate agreement under section
1860D-2(f) shall be deposited into the Account and shall be
used to pay for all or part of the gradual elimination of the
coverage gap under section 1860D-2(b)(7).''.
SEC. 1182. DISCOUNTS FOR CERTAIN PART D DRUGS IN ORIGINAL COVERAGE GAP.
Section 1860D-2 of the Social Security Act (42 U.S.C. 1395w-102),
as amended by section 1181, is amended--
(1) in subsection (b)(4)(C)(ii), by inserting ``subject to
subsection (g)(2)(C),'' after ``(ii)'';
(2) in subsection (e)(1), in the matter before subparagraph
(A), by striking ``subsection (f)'' and inserting ``subsections
(f) and (g)'' after ``this subsection''; and
(3) by adding at the end the following new subsection:
``(g) Requirement for Manufacturer Discount Agreement for Certain
Qualifying Drugs.--
``(1) In general.--In this part, the term `covered part D
drug' does not include any drug or biological product that is
manufactured by a manufacturer that has not entered into and
have in effect for all qualifying drugs (as defined in
paragraph (5)(A)) a discount agreement described in paragraph
(2).
``(2) Discount agreement.--
``(A) Periodic discounts.--A discount agreement
under this paragraph shall require the manufacturer
involved to provide, to each PDP sponsor with respect
to a prescription drug plan or each MA organization
with respect to each MA-PD plan, a discount in an
amount specified in paragraph (3) for qualifying drugs
(as defined in paragraph (5)(A)) of the manufacturer
dispensed to a qualifying enrollee after January 1,
2010, insofar as the individual is in the original gap
in coverage (as defined in paragraph (5)(E)).
``(B) Discount agreement.--Insofar as not
inconsistent with this subsection, the Secretary shall
establish terms and conditions of such agreement,
including terms and conditions relating to compliance,
similar to the terms and conditions for rebate
agreements under paragraphs (2), (3), and (4) of
section 1927(b), except that--
``(i) discounts shall be applied under this
subsection to prescription drug plans and MA-PD
plans instead of State plans under title XIX;
``(ii) PDP sponsors and MA organizations
shall be responsible, instead of States, for
provision of necessary utilization information
to drug manufacturers; and
``(iii) sponsors and MA organizations shall
be responsible for reporting information on
drug-component negotiated price.
``(C) Counting discount toward true out-of-pocket
costs.--Under the discount agreement, in applying
subsection (b)(4), with regard to subparagraph (C)(i)
of such subsection, if a qualified enrollee purchases
the qualified drug insofar as the enrollee is in an
actual gap of coverage (as defined in paragraph
(5)(D)), the amount of the discount under the agreement
shall be treated and counted as costs incurred by the
plan enrollee.
``(3) Discount amount.--The amount of the discount
specified in this paragraph for a discount period for a plan is
equal to 50 percent of the amount of the drug-component
negotiated price (as defined in paragraph (5)(C)) for
qualifying drugs for the period involved.
``(4) Additional terms.--In the case of a discount provided
under this subsection with respect to a prescription drug plan
offered by a PDP sponsor or an MA-PD plan offered by an MA
organization, if a qualified enrollee purchases the qualified
drug--
``(A) insofar as the enrollee is in an actual gap
of coverage (as defined in paragraph (5)(D)), the
sponsor or plan shall provide the discount to the
enrollee at the time the enrollee pays for the drug;
and
``(B) insofar as the enrollee is in the portion of
the original gap in coverage (as defined in paragraph
(5)(E)) that is not in the actual gap in coverage, the
discount shall not be applied against the negotiated
price (as defined in subsection (d)(1)(B)) for the
purpose of calculating the beneficiary payment.
``(5) Definitions.--In this subsection:
``(A) Qualifying drug.--The term `qualifying drug'
means, with respect to a prescription drug plan or MA-
PD plan, a drug or biological product that--
``(i)(I) is a drug produced or distributed
under an original new drug application approved
by the Food and Drug Administration, including
a drug product marketed by any cross-licensed
producers or distributors operating under the
new drug application;
``(II) is a drug that was originally
marketed under an original new drug application
approved by the Food and Drug Administration;
or
``(III) is a biological product as approved
under Section 351(a) of the Public Health
Services Act;
``(ii) is covered under the formulary of
the plan or is treated as covered under the
formulary of the plan as a result of a coverage
determination or appeal under subsection (g) or
(h) of section 1860D-4; and
``(iii) is dispensed to an individual who
is in the original gap in coverage.
``(B) Qualifying enrollee.--The term `qualifying
enrollee' means an individual enrolled in a
prescription drug plan or MA-PD plan other than such an
individual who is a subsidy-eligible individual (as
defined in section 1860D-14(a)(3)).
``(C) Drug-component negotiated price.--The term
`drug-component negotiated price' means, with respect
to a qualifying drug, the negotiated price (as defined
in section 423.100 of title 42, Code of Federal
Regulations, as in effect on the date of enactment of
this subsection), as determined without regard to any
dispensing fee, of the drug under the prescription drug
plan or MA-PD plan involved.
``(D) Actual gap in coverage.--The term `actual gap
in coverage' means the gap in prescription drug
coverage that occurs between the initial coverage limit
(as modified under paragraph (7) and subparagraph (B)
of paragraph (8) of subsection (b)) and the annual out-
of-pocket threshold (as modified under subparagraph (C)
of such subsection).
``(E) Original gap in coverage.--The term `original
in gap coverage' means the gap in prescription drug
coverage that would occur between the initial coverage
limit (described in subsection (b)(3)) and the out-of-
pocket threshold (as defined in subsection (b)(4)(B))
if subsections (b)(7) and (b)(8) did not apply.
``(6) Special rule for 2010.--For the period beginning
January 1, 2010, and ending December 31, 2010, the Secretary
may--
``(A) enter into agreements with manufacturers to
directly receive the discount amount described in
paragraph (3);
``(B) collect the necessary information from
prescription drug plans and MA-PD plans to calculate
the discount amount described in such paragraph; and
``(C) provide the discount described in such
paragraph to beneficiaries as close as practicable
after the point of sale.
``(7) Waiver.--Chapter 35 of title 44, United States Code,
shall not apply to the requirements under this subsection for
the period beginning on January 1, 2010, and ending on December
31, 2010.''.
SEC. 1183. REPEAL OF PROVISION RELATING TO SUBMISSION OF CLAIMS BY
PHARMACIES LOCATED IN OR CONTRACTING WITH LONG-TERM CARE
FACILITIES.
(a) Part D Submission.--Section 1860D-12(b) of the Social Security
Act (42 U.S.C. 1395w-112(b)), as amended by section 172(a)(1) of Public
Law 110-275, is amended by striking paragraph (5) and redesignating
paragraph (6) and paragraph (7), as added by section 1181(c)(2)(A), as
paragraph (5) and paragraph (6), respectively.
(b) Submission to MA-PD Plans.--Section 1857(f)(3) of the Social
Security Act (42 U.S.C. 1395w-27(f)(3)), as added by section 171(b) of
Public Law 110-275 and amended by section 172(a)(2) of such Public Law
and section 1181 of this Act, is amended by striking subparagraph (B)
and redesignating subparagraphs (C) and (D) as subparagraphs (B) and
(C) respectively.
(c) Effective Date.--The amendments made by this section shall
apply for contract years beginning with 2010.
SEC. 1184. 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 ``and 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. 1185. NO MID-YEAR FORMULARY CHANGES PERMITTED.
(a) In General.--Section 1860D-4(b)(3)(E) of the Social Security
Act (42 U.S.C. 1395w-104(b)(3)(E)) is amended--
(1) in the heading, by inserting ``; certain formulary
changes only before initiating marketing for a plan year''
after ``status of drug'';
(2) by striking ``Any removal'' and inserting ``(i)
notice.--Any removal'' with the same indentation as the clause
added by paragraph (2);
(3) by adding at the end the following new clause:
``(ii) Certain changes in formulary only
before initiating marketing for a plan year.--
Any removal of a covered part D drug from a
formulary used by a PDP sponsor of a
prescription drug plan (or MA organization of a
MA-PD plan) or any other material change to the
formulary so as to reduce the coverage (or
increase the cost-sharing) of the drug under
the plan for a plan year shall take effect by a
date specified by the Secretary but no later
than the start of plan marketing activities for
the plan year. In addition to any exceptions to
the previous sentence specified by the
Secretary, the previous sentence shall not
apply in the case that a drug is removed from
the formulary of a plan because of a recall or
withdrawal of the drug issued by the Food and
Drug Administration, because the drug is
replaced with a generic drug that is a
therapeutic equivalent, or because of
utilization management applied to--
``(I) a drug whose labeling
includes a boxed warning required by
the Food and Drug Administration under
section 201.57(c)(1) of title 21, Code
of Federal Regulations (or a successor
regulation); or
``(II) a drug required under
subsection (c)(2) of section 505-1 of
the Federal Food, Drug, and Cosmetic
Act to have a Risk Evaluation and
Management Strategy that includes
elements under subsection (f) of such
section.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to contract years beginning on or after January 1, 2011.
SEC. 1186. NEGOTIATION OF LOWER COVERED PART D DRUG PRICES ON BEHALF OF
MEDICARE BENEFICIARIES.
(a) Negotiation by Secretary.--Section 1860D-11 of the Social
Security Act (42 U.S.C. 1395w-111) is amended by striking subsection
(i) (relating to noninterference) and inserting the following:
``(i) Negotiation of Lower Drug Prices.--
``(1) In general.--Notwithstanding any other provision of
law, the Secretary shall negotiate with pharmaceutical
manufacturers the prices (including discounts, rebates, and
other price concessions) that may be charged to PDP sponsors
and MA organizations for covered part D drugs for part D
eligible individuals who are enrolled under a prescription drug
plan or under an MA-PD plan.
``(2) No change in rules for formularies.--
``(A) In general.--Nothing in paragraph (1) shall
be construed to authorize the Secretary to establish or
require a particular formulary.
``(B) Construction.--Subparagraph (A) shall not be
construed as affecting the Secretary's authority to
ensure appropriate and adequate access to covered part
D drugs under prescription drug plans and under MA-PD
plans, including compliance of such plans with
formulary requirements under section 1860D-4(b)(3).
``(3) Construction.--Nothing in this subsection shall be
construed as preventing the sponsor of a prescription drug
plan, or an organization offering an MA-PD plan, from obtaining
a discount or reduction of the price for a covered part D drug
below the price negotiated under paragraph (1).
``(4) Annual reports to congress.--Not later than June 1,
2011, and annually thereafter, the Secretary shall submit to
the Committees on Ways and Means, Energy and Commerce, and
Oversight and Government Reform of the House of Representatives
and the Committee on Finance of the Senate a report on
negotiations conducted by the Secretary to achieve lower prices
for Medicare beneficiaries, and the prices and price discounts
achieved by the Secretary as a result of such negotiations.''.
(b) Effective Date.--The amendment made by subsection (a) shall
take effect on the date of the enactment of this Act and shall first
apply to negotiations and prices for plan years beginning on January 1,
2011.
SEC. 1187. ACCURATE DISPENSING IN LONG-TERM CARE FACILITIES.
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) Reduction of wasteful dispensing.--
``(A) In general.--For plan years beginning on or
after January 1, 2012, a PDP sponsor offering a
prescription drug plan and MA organization offering a
MA-PD plan under part C shall have in place the
utilization management techniques established under
subparagraph (B).
``(B) Requirements.--The Secretary shall establish
utilization management techniques, such as daily,
weekly, or automated dose dispensing, to apply to PDP
sponsors and MA organizations to reduce the quantities
of covered part D drugs dispensed to enrollees who are
residing in long-term care facilities in order to
reduce waste associated with unused medications.
``(C) Consultation.--In establishing the
requirements under subparagraph (A), the Secretary
shall consult with the Administrator of the
Environmental Protection Agency, Administrator of the
Food and Drug Administration, Administrator of the Drug
Enforcement Administration, State Boards of Pharmacy,
pharmacy and physician organizations, and other
appropriate stakeholders to study and determine
additional methods for prescription drug plans to
reduce waste associated with unused prescription
drugs.''.
SEC. 1188. FREE GENERIC FILL.
(a) In General.--Section 1128A(i)(6) of the Social Security Act (42
U.S.C. 1320a-7a(i)(6)) is amended--
(1) in subparagraph (C), by striking ``of 1996'' and all
that follows and inserting ``of 1996;'';
(2) in the first subparagraph (D), by striking
``promulgated'' and all that follows and inserting
``promulgated;'';
(3) by redesignating the second subparagraph (D) as a
subparagraph (E) and by striking the period at the end of such
subparagraph and inserting ``; and''; and
(4) by adding at the end the following new subparagraph:
``(F) with regard to a prescription drug plan
offered by a PDP sponsor or an MA-PD plan offered by an
MA organization, a reduction in or waiver of the
copayment amount under the plan given to an individual
to induce the individual to switch to a generic,
bioequivalent drug, or biosimilar.''.
(b) Effective Date.--The amendments made by this subsection shall
take effect on the date of the enactment of this Act and shall first
apply with respect to remuneration offered, paid, solicited, or
received on or after January 1, 2011.
SEC. 1189. STATE CERTIFICATION PRIOR TO WAIVER OF LICENSURE
REQUIREMENTS UNDER MEDICARE PRESCRIPTION DRUG PROGRAM.
(a) In General.--Section 1860D-12(c) of the Social Security Act (42
U.S.C. 1395w-112(c)) is amended--
(1) in paragraph (1)(A), by striking ``In the case'' and
inserting ``Subject to paragraph (5), in the case''; and
(2) by adding at the end the following new paragraph:
``(5) State certification required.--
``(A) In general.--Except as provided in section
1860D-21(f)(4), the Secretary may only grant a waiver
under paragraph (1)(A) if the Secretary has received a
certification from the State insurance commissioner
that the prescription drug plan has a substantially
complete application pending in the State.
``(B) Revocation of waiver upon finding of fraud
and abuse.--The Secretary shall revoke a waiver granted
under paragraph (1)(A) if the State insurance
commissioner submits a certification to the Secretary
that the recipient of such a waiver--
``(i) has committed fraud or abuse with
respect to such waiver;
``(ii) has failed to make a good faith
effort to satisfy State licensing requirements;
or
``(iii) was determined ineligible for
licensure by the State.''.
(b) Exception for PACE Programs.--Section 1860D-21(f) of such Act
(42 U.S.C. 1395w-131(f)) is amended--
(1) in paragraph (1), by striking ``paragraphs (2) and
(3)'' and inserting ``the succeeding paragraphs''; and
(2) by adding at the end the following new paragraph:
``(4) Inapplicability of certain licensure waiver
requirements.--The provisions of paragraph (1) of section
1860D-12(c) (relating to waiver of licensure under certain
circumstances) shall apply without regard to paragraph (5) of
such section in the case of a PACE program that elects to
provide qualified prescription drug coverage to a part D
eligible individual who is enrolled under such program.''.
(b) Effective Date.--The amendments made by this section shall
apply with respect to plan years beginning on or after January 1, 2010.
Subtitle F--Medicare Rural Access Protections
SEC. 1191. TELEHEALTH EXPANSION AND ENHANCEMENTS.
(a) Additional Telehealth Site.--
(1) In general.--Paragraph (4)(C)(ii) of section 1834(m) of
the Social Security Act (42 U.S.C. 1395m(m)) is amended by
adding at the end the following new subclause:
``(IX) A renal dialysis facility.''
(2) Effective date.--The amendment made by paragraph (1)
shall apply to services furnished on or after January 1, 2011.
(b) Telehealth Advisory Committee.--
(1) Establishment.--Section 1868 of the Social Security Act
(42 U.S.C. 1395ee) is amended--
(A) in the heading, by adding at the end the
following: ``telehealth advisory committee''; and
(B) by adding at the end the following new
subsection:
``(c) Telehealth Advisory Committee.--
``(1) In general.--The Secretary shall appoint a Telehealth
Advisory Committee (in this subsection referred to as the
`Advisory Committee') to make recommendations to the Secretary
on policies of the Centers for Medicare & Medicaid Services
regarding telehealth services as established under section
1834(m), including the appropriate addition or deletion of
services (and HCPCS codes) to those specified in paragraphs
(4)(F)(i) and (4)(F)(ii) of such section and for authorized
payment under paragraph (1) of such section.
``(2) Membership; terms.--
``(A) Membership.--
``(i) In general.--The Advisory Committee
shall be composed of 9 members, to be appointed
by the Secretary, of whom--
``(I) 5 shall be practicing
physicians;
``(II) 2 shall be practicing non-
physician health care practitioners;
and
``(III) 2 shall be administrators
of telehealth programs.
``(ii) Requirements for appointing
members.--In appointing members of the Advisory
Committee, the Secretary shall--
``(I) ensure that each member has
prior experience with the practice of
telemedicine or telehealth;
``(II) give preference to
individuals who are currently providing
telemedicine or telehealth services or
who are involved in telemedicine or
telehealth programs;
``(III) ensure that the membership
of the Advisory Committee represents a
balance of specialties and geographic
regions; and
``(IV) take into account the
recommendations of stakeholders.
``(B) Terms.--The members of the Advisory Committee
shall serve for such term as the Secretary may specify.
``(C) Conflicts of interest.--An advisory committee
member may not participate with respect to a particular
matter considered in an advisory committee meeting if
such member (or an immediate family member of such
member) has a financial interest that could be affected
by the advice given to the Secretary with respect to
such matter.
``(3) Meetings.--The Advisory Committee shall meet twice
each calendar year and at such other times as the Secretary may
provide.
``(4) Permanent committee.--Section 14 of the Federal
Advisory Committee Act (5 U.S.C. App.) shall not apply to the
Advisory Committee.''
(2) Following recommendations.--Section 1834(m)(4)(F) of
such Act (42 U.S.C. 1395m(m)(4)(F)) is amended by adding at the
end the following new clause:
``(iii) Recommendations of the telehealth
advisory committee.--In making determinations
under clauses (i) and (ii), the Secretary shall
take into account the recommendations of the
Telehealth Advisory Committee (established
under section 1868(c)) when adding or deleting
services (and HCPCS codes) and in establishing
policies of the Centers for Medicare & Medicaid
Services regarding the delivery of telehealth
services. If the Secretary does not implement
such a recommendation, the Secretary shall
publish in the Federal Register a statement
regarding the reason such recommendation was
not implemented.''
(3) Waiver of administrative limitation.--The Secretary of
Health and Human Services shall establish the Telehealth
Advisory Committee under the amendment made by paragraph (1)
notwithstanding any limitation that may apply to the number of
advisory committees that may be established (within the
Department of Health and Human Services or otherwise).
(c) Hospital Credentialing of Telemedicine Physicians and
Practitioners.--
(1) In general.--Not later than 60 days after the date of
the enactment of this Act, the Secretary of Health and Human
Services shall issue guidance for hospitals (as defined in
paragraph (4)) to simplify requirements regarding compiling
practitioner credentials for the purpose of rendering a medical
staff privileging decision (under bylaws of the type described
in section 1861(e)(3) of the Social Security Act) for
physicians and practitioners (as defined in paragraph (4))
delivering telehealth services that are furnished via a
telecommunications system.
(2) Flexibility in accepting credentialing by another
medicare participating hospital.--
(A) In general.--Such guidance shall permit a
hospital to accept credentialing packages compiled by
another hospital participating under Medicare with
regard to physicians and practitioners who seek medical
staff privileges in the hospital to provide telehealth
services via a telecommunications system from a site
other than the hospital where the patient is located.
(B) Construction.--Nothing in this subsection shall
be construed to require a hospital to accept the
credentialing package compiled by another facility.
(C) No oversight required.--If a hospital does
accept the credentialing materials prepared by another
hospital, the hospital shall not be required to
exercise oversight over the other hospital's process
for compiling and verifying credentials.
(D) Privileging.--This paragraph shall only apply
to credentialing and does not relieve a hospital from
any applicable privileging requirements.
(3) Construction.--This subsection shall not be construed
as limiting the ability of the Secretary to issue additional
guidance regarding the requirements for the compilation of
credentials for physicians and practitioners not described in
paragraph (1).
(4) Definitions.--In this subsection:
(A) The term ``hospital'' has the meaning given
such term in subsection (e) of section 1861 of the
Social Security Act (42 U.S.C. 1395x) and includes a
critical access hospital (as defined in subsection
(mm)(1) of such section).
(B) The term ``physician'' has the meaning given
such term in subsection (r) of such section.
(C) The term ``practitioner'' means a practitioner
described in section 1842(b)(18)(C) of the Social
Security Act (42 U.S.C. 1395u(b)(18)(C)).
SEC. 1192. EXTENSION OF OUTPATIENT HOLD HARMLESS PROVISION.
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 ``2012''; and
(B) in the second sentence, by striking ``or 2009''
and inserting ``, 2009, 2010, or 2011''; and
(2) in subclause (III), by striking ``January 1, 2010'' and
inserting ``January 1, 2012''.
SEC. 1193. EXTENSION OF SECTION 508 HOSPITAL RECLASSIFICATIONS.
(a) 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, 2011''.
(b) Use of Particular Wage Index for Fiscal Year 2010.--For
purposes of implementation of the amendment made by subsection (a) for
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.
SEC. 1194. EXTENSION OF GEOGRAPHIC FLOOR FOR WORK.
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, 2012''.
SEC. 1195. 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 1008 (Public Law 110-275), is amended by striking
``and 2009'' and inserting ``2009, 2010, and 2011''.
SEC. 1196. EXTENSION OF AMBULANCE ADD-ONS.
(a) In General.--Section 1834(l)(13) of the Social Security Act (42
U.S.C. 1395m(l)(13)) is amended--
(1) in subparagraph (A)--
(A) in the matter preceding clause (i), by striking
``before January 1, 2010'' and inserting ``before
January 1, 2012''; and
(B) in each of clauses (i) and (ii), by striking
``before January 1, 2010'' and inserting ``before
January 1, 2012''.
(b) Air Ambulance Improvements.--Section 146(b)(1) of the Medicare
Improvements for Patients and Providers Act of 2008 (Public Law 110-
275) is amended by striking ``ending on December 31, 2009'' and
inserting ``ending on December 31, 2011''.
TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A--Improving and Simplifying Financial Assistance for Low
Income Medicare Beneficiaries
SEC. 1201. IMPROVING ASSETS TESTS FOR MEDICARE SAVINGS PROGRAM AND LOW-
INCOME SUBSIDY PROGRAM.
(a) Application of Highest Level Permitted Under LIS to All Subsidy
Eligible Individuals.--
(1) In general.--Section 1860D-14(a)(1) of the Social
Security Act (42 U.S.C. 1395w-114(a)(1)) is amended in the
matter before subparagraph (A), by inserting ``(or, beginning
with 2012, paragraph (3)(E))'' after ``paragraph (3)(D)''.
(2) Annual increase in lis resource test.--Section 1860D-
14(a)(3)(E)(i) of such Act (42 U.S.C. 1395w-114(a)(3)(E)(i)) is
amended--
(A) by striking ``and'' at the end of subclause
(I);
(B) in subclause (II), by inserting ``(before
2012)'' after ``subsequent year'';
(C) by striking the period at the end of subclause
(II) and inserting a semicolon;
(D) by inserting after subclause (II) the following
new subclauses:
``(III) for 2012, $17,000 (or
$34,000 in the case of the combined
value of the individual's assets or
resources and the assets or resources
of the individual's spouse); and
``(IV) for a subsequent year, the
dollar amounts specified in this
subclause (or subclause (III)) for the
previous year increased by the annual
percentage increase in the consumer
price index (all items; U.S. city
average) as of September of such
previous year.''; and
(E) in the last sentence, by inserting ``or (IV)''
after ``subclause (II)''.
(3) Application of lis test under medicare savings
program.--Section 1905(p)(1)(C) of such Act (42 U.S.C.
1396d(p)(1)(C)) is amended--
(A) by striking ``effective beginning with January
1, 2010'' and inserting ``effective for the period
beginning with January 1, 2010, and ending with
December 31, 2011''; and
(B) by inserting before the period at the end the
following: ``or, effective beginning with January 1,
2012, whose resources (as so determined) do not exceed
the maximum resource level applied for the year under
subparagraph (E) of section 1860D-14(a)(3) (determined
without regard to the life insurance policy exclusion
provided under subparagraph (G) of such section)
applicable to an individual or to the individual and
the individual's spouse (as the case may be)''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to eligibility determinations for income-related subsidies and
medicare cost-sharing furnished for periods beginning on or after
January 1, 2012.
SEC. 1202. ELIMINATION OF PART D COST-SHARING FOR CERTAIN NON-
INSTITUTIONALIZED FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS.
(a) In General.--Section 1860D-14(a)(1)(D)(i) of the Social
Security Act (42 U.S.C. 1395w-114(a)(1)(D)(i)) is amended--
(1) by striking ``Institutionalized individuals.--In'' and
inserting ``Elimination of cost-sharing for certain full-
benefit dual eligible individuals.--
``(I) Institutionalized
individuals.--In''; and
(2) by adding at the end the following new subclause:
``(II) Certain other individuals.--
In the case of an individual who is a
full-benefit dual eligible individual
and with respect to whom there has been
a determination that but for the
provision of home and community based
care (whether under section 1915, 1932,
or under a waiver under section 1115)
the individual would require the level
of care provided in a hospital or a
nursing facility or intermediate care
facility for the mentally retarded the
cost of which could be reimbursed under
the State plan under title XIX, the
elimination of any beneficiary
coinsurance described in section 1860D-
2(b)(2) (for all amounts through the
total amount of expenditures at which
benefits are available under section
1860D-2(b)(4)).''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to drugs dispensed on or after January 1, 2011.
SEC. 1203. ELIMINATING BARRIERS TO ENROLLMENT.
(a) Administrative Verification of Income and Resources Under the
Low-income Subsidy Program.--
(1) In general.--Clause (iii) of section 1860D-14(a)(3)(E)
of the Social Security Act (42 U.S.C. 1395w-114(a)(3)(E)) is
amended to read as follows:
``(iii) Certification of income and
resources.--For purposes of applying this
section--
``(I) an individual shall be
permitted to apply on the basis of
self-certification of income and
resources; and
``(II) matters attested to in the
application shall be subject to
appropriate methods of verification
without the need of the individual to
provide additional documentation,
except in extraordinary situations as
determined by the Commissioner.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply beginning January 1, 2010.
(b) Disclosures to Facilitate Identification of Individuals Likely
to Be Ineligible for the Low-income Assistance Under the Medicare
Prescription Drug Program to Assist Social Security Administration's
Outreach to Eligible Individuals.--For provision authorizing disclosure
of return information to facilitate identification of individuals
likely to be ineligible for low-income subsidies under Medicare
prescription drug program, see section 1801.
SEC. 1204. ENHANCED OVERSIGHT RELATING TO REIMBURSEMENTS FOR
RETROACTIVE LOW INCOME SUBSIDY ENROLLMENT.
(a) In General.--In the case of a retroactive LIS enrollment
beneficiary who is enrolled under a prescription drug plan under part D
of title XVIII of the Social Security Act (or an MA-PD plan under part
C of such title), the beneficiary (or any eligible third party) is
entitled to reimbursement by the plan for covered drug costs incurred
by the beneficiary during the retroactive coverage period of the
beneficiary in accordance with subsection (b) and in the case of such a
beneficiary described in subsection (c)(4)(A)(i), such reimbursement
shall be made automatically by the plan upon receipt of appropriate
notice the beneficiary is eligible for assistance described in such
subsection (c)(4)(A)(i) without further information required to be
filed with the plan by the beneficiary.
(b) Administrative Requirements Relating to Reimbursements.--
(1) Line-item description.--Each reimbursement made by a
prescription drug plan or MA-PD plan under subsection (a) shall
include a line-item description of the items for which the
reimbursement is made.
(2) Timing of reimbursements.--A prescription drug plan or
MA-PD plan must make a reimbursement under subsection (a) to a
retroactive LIS enrollment beneficiary, with respect to a
claim, not later than 45 days after--
(A) in the case of a beneficiary described in
subsection (c)(4)(A)(i), the date on which the plan
receives notice from the Secretary that the beneficiary
is eligible for assistance described in such
subsection; or
(B) in the case of a beneficiary described in
subsection (c)(4)(A)(ii), the date on which the
beneficiary files the claim with the plan.
(3) Reporting requirement.--For each month beginning with
January 2011, each prescription drug plan and each MA-PD plan
shall report to the Secretary the following:
(A) The number of claims the plan has readjudicated
during the month due to a beneficiary becoming
retroactively eligible for subsidies available under
section 1860D-14 of the Social Security Act.
(B) The total value of the readjudicated claim
amount for the month.
(C) The Medicare Health Insurance Claims Number of
beneficiaries for whom claims were readjudicated.
(D) For the claims described in subparagraphs (A)
and (B), an attestation to the Administrator of the
Centers for Medicare & Medicaid Services of the total
amount of reimbursement the plan has provided to
beneficiaries for premiums and cost-sharing that the
beneficiary overpaid for which the plan received
payment from the Centers for Medicare & Medicaid
Services.
(c) Definitions.--For purposes of this section:
(1) Covered drug costs.--The term ``covered drug costs''
means, with respect to a retroactive LIS enrollment beneficiary
enrolled under a prescription drug plan under part D of title
XVIII of the Social Security Act (or an MA-PD plan under part C
of such title), the amount by which--
(A) the costs incurred by such beneficiary during
the retroactive coverage period of the beneficiary for
covered part D drugs, premiums, and cost-sharing under
such title; exceeds
(B) such costs that would have been incurred by
such beneficiary during such period if the beneficiary
had been both enrolled in the plan and recognized by
such plan as qualified during such period for the low
income subsidy under section 1860D-14 of the Social
Security Act to which the individual is entitled.
(2) Eligible third party.--The term ``eligible third
party'' means, with respect to a retroactive LIS enrollment
beneficiary, an organization or other third party that is owed
payment on behalf of such beneficiary for covered drug costs
incurred by such beneficiary during the retroactive coverage
period of such beneficiary.
(3) Retroactive coverage period.--The term ``retroactive
coverage period'' means--
(A) with respect to a retroactive LIS enrollment
beneficiary described in paragraph (4)(A)(i), the
period--
(i) beginning on the effective date of the
assistance described in such paragraph for
which the individual is eligible; and
(ii) ending on the date the plan
effectuates the status of such individual as so
eligible; and
(B) with respect to a retroactive LIS enrollment
beneficiary described in paragraph (4)(A)(ii), the
period--
(i) beginning on the date the individual is
both entitled to benefits under part A, or
enrolled under part B, of title XVIII of the
Social Security Act and eligible for medical
assistance under a State plan under title XIX
of such Act; and
(ii) ending on the date the plan
effectuates the status of such individual as a
full-benefit dual eligible individual (as
defined in section 1935(c)(6) of such Act).
(4) Retroactive lis enrollment beneficiary.--
(A) In general.--The term ``retroactive LIS
enrollment beneficiary'' means an individual who--
(i) is enrolled in a prescription drug plan
under part D of title XVIII of the Social
Security Act (or an MA-PD plan under part C of
such title) and subsequently becomes eligible
as a full-benefit dual eligible individual (as
defined in section 1935(c)(6) of such Act), an
individual receiving a low-income subsidy under
section 1860D-14 of such Act, an individual
receiving assistance under the Medicare Savings
Program implemented under clauses (i), (iii),
and (iv) of section 1902(a)(10)(E) of such Act,
or an individual receiving assistance under the
supplemental security income program under
section 1611 of such Act; or
(ii) subject to subparagraph (B)(i), is a
full-benefit dual eligible individual (as
defined in section 1935(c)(6) of such Act) who
is automatically enrolled in such a plan under
section 1860D-1(b)(1)(C) of such Act.
(B) Exception for beneficiaries enrolled in rfp
plan.--
(i) In general.--In no case shall an
individual described in subparagraph (A)(ii)
include an individual who is enrolled, pursuant
to a RFP contract described in clause (ii), in
a prescription drug plan offered by the sponsor
of such plan awarded such contract.
(ii) RFP contract described.--The RFP
contract described in this section is a
contract entered into between the Secretary and
a sponsor of a prescription drug plan pursuant
to the Centers for Medicare & Medicaid
Services' request for proposals issued on
February 17, 2009, relating to Medicare part D
retroactive coverage for certain low income
beneficiaries, or a similar subsequent request
for proposals.
SEC. 1205. INTELLIGENT ASSIGNMENT IN ENROLLMENT.
(a) In General.--Section 1860D-1(b)(1)(C) of the Social Security
Act (42 U.S.C. 1395w-101(b)(1)(C)) is amended by adding after ``PDP
region'' the following: ``or through use of an intelligent assignment
process that is designed to maximize the access of such individual to
necessary prescription drugs while minimizing costs to such individual
and to the program under this part to the greatest extent possible. In
the case the Secretary enrolls such individuals through use of an
intelligent assignment process, such process shall take into account
the extent to which prescription drugs necessary for the individual are
covered in the case of a PDP sponsor of a prescription drug plan that
uses a formulary, the use of prior authorization or other restrictions
on access to coverage of such prescription drugs by such a sponsor, and
the overall quality of a prescription drug plan as measured by quality
ratings established by the Secretary''
(b) Effective Date.--The amendment made by subsection (a) shall
take effect for contract years beginning with 2012.
SEC. 1206. SPECIAL ENROLLMENT PERIOD AND AUTOMATIC ENROLLMENT PROCESS
FOR CERTAIN SUBSIDY ELIGIBLE INDIVIDUALS.
(a) Special Enrollment Period.--Section 1860D-1(b)(3)(D) of the
Social Security Act (42 U.S.C. 1395w-101(b)(3)(D)) is amended to read
as follows:
``(D) Subsidy eligible individuals.--In the case of
an individual (as determined by the Secretary) who is
determined under subparagraph (B) of section 1860D-
14(a)(3) to be a subsidy eligible individual.''.
(b) Automatic Enrollment.--Section 1860D-1(b)(1) of the Social
Security Act (42 U.S.C. 1395w-101(b)(1)) is amended by adding at the
end the following new subparagraph:
``(D) Special rule for subsidy eligible
individuals.--The process established under
subparagraph (A) shall include, in the case of an
individual described in section 1860D-1(b)(3)(D) who
fails to enroll in a prescription drug plan or an MA-PD
plan during the special enrollment established under
such section applicable to such individual, the
application of the assignment process described in
subparagraph (C) to such individual in the same manner
as such assignment process applies to a part D eligible
individual described in such subparagraph (C). Nothing
in the previous sentence shall prevent an individual
described in such sentence from declining enrollment in
a plan determined appropriate by the Secretary (or in
the program under this part) or from changing such
enrollment.''.
(c) Effective Date.--The amendments made by this section shall
apply to subsidy determinations made for months beginning with January
2011.
SEC. 1207. APPLICATION OF MA PREMIUMS PRIOR TO REBATE AND QUALITY BONUS
PAYMENTS IN CALCULATION OF LOW INCOME SUBSIDY BENCHMARK.
(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 before the period the following: ``before the application of
the monthly rebate computed under section 1854(b)(1)(C)(i) for that
plan and year involved and, in the case of a qualifying plan in a
qualifying county, before the application of the increase under section
1853(o) for that plan and year involved''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to subsidy determinations made for months beginning with January
2011.
Subtitle B--Reducing Health Disparities
SEC. 1221. ENSURING EFFECTIVE COMMUNICATION IN MEDICARE.
(a) Ensuring Effective Communication by the Centers for Medicare &
Medicaid Services.--
(1) Study on medicare payments for language services.--The
Secretary of Health and Human Services shall conduct a study
that examines the extent to which Medicare service providers
utilize, offer, or make available language services for
beneficiaries who are limited English proficient and ways that
Medicare should develop payment systems for language services.
(2) Analyses.--The study shall include an analysis of each
of the following:
(A) How to develop and structure appropriate
payment systems for language services for all Medicare
service providers.
(B) The feasibility of adopting a payment
methodology for on-site interpreters, including
interpreters who work as independent contractors and
interpreters who work for agencies that provide on-site
interpretation, pursuant to which such interpreters
could directly bill Medicare for services provided in
support of physician office services for an LEP
Medicare patient.
(C) The feasibility of Medicare contracting
directly with agencies that provide off-site
interpretation including telephonic and video
interpretation pursuant to which such contractors could
directly bill Medicare for the services provided in
support of physician office services for an LEP
Medicare patient.
(D) The feasibility of modifying the existing
Medicare resource-based relative value scale (RBRVS) by
using adjustments (such as multipliers or add-ons) when
a patient is LEP.
(E) How each of options described in a previous
paragraph would be funded and how such funding would
affect physician payments, a physician's practice, and
beneficiary cost-sharing.
(F) The extent to which providers under parts A and
B of title XVIII of the Social Security Act, MA
organizations offering Medicare Advantage plans under
part C of such title and PDP sponsors of a prescription
drug plan under part D of such title utilize, offer, or
make available language services for beneficiaries with
limited English proficiency.
(G) The nature and type of language services
provided by States under title XIX of the Social
Security Act and the extent to which such services
could be utilized by beneficiaries and providers under
title XVIII of such Act.
(H) The extent to which interpreters and
translators providing services to Medicare
beneficiaries under title XVIII of such Act are trained
or accredited.
(3) Variation in payment system described.--The payment
systems described in paragraph (2)(A) may allow variations
based upon types of service providers, available delivery
methods, and costs for providing language services including
such factors as--
(A) the type of language services provided (such as
provision of health care or health care related
services directly in a non-English language by a
bilingual provider or use of an interpreter);
(B) type of interpretation services provided (such
as in-person, telephonic, video interpretation);
(C) the methods and costs of providing language
services (including the costs of providing language
services with internal staff or through contract with
external independent contractors or agencies, or both);
(D) providing services for languages not frequently
encountered in the United States; and
(E) providing services in rural areas.
(4) Report.--The Secretary shall submit a report on the
study conducted under subsection (a) to appropriate committees
of Congress not later than 12 months after the date of the
enactment of this Act.
(5) Exemption from paperwork reduction act.--Chapter 35 of
title 44, United States Code (commonly known as the ``Paperwork
Reduction Act'' ), shall not apply for purposes of carrying out
this subsection.
(6) Authorization of appropriations.--The Secretary shall
provide for the transfer, from the Federal Supplementary
Medical Insurance Trust Fund under section 1841 of the Social
Security Act (42 U.S.C. 1395t) of $2,000,000 for purposes of
carrying out this subsection.
(b) Health Plans.--Section 1857(g)(1) of the Social Security Act
(42 U.S.C. 1395w-27(g)(1)) is amended--
(1) by striking ``or'' at the end of subparagraph (F);
(2) by adding ``or'' at the end of subparagraph (G); and
(3) by inserting after subparagraph (G) the following new
subparagraph:
``(H) fails substantially to provide language
services to limited English proficient beneficiaries
enrolled in the plan that are required under law;''.
SEC. 1222. DEMONSTRATION TO PROMOTE ACCESS FOR MEDICARE BENEFICIARIES
WITH LIMITED ENGLISH PROFICIENCY BY PROVIDING
REIMBURSEMENT FOR CULTURALLY AND LINGUISTICALLY
APPROPRIATE SERVICES.
(a) In General.--Not later than 6 months after the date of the
completion of the study described in section 1221(a) of this Act, the
Secretary, acting through the Centers for Medicare & Medicaid Services
and the Center for Medicare and Medicaid Innovation established under
section 1115A of the Social Security Act (as added by section 1907) and
consistent with the applicable provisions of such section, shall carry
out a demonstration program under which the Secretary shall award not
fewer than 24 3-year grants to eligible Medicare service providers (as
described in subsection (b)(1)) to improve effective communication
between such providers and Medicare beneficiaries who are living in
communities where racial and ethnic minorities, including populations
that face language barriers, are underserved with respect to such
services. In designing and carrying out the demonstration the Secretary
shall take into consideration the results of the study conducted under
section 1221(a) of this Act and adjust, as appropriate, the
distribution of grants so as to better target Medicare beneficiaries
who are in the greatest need of language services. The Secretary shall
not authorize a grant larger than $500,000 over three years for any
grantee.
(b) Eligibility; Priority.--
(1) Eligibility.--To be eligible to receive a grant under
subsection (a) an entity shall--
(A) be--
(i) a provider of services under part A of
title XVIII of the Social Security Act;
(ii) a service provider under part B of
such title;
(iii) a part C organization offering a
Medicare part C plan under part C of such
title; or
(iv) a PDP sponsor of a prescription drug
plan under part D of such title; and
(B) prepare and submit to the Secretary an
application, at such time, in such manner, and
accompanied by such additional information as the
Secretary may require.
(2) Priority.--
(A) Distribution.--To the extent feasible, in
awarding grants under this section, the Secretary shall
award--
(i) at least 6 grants to providers of
services described in paragraph (1)(A)(i);
(ii) at least 6 grants to service providers
described in paragraph (1)(A)(ii);
(iii) at least 6 grants to organizations
described in paragraph (1)(A)(iii); and
(iv) at least 6 grants to sponsors
described in paragraph (1)(A)(iv).
(B) For community organizations.--The Secretary
shall give priority to applicants that have developed
partnerships with community organizations or with
agencies with experience in language access.
(C) Variation in grantees.--The Secretary shall
also ensure that the grantees under this section
represent, among other factors--
(i) different types of language services
provided and of service providers and
organizations under parts A through D of title
XVIII of the Social Security Act;
(ii) variations in languages needed and
their frequency of use;
(iii) urban and rural settings;
(iv) at least two geographic regions, as
defined by the Secretary; and
(v) at least two large metropolitan
statistical areas with diverse populations.
(c) Use of Funds.--
(1) In general.--A grantee shall use grant funds received
under this section to pay for the provision of competent
language services to Medicare beneficiaries who are limited
English proficient. Competent interpreter services may be
provided through on-site interpretation, telephonic
interpretation, or video interpretation or direct provision of
health care or health care related services by a bilingual
health care provider. A grantee may use bilingual providers,
staff, or contract interpreters. A grantee may use grant funds
to pay for competent translation services. A grantee may use up
to 10 percent of the grant funds to pay for administrative
costs associated with the provision of competent language
services and for reporting required under subsection (e).
(2) Organizations.--Grantees that are part C organizations
or PDP sponsors must ensure that their network providers
receive at least 50 percent of the grant funds to pay for the
provision of competent language services to Medicare
beneficiaries who are limited English proficient, including
physicians and pharmacies.
(3) Determination of payments for language services.--
Payments to grantees shall be calculated based on the estimated
numbers of limited English proficient Medicare beneficiaries in
a grantee's service area utilizing--
(A) data on the numbers of limited English
proficient individuals who speak English less than
``very well'' from the most recently available data
from the Bureau of the Census or other State-based
study the Secretary determines likely to yield accurate
data regarding the number of such individuals served by
the grantee; or
(B) the grantee's own data if the grantee routinely
collects data on Medicare beneficiaries' primary
language in a manner determined by the Secretary to
yield accurate data and such data shows greater numbers
of limited English proficient individuals than the data
listed in subparagraph (A).
(4) Limitations.--
(A) Reporting.--Payments shall only be provided
under this section to grantees that report their costs
of providing language services as required under
subsection (e) and may be modified annually at the
discretion of the Secretary. If a grantee fails to
provide the reports under such section for the first
year of a grant, the Secretary may terminate the grant
and solicit applications from new grantees to
participate in the subsequent two years of the
demonstration program.
(B) Type of services.--
(i) In general.--Subject to clause (ii),
payments shall be provided under this section
only to grantees that utilize competent
bilingual staff or competent interpreter or
translation services which--
(I) if the grantee operates in a
State that has statewide health care
interpreter standards, meet the State
standards currently in effect; or
(II) if the grantee operates in a
State that does not have statewide
health care interpreter standards,
utilizes competent interpreters who
follow the National Council on
Interpreting in Health Care's Code of
Ethics and Standards of Practice.
(ii) Exemptions.--The requirements of
clause (i) shall not apply--
(I) in the case of a Medicare
beneficiary who is limited English
proficient (who has been informed in
the beneficiary's primary language of
the availability of free interpreter
and translation services) and who
requests the use of family, friends, or
other persons untrained in
interpretation or translation and the
grantee documents the request in the
beneficiary's record; and
(II) in the case of a medical
emergency where the delay directly
associated with obtaining a competent
interpreter or translation services
would jeopardize the health of the
patient.
Nothing in clause (ii)(II) shall be construed
to exempt emergency rooms or similar entities
that regularly provide health care services in
medical emergencies from having in place
systems to provide competent interpreter and
translation services without undue delay.
(d) Assurances.--Grantees under this section shall--
(1) ensure that appropriate clinical and support staff
receive ongoing education and training in linguistically
appropriate service delivery;
(2) ensure the linguistic competence of bilingual
providers;
(3) offer and provide appropriate language services at no
additional charge to each patient with limited English
proficiency at all points of contact, in a timely manner during
all hours of operation;
(4) notify Medicare beneficiaries of their right to receive
language services in their primary language;
(5) post signage in the languages of the commonly
encountered group or groups present in the service area of the
organization; and
(6) ensure that--
(A) primary language data are collected for
recipients of language services and are consistent with
standards developed under section 1709(b)(3)(B)(iv) of
the Public Health Service Act, as added by section 2402
of this Act, to the extent such standards are available
upon the initiation of the demonstration; and
(B) consistent with the privacy protections
provided under the regulations promulgated pursuant to
section 264(c) of the Health Insurance Portability and
Accountability Act of 1996 (42 U.S.C. 1320d-2 note), if
the recipient of language services is a minor or is
incapacitated, the primary language of the parent or
legal guardian is collected and utilized.
(e) Reporting Requirements.--Grantees under this section shall
provide the Secretary with reports at the conclusion of the each year
of a grant under this section. Each report shall include at least the
following information:
(1) The number of Medicare beneficiaries to whom language
services are provided.
(2) The languages of those Medicare beneficiaries.
(3) The types of language services provided (such as
provision of services directly in non-English language by a
bilingual health care provider or use of an interpreter).
(4) Type of interpretation (such as in-person, telephonic,
or video interpretation).
(5) The methods of providing language services (such as
staff or contract with external independent contractors or
agencies).
(6) The length of time for each interpretation encounter.
(7) The costs of providing language services (which may be
actual or estimated, as determined by the Secretary).
(8) An account of the training or accreditation of
bilingual staff, interpreters, or translators providing
services under this demonstration.
(f) No Cost Sharing.--Limited English proficient Medicare
beneficiaries shall not have to pay cost-sharing or co-pays for
language services provided through this demonstration program.
(g) Evaluation and Report.--The Secretary shall conduct an
evaluation of the demonstration program under this section and shall
submit to the appropriate committees of Congress a report not later
than 1 year after the completion of the program. The report shall
include the following:
(1) An analysis of the patient outcomes and costs of
furnishing care to the limited English proficient Medicare
beneficiaries participating in the project as compared to such
outcomes and costs for limited English proficient Medicare
beneficiaries not participating.
(2) The effect of delivering culturally and linguistically
appropriate services on beneficiary access to care, utilization
of services, efficiency and cost-effectiveness of health care
delivery, patient satisfaction, and select health outcomes.
(3) The extent to which bilingual staff, interpreters, and
translators providing services under such demonstration were
trained or accredited and the nature of accreditation or
training needed by type of provider, service, or other category
as determined by the Secretary to ensure the provision of high-
quality interpretation, translation, or other language services
to Medicare beneficiaries if such services are expanded
pursuant to subsection (c) of section 1907 of this Act.
(4) Recommendations, if any, regarding the extension of
such project to the entire Medicare program.
(h) Accreditation or Training for Providers of Interpretation,
Translation or Language Services in Medicare.--
(1) In general.--
(A) Designation of standards.--If the Secretary,
pursuant to section 1907(c) of this Act, expands the
model initially developed through the demonstration
program under this section, the Secretary shall use the
results of the study under section 1221 and the
demonstration under this section to designate standards
for training or accreditation. The Secretary may
designate one or more training or accreditation
organizations, as appropriate for the nature and type
of interpretation and translation services provided to
Medicare beneficiaries to ensure that payments are made
only for approved services by trained or accredited
language services providers.
(B) Alternatives to training or accreditation.--If
the Secretary designates one or more training or
accreditation organizations but determines that
accreditation is not available in all languages for
which payments may be initiated, the Secretary shall
provide payments for and accept alternatives to
training or accreditation for certain languages,
including languages of lesser diffusion. The
Secretary must ensure that the alternatives to
training or accreditation provide, at a minimum--
(i) a determination that the interpreter is
proficient and able to communicate information
accurately in both English and in the language
for which interpreting is needed;
(ii) an attestation from the interpreter to
comply with and adhere to the role of an
interpreter as defined by the National Code of
Ethics and National Standards of Practice as
published by the National Council on
Interpreting in Health Care; and
(iii) an attestation to adhere to HIPAA
privacy and security law, as defined in section
3009(a)(2) of the Public Health Service Act, to
the same extent as the healthcare provider for
whom interpreting is provided.
(C) Modifiers, add-ons, and other forms of
payment.--If the Secretary decides that modifiers, add-
ons, or other forms of payment may be made for the
provision of services directly by bilingual providers,
the Secretary shall designate standards to ensure the
competency of such providers delivering such services
in a non-English language.
(2) Consultation with stakeholders and considerations for
accreditation or training.--
(A) Consultation.--In designating accreditation or
training requirements under this subsection, the
Secretary shall consult with patients, providers,
organizations that advocate on behalf of limited
English proficient individuals, and other individuals
or entities determined appropriate by the Secretary.
(B) Considerations.--In designating accreditation
or training requirements under this section, the
Secretary shall consider, as appropriate--
(i) standards for qualifications of health
care interpreters who interpret infrequently
encountered languages;
(ii) standards for qualifications of health
care interpreters who interpret in languages of
lesser diffusion;
(iii) standards for training of
interpreters; and
(iv) standards for continuing education of
interpreters.
(i) General Provisions.--Nothing in this section shall be construed
to limit otherwise existing obligations of recipients of Federal
financial assistance under title VI of the Civil Rights Act of 1964 (42
U.S.C. 2000(d) et seq.) or any other statute.
(j) Appropriations.--There are appropriated to carry out this
section, in equal parts from the Federal Hospital Insurance Trust Fund
and the Federal Supplementary Medical Insurance Trust Fund, $16,000,000
for each fiscal year of the demonstration program.
SEC. 1223. IOM REPORT ON IMPACT OF LANGUAGE ACCESS SERVICES.
(a) In General.--The Secretary of Health and Human Services shall
enter into an arrangement with the Institute of Medicine under which
the Institute will prepare and publish, not later than 3 years after
the date of the enactment of this Act, a report on the impact of
language access services on the health and health care of limited
English proficient populations.
(b) Contents.--Such report shall include--
(1) recommendations on the development and implementation
of policies and practices by health care organizations and
providers for limited English proficient patient populations;
(2) a description of the effect of providing language
access services on quality of health care and access to care
and reduced medical error; and
(3) a description of the costs associated with or savings
related to provision of language access services.
SEC. 1224. DEFINITIONS.
In this subtitle:
(1) Bilingual.--The term ``bilingual'' with respect to an
individual means a person who has sufficient degree of
proficiency in two languages and can ensure effective
communication can occur in both languages.
(2) Competent interpreter services.--The term ``competent
interpreter services'' means a trans-language rendition of a
spoken message in which the interpreter comprehends the source
language and can speak comprehensively in the target language
to convey the meaning intended in the source language. The
interpreter knows health and health-related terminology and
provides accurate interpretations by choosing equivalent
expressions that convey the best matching and meaning to the
source language and captures, to the greatest possible extent,
all nuances intended in the source message.
(3) Competent translation services.--The term ``competent
translation services'' means a trans-language rendition of a
written document in which the translator comprehends the source
language and can write comprehensively in the target language
to convey the meaning intended in the source language. The
translator knows health and health-related terminology and
provides accurate translations by choosing equivalent
expressions that convey the best matching and meaning to the
source language and captures, to the greatest possible extent,
all nuances intended in the source document.
(4) Effective communication.--The term ``effective
communication'' means an exchange of information between the
provider of health care or health care-related services and the
limited English proficient recipient of such services that
enables limited English proficient individuals to access,
understand, and benefit from health care or health care-related
services.
(5) Interpreting/interpretation.--The terms
``interpreting'' and ``interpretation'' mean the transmission
of a spoken message from one language into another, faithfully,
accurately, and objectively.
(6) Health care services.--The term ``health care
services'' means services that address physical as well as
mental health conditions in all care settings.
(7) Health care-related services.--The term ``health care-
related services'' means human or social services programs or
activities that provide access, referrals or links to health
care.
(8) Language access.--The term ``language access'' means
the provision of language services to an LEP individual
designed to enhance that individual's access to, understanding
of or benefit from health care or health care-related services.
(9) Language services.--The term ``language services''
means provision of health care services directly in a non-
English language, interpretation, translation, and non-English
signage.
(10) Limited english proficient.--The term ``limited
English proficient'' or ``LEP'' with respect to an individual
means an individual who speaks a primary language other than
English and who cannot speak, read, write or understand the
English language at a level that permits the individual to
effectively communicate with clinical or nonclinical staff at
an entity providing health care or health care related
services.
(11) Medicare beneficiary.--The term ``Medicare
beneficiary'' means an individual entitled to benefits under
part A of title XVIII of the Social Security Act or enrolled
under part B of such title.
(12) Medicare program.--The term ``Medicare program'' means
the programs under parts A through D of title XVIII of the
Social Security Act.
(13) Service provider.--The term ``service provider''
includes all suppliers, providers of services, or entities
under contract to provide coverage, items or services under any
part of title XVIII of the Social Security Act.
Subtitle C--Miscellaneous Improvements
SEC. 1231. EXTENSION OF THERAPY CAPS EXCEPTIONS PROCESS.
Section 1833(g)(5) of the Social Security Act (42 U.S.C.
1395l(g)(5)), as amended by section 141 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, 2011''.
SEC. 1232. EXTENDED MONTHS OF COVERAGE OF IMMUNOSUPPRESSIVE DRUGS FOR
KIDNEY TRANSPLANT PATIENTS AND OTHER RENAL DIALYSIS
PROVISIONS.
(a) Provision of Appropriate Coverage of Immunosuppressive Drugs
Under the Medicare Program for Kidney Transplant Recipients.--
(1) Continued entitlement to immunosuppressive drugs.--
(A) Kidney transplant recipients.--Section
226A(b)(2) of the Social Security Act (42 U.S.C. 426-
1(b)(2)) is amended by inserting ``(except for coverage
of immunosuppressive drugs under section
1861(s)(2)(J))'' before ``, with the thirty-sixth
month''.
(B) Application.--Section 1836 of such Act (42
U.S.C. 1395o) is amended--
(i) by striking ``Every individual who''
and inserting ``(a) In General.--Every
individual who''; and
(ii) by adding at the end the following new
subsection:
``(b) Special Rules Applicable to Individuals Only Eligible for
Coverage of Immunosuppressive Drugs.--
``(1) In general.--In the case of an individual whose
eligibility for benefits under this title has ended on or after
January 1, 2012, except for the coverage of immunosuppressive
drugs by reason of section 226A(b)(2), the following rules
shall apply:
``(A) The individual shall be deemed to be enrolled
under this part for purposes of receiving coverage of
such drugs.
``(B) The individual shall be responsible for
providing for payment of the portion of the premium
under section 1839 which is not covered under the
Medicare savings program (as defined in section
1144(c)(7)) in order to receive such coverage.
``(C) The provision of such drugs shall be subject
to the application of--
``(i) the deductible under section 1833(b);
and
``(ii) the coinsurance amount applicable
for such drugs (as determined under this part).
``(D) If the individual is an inpatient of a
hospital or other entity, the individual is entitled to
receive coverage of such drugs under this part.
``(2) Establishment of procedures in order to implement
coverage.--The Secretary shall establish procedures for--
``(A) identifying individuals that are entitled to
coverage of immunosuppressive drugs by reason of
section 226A(b)(2); and
``(B) distinguishing such individuals from
individuals that are enrolled under this part for the
complete package of benefits under this part.''.
(C) Technical amendment to correct duplicate
subsection designation.--Subsection (c) of section 226A
of such Act (42 U.S.C. 426-1), as added by section
201(a)(3)(D)(ii) of the Social Security Independence
and Program Improvements Act of 1994 (Public Law 103-
296; 108 Stat. 1497), is redesignated as subsection
(d).
(2) Extension of secondary payer requirements for esrd
beneficiaries.--Section 1862(b)(1)(C) of such Act (42 U.S.C.
1395y(b)(1)(C)) is amended by adding at the end the following
new sentence: ``With regard to immunosuppressive drugs
furnished on or after the date of the enactment of the
Affordable Health Care for America Act, this subparagraph shall
be applied without regard to any time limitation.''.
(b) Medicare Coverage for ESRD Patients.--Section 1881 of such Act
is further amended--
(1) in subsection (b)(14)(B)(iii), by inserting ``,
including oral drugs that are not the oral equivalent of an
intravenous drug (such as oral phosphate binders and
calcimimetics),'' after ``other drugs and biologicals'';
(2) in subsection (b)(14)(E)(ii)--
(A) in the first sentence--
(i) by striking ``a one-time election to be
excluded from the phase-in'' and inserting ``an
election, with respect to 2011, 2012, or 2013,
to be excluded from the phase-in (or the
remainder of the phase-in)''; and
(ii) by adding before the period at the end
the following: ``for such year and for each
subsequent year during the phase-in described
in clause (i)''; and
(B) in the second sentence--
(i) by striking ``January 1, 2011'' and
inserting ``the first date of such year''; and
(ii) by inserting ``and at a time'' after
``form and manner''; and
(3) in subsection (h)(4)(E), by striking ``lesser'' and
inserting ``greater''.
SEC. 1233. VOLUNTARY ADVANCE CARE PLANNING CONSULTATION.
(a) In General.--Section 1861 of the Social Security Act (42 U.S.C.
1395x) is amended--
(1) in subsection (s)(2)--
(A) by striking ``and'' at the end of subparagraph
(DD);
(B) by adding ``and'' at the end of subparagraph
(EE); and
(C) by adding at the end the following new
subparagraph:
``(FF) voluntary advance care planning consultation (as
defined in subsection (hhh)(1));''; and
(2) by adding at the end the following new subsection:
``Voluntary Advance Care Planning Consultation
``(hhh)(1) Subject to paragraphs (3) and (4), the term `voluntary
advance care planning consultation' means an optional consultation
between the individual and a practitioner described in paragraph (2)
regarding advance care planning. Such consultation may include the
following, as specified by the Secretary:
``(A) An explanation by the practitioner of advance care
planning, including a review of key questions and
considerations, advance directives (including living wills and
durable powers of attorney) and their uses.
``(B) An explanation by the practitioner of the role and
responsibilities of a health care proxy and of the continuum of
end-of-life services and supports available, including
palliative care and hospice, and benefits for such services and
supports that are available under this title.
``(C) An explanation by the practitioner of physician
orders regarding life sustaining treatment or similar orders,
in States where such orders or similar orders exist.
``(2) A practitioner described in this paragraph is--
``(A) a physician (as defined in subsection (r)(1)); and
``(B) another health care professional (as specified by the
Secretary and who has the authority under State law to sign
orders for life sustaining treatments, such as a nurse
practitioner or physician assistant).
``(3) An individual may receive the voluntary advance care planning
care planning consultation provided for under this subsection no more
than once every 5 years unless there is a significant change in the
health or health-related condition of the individual.
``(4) For purposes of this section, the term `order regarding life
sustaining treatment' means, with respect to an individual, an
actionable medical order relating to the treatment of that individual
that effectively communicates the individual's preferences regarding
life sustaining treatment, is signed and dated by a practitioner, and
is in a form that permits it to be followed by health care
professionals across the continuum of care.''.
(b) Construction.--The voluntary advance care planning consultation
described in section 1861(hhh) of the Social Security Act, as added by
subsection (a), shall be completely optional. Nothing in this section
shall--
(1) require an individual to complete an advance directive,
an order for life sustaining treatment, or other advance care
planning document;
(2) require an individual to consent to restrictions on the
amount, duration, or scope of medical benefits an individual is
entitled to receive under this title; or
(3) encourage the promotion of suicide or assisted suicide.
(c) Payment.--Section 1848(j)(3) of such Act (42 U.S.C. 1395w-
4(j)(3)) is amended by inserting ``(2)(FF),'' after ``(2)(EE),''.
(d) Frequency Limitation.--Section 1862(a) of such 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 voluntary advance care
planning consultations (as defined in paragraph (1) of
section 1861(hhh)), 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 consultations furnished on or after January 1, 2011.
SEC. 1234. PART B SPECIAL ENROLLMENT PERIOD AND WAIVER OF LIMITED
ENROLLMENT PENALTY FOR TRICARE BENEFICIARIES.
(a) Part B Special Enrollment Period.--
(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 hospital insurance benefits under
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, on the first
day of the second month following the last month of the individual's
initial enrollment period.
``(4) The Secretary of Defense shall establish a method for
identifying individuals described in paragraph (1) and providing notice
to them of their eligibility for enrollment during the special
enrollment period described in paragraph (2).''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to elections made on or after the date of the
enactment of this Act.
(b) Waiver of Increase of Premium.--
(1) In general.--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''.
(2) Effective date.--
(A) In general.--The amendment made by paragraph
(1) shall apply with respect to elections made on or
after the date of the enactment of this Act.
(B) Rebates for certain disabled and esrd
beneficiaries.--
(i) In general.--With respect to premiums
for months on or after January 2005 and before
the month of the enactment of this Act, no
increase in the premium shall be effected for a
month 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 hospital
insurance benefits under part A of title XVIII
of the Social Security Act under section 226(b)
or 226A of such Act, 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, and who enrolls
under this part within the 12-month period that
begins on the first day of the month after the
month of notification of entitlement under this
part.
(ii) Consultation with department of
defense.--The Secretary of Health and Human
Services shall consult with the Secretary of
Defense in identifying individuals described in
this paragraph.
(iii) Rebates.--The Secretary of Health and
Human Services shall establish a method for
providing rebates of premium increases paid for
months on or after January 1, 2005, and before
the month of the enactment of this Act for
which a penalty was applied and collected.
SEC. 1235. EXCEPTION FOR USE OF MORE RECENT TAX YEAR IN CASE OF GAINS
FROM SALE OF PRIMARY RESIDENCE IN COMPUTING PART B
INCOME-RELATED PREMIUM.
(a) In General.--Section 1839(i)(4)(C)(ii)(II) of the Social
Security Act (42 U.S.C. 1395r(i)(4)(C)(ii)(II)) is amended by inserting
``sale of primary residence,'' after ``divorce of such individual,''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to premiums and payments for years beginning with 2011.
SEC. 1236. DEMONSTRATION PROGRAM ON USE OF PATIENT DECISIONS AIDS.
(a) In General.--The Secretary of Health and Human Services ,
acting through the Center for Medicare and Medicaid Innovation
established under section 1115A of the Social Security Act (as added by
section 1907) and consistent with the applicable provisions of such
section, shall establish a shared decision making demonstration program
(in this subsection referred to as the ``program'') under the Medicare
program using patient decision aids to meet the objective of improving
the understanding by Medicare beneficiaries of their medical treatment
options, as compared to comparable Medicare beneficiaries who do not
participate in a shared decision making process using patient decision
aids.
(b) Sites.--
(1) Enrollment.--The Secretary shall enroll in the program
not more than 30 eligible providers who have experience in
implementing, and have invested in the necessary infrastructure
to implement, shared decision making using patient decision
aids.
(2) Application.--An eligible provider seeking to
participate in the program shall submit to the Secretary an
application at such time and containing such information as the
Secretary may require.
(3) Preference.--In enrolling eligible providers in the
program, the Secretary shall give preference to eligible
providers that--
(A) have documented experience in using patient
decision aids for the conditions identified by the
Secretary and in using shared decision making;
(B) have the necessary information technology
infrastructure to collect the information required by
the Secretary for reporting purposes; and
(C) are trained in how to use patient decision aids
and shared decision making.
(c) Follow-up Counseling Visit.--
(1) In general.--An eligible provider participating in the
program shall routinely schedule Medicare beneficiaries for a
counseling visit after the viewing of such a patient decision
aid to answer any questions the beneficiary may have with
respect to the medical care of the condition involved and to
assist the beneficiary in thinking through how their
preferences and concerns relate to their medical care.
(2) Payment for follow-up counseling visit.--The Secretary
shall establish procedures for making payments for such
counseling visits provided to Medicare beneficiaries under the
program. Such procedures shall provide for the establishment--
(A) of a code (or codes) to represent such
services; and
(B) of a single payment amount for such service
that includes the professional time of the health care
provider and a portion of the reasonable costs of the
infrastructure of the eligible provider such as would
be made under the applicable payment systems to that
provider for similar covered services.
(d) Costs of Aids.--An eligible provider participating in the
program shall be responsible for the costs of selecting, purchasing,
and incorporating such patient decision aids into the provider's
practice, and reporting data on quality and outcome measures under the
program.
(e) Funding.--The Secretary shall provide for the transfer from the
Federal Supplementary Medical Insurance Trust Fund established under
section 1841 of the Social Security Act (42 U.S.C. 1395t) of such funds
as are necessary for the costs of carrying out the program.
(f) Waiver Authority.--The Secretary may waive such requirements of
titles XI and XVIII of the Social Security Act (42 U.S.C. 1301 et seq.
and 1395 et seq.) as may be necessary for the purpose of carrying out
the program.
(g) Report.--Not later than 12 months after the date of completion
of the program, the Secretary shall submit to Congress a report on such
program, together with recommendations for such legislation and
administrative action as the Secretary determines to be appropriate.
The final report shall include an evaluation of the impact of the use
of the program on health quality, utilization of health care services,
and on improving the quality of life of such beneficiaries.
(h) Definitions.--In this section:
(1) Eligible provider.--The term ``eligible provider''
means the following:
(A) A primary care practice.
(B) A specialty practice.
(C) A multispecialty group practice.
(D) A hospital.
(E) A rural health clinic.
(F) A Federally qualified health center (as defined
in section 1861(aa)(4) of the Social Security Act (42
U.S.C. 1395x(aa)(4)).
(G) An integrated delivery system.
(H) A State cooperative entity that includes the
State government and at least one other health care
provider which is set up for the purpose of testing
shared decision making and patient decision aids.
(2) Patient decision aid.--The term ``patient decision
aid'' means an educational tool (such as the Internet, a video,
or a pamphlet) that helps patients (or, if appropriate, the
family caregiver of the patient) 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.
(3) Shared decision making.--The term ``shared decision
making'' means a collaborative process between patient and
clinician that engages the patient in decision making, provides
patients with information about trade-offs among treatment
options, and facilitates the incorporation of patient
preferences and values into the medical plan.
TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND
COORDINATED CARE
SEC. 1301. ACCOUNTABLE CARE ORGANIZATION PILOT PROGRAM.
Title XVIII of the Social Security Act is amended by inserting
after section 1866D, as added by section 1152(f), the following new
section:
``accountable care organization pilot program
``Sec. 1866E. (a) Establishment.--
``(1) In General.-- The Secretary shall conduct a pilot program (in
this section referred to as the `pilot program') to test different
payment incentive models, including (to the extent practicable) the
specific payment incentive models described in subsection (c), designed
to reduce the growth of expenditures and improve health outcomes in the
provision of items and services under this title to applicable
beneficiaries (as defined in subsection (e)) by qualifying accountable
care organizations (as defined in subsection (b)(1)) in order to--
``(A) promote accountability for a patient population and
coordinate items and services under parts A and B (and may
include Part D, if the Secretary determines appropriate);
``(B) encourage investment in infrastructure and redesigned
care processes for high quality and efficient service delivery;
and
``(C) reward physician practices and other physician
organizational models for the provision of high quality and
efficient health care services.
``(2) Scope.--The Secretary shall set specific goals for the number
of accountable care organizations, participating practitioners, and
patients served in the initial tests under the pilot program to ensure
that the pilot program is of sufficient size and scope to--
``(A) test the approach involved in a variety of settings,
including urban, rural, and underserved areas; and
``(B) subject to subsection (g)(1), disseminate such
approach rapidly on a national basis.
To the extent that the Secretary finds a qualifying accountable care
organization model to be successful in improving quality and reducing
costs, the Secretary shall seek to implement such models on as large a
geographic scale as practical and economical.
``(b) Qualifying Accountable Care Organizations (ACOs).--
``(1) Qualifying aco defined.--In this section:
``(A) In general.--The terms `qualifying
accountable care organization' and `qualifying ACO'
mean a group of physicians or other physician
organizational model (as defined in subparagraph (D))
that--
``(i) is organized at least in part for the
purpose of providing physicians' services; and
``(ii) meets such criteria as the Secretary
determines to be appropriate to participate in
the pilot program, including the criteria
specified in paragraph (2).
``(B) Inclusion of other providers of services and
suppliers.--Nothing in this subsection shall be
construed as preventing a qualifying ACO from including
a hospital or any other provider of services or
supplier furnishing items or services for which payment
may be made under this title that is affiliated with
the ACO under an arrangement structured so that such
provider or supplier participates in the pilot program
and shares in any incentive payments under the pilot
program.
``(C) 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 under this title.
``(D) Other physician organizational model.--The
term `other physician organization model' means, with
respect to a qualifying ACO any model of organization
under which physicians enter into agreements with other
providers of services for the purposes of participation
in the pilot program in order to provide high quality
and efficient health care services and share in any
incentive payments under such program
``(E) Other services.--Nothing in this paragraph
shall be construed as preventing a qualifying ACO from
furnishing items or services, for which payment may not
be made under this title, for purposes of achieving
performance goals under the pilot program.
``(2) Qualifying criteria.--The following are criteria
described in this paragraph for an organized group of
physicians to be a qualifying ACO:
``(A) The group has a legal structure that would
allow the group to receive and distribute incentive
payments under this section.
``(B) The group includes a sufficient number of
primary care physicians (regardless of specialty) for
the applicable beneficiaries for whose care the group
is accountable (as determined by the Secretary).
``(C) The group reports 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).
``(D) The group reports 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 pilot program.
``(E) The group provides notice to applicable
beneficiaries regarding the pilot program (as
determined appropriate by the Secretary).
``(F) The group contributes to a best practices
network or website, that shall be maintained by the
Secretary for the purpose of sharing strategies on
quality improvement, care coordination, and efficiency
that the groups believe are effective.
``(G) The group utilizes patient-centered processes
of care, including those that emphasize patient and
caregiver involvement in planning and monitoring of
ongoing care management plan.
``(H) The group meets other criteria determined to
be appropriate by the Secretary.
``(c) Specific Payment Incentive Models.--The specific payment
incentive models described in this subsection are the following:
``(1) Performance target model.--Under the performance
target model under this paragraph (in this paragraph referred
to as the `performance target model'):
``(A) In general.--A qualifying ACO qualifies to
receive an incentive payment if expenditures for items
and services for applicable beneficiaries are less than
a target spending level or a target rate of growth. The
incentive payment shall be made only if savings are
greater than would result from normal variation in
expenditures for items and services covered under parts
A and B (and may include Part D, if the Secretary
determines appropriate).
``(B) Computation of performance target.--
``(i) In general.--The Secretary shall
establish a performance target for each
qualifying ACO comprised of a base amount
(described in clause (ii)) increased to the
current year by an adjustment factor (described
in clause (iii)). Such a target may be
established on a per capita basis or adjusted
for risk, as the Secretary determines to be
appropriate.
``(ii) Base amount.--For purposes of clause
(i), the base amount in this subparagraph is
equal to the average total payments (or allowed
charges) under parts A and B (and may include
part D, if the Secretary determines
appropriate) for applicable beneficiaries for
whom the qualifying ACO furnishes items and
services in a base period determined by the
Secretary. Such base amount may be determined
on a per capita basis or adjusted for risk.
``(iii) Adjustment factor.--For purposes of
clause (i), the adjustment factor in this
clause may equal an annual per capita amount
that reflects changes in expenditures from the
period of the base amount to the current year
that would represent an appropriate performance
target for applicable beneficiaries (as
determined by the Secretary).
``(iv) Rebasing.--Under this model the
Secretary shall periodically rebase the base
expenditure amount described in clause (ii).
``(C) Meeting target.--
``(i) In general.--Subject to clause (ii),
a qualifying ACO that meets or exceeds annual
quality and performance targets for a year
shall receive an incentive payment for such
year equal to a portion (as determined
appropriate by the Secretary) of the amount by
which payments under this title for such year
are estimated to be below the performance
target for such year, as determined by the
Secretary. The Secretary may establish a cap on
incentive payments for a year for a qualifying
ACO.
``(ii) Limitation.-- The Secretary shall
limit incentive payments to each qualifying ACO
under this paragraph as necessary to ensure
that the aggregate expenditures with respect to
applicable beneficiaries for such ACOs under
this title (inclusive of incentive payments
described in this subparagraph) do not exceed
the amount that the Secretary estimates would
be expended for such ACO for such beneficiaries
if the pilot program under this section were
not implemented.
``(D) Reporting and other requirements.--In
carrying out such model, the Secretary may (as the
Secretary determines to be appropriate) incorporate
reporting requirements, incentive payments, and
penalties related to the physician quality reporting
initiative (PQRI), 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 this subparagraph shall
not be included in the limit described in subparagraph
(C)(ii) or in the performance target model described in
this paragraph.
``(2) Partial capitation model.--
``(A) In general.--Subject to subparagraph (B), a
partial capitation model described in this paragraph
(in this paragraph referred to as a `partial capitation
model') is a model in which a qualifying ACO would be
at financial risk for some, but not all, of the items
and services covered under parts A and B (and may
include part D, if the Secretary determines
appropriate), 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 a qualifying ACO for items and services under this
title for applicable 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 pilot program were not implemented, as
estimated by the Secretary.
``(3) Other payment models.--
``(A) In general.--Subject to subparagraph (B), the
Secretary may develop other payment models that meet
the goals of this pilot program to improve quality and
efficiency.
``(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).
``(d) Annual Quality Targets.--
``(1) In general.--The Secretary shall establish annual
quality targets that qualifying ACOs must meet to receive
incentive payments, operate at financial risk, or otherwise
participate in alternative financing models under this section.
The Secretary shall establish a process for developing annual
targets based on ACO reporting of multiple quality measures. In
selecting measures the Secretary shall--
``(A) for years one and two of each ACOs
participation in the pilot program established by this
section, require reporting of a starter set of measures
focused on clinical care, care coordination and patient
experience of care; and
``(B) for each subsequent year, require reporting
of a more comprehensive set of clinical outcomes
measures, care coordination measures and patient
experience of care measures.
``(2) Measure selection.--To the extent feasible, the
Secretary shall select measures that reflect national
priorities for quality improvement and patient-centered care
consistent with the measures developed under section
1192(c)(1).
``(e) Applicable Beneficiaries.--
``(1) In general.--In this section, the term `applicable
beneficiary' means, with respect to a qualifying ACO, an
individual who--
``(A) is enrolled under part B and entitled to
benefits under part A;
``(B) is not enrolled in a Medicare Advantage plan
under part C or a PACE program under section 1894; and
``(C) meets such other criteria as the Secretary
determines appropriate, which may include criteria
relating to frequency of contact with physicians in the
ACO
``(2) Following 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 ACO.
``(f) Implementation.--
``(1) Starting date.--The pilot program shall begin no
later than January 1, 2012. An agreement with a qualifying ACO
under the pilot program may cover a multi-year period of
between 3 and 5 years.
``(2) Waiver.--The Secretary may waive such provisions of
this title (including section 1877) and title XI in the manner
the Secretary determines necessary in order implement the pilot
program.
``(3) Performance results reports.--The Secretary shall
report performance results to qualifying ACOs under the pilot
program at least annually.
``(4) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of--
``(A) the elements, parameters, scope, and duration
of the pilot program;
``(B) the selection of qualifying ACOs for the
pilot program;
``(C) the establishment of targets, measurement of
performance, determinations with respect to whether
savings have been achieved and the amount of savings;
``(D) determinations regarding whether, to whom,
and in what amounts incentive payments are paid; and
``(E) decisions about the extension of the program
under subsection (h), expansion of the program under
subsection (i) or extensions under subsections (j) or
(k).
``(5) Administration.--Chapter 35 of title 44, United
States Code shall not apply to this section.
``(g) Evaluation; Monitoring.--
``(1) In general.--The Secretary shall evaluate the payment
incentive model for each qualifying ACO under the pilot program
to assess impacts on beneficiaries, providers of services,
suppliers and the program under this title. The Secretary shall
make such evaluation publicly available within 60 days of the
date of completion of such report.
``(2) Monitoring.--The Inspector General of the Department
of Health and Human Services shall provide for monitoring of
the operation of ACOs under the pilot program with regard to
violations of section 1877 (popularly known as the `Stark
law').
``(h) Extension of Pilot Agreement With Successful Organizations.--
``(1) Reports to congress.--Not later than 2 years after
the date the first agreement is entered into under this
section, and biennially thereafter for six years, the Secretary
shall submit to Congress and make publicly available a report
on the use of ACO payment models under the pilot program. Each
report shall address the impact of the use of those models on
expenditures, access, and quality under this title.
``(2) Extension.--Subject to the report provided under
paragraph (1), with respect to a qualifying ACO, the Secretary
may extend the duration of the agreement for such ACO under the
pilot program as the Secretary determines appropriate if--
``(A) the ACO receives incentive payments with
respect to any of the first 4 years of the pilot
agreement and is consistently meeting quality standards
or
``(B) the ACO is consistently exceeding quality
standards and is not increasing spending under the
program.
``(3) Termination.--The Secretary may terminate an
agreement with a qualifying ACO under the pilot program if such
ACO did not receive incentive payments or consistently failed
to meet quality standards in any of the first 3 years under the
program.
``(i) Expansion to Additional ACOs.--
``(1) Testing and refinement of payment incentive models.--
Subject to the evaluation described in subsection (g), the
Secretary may enter into agreements under the pilot program
with additional qualifying ACOs to further test and refine
payment incentive models with respect to qualifying ACOs.
``(2) Expanding use of successful models to program
implementation.--
``(A) In general.--Subject to subparagraph (B), the
Secretary may issue regulations to implement, on a
permanent basis, 1 or more models if, and to the extent
that, such models are beneficial to the program under
this title, as determined by the Secretary.
``(B) Certification.--The Chief Actuary of the
Centers for Medicare & Medicaid Services shall certify
that 1 or more of such models described in subparagraph
(A) would result in estimated spending that would be
less than what spending would otherwise be estimated to
be in the absence of such expansion.
``(j) Treatment of Physician Group Practice Demonstration.--
``(1) Extension.--The Secretary may enter in to an
agreement with a qualifying ACO under the demonstration under
section 1866A, subject to rebasing and other modifications
deemed appropriate by the Secretary, until the pilot program
under this section is operational.
``(2) Transition.--For purposes of extension of an
agreement with a qualifying ACO under subsection (h)(2), the
Secretary shall treat receipt of an incentive payment for a
year by an organization under the physician group practice
demonstration pursuant to section 1866A as a year for which an
incentive payment is made under such subsection, as long as
such practice group practice organization meets the criteria
under subsection (b)(2).
``(k) Additional Provisions.--
``(1) Authority for separate incentive arrangements.--The
Secretary may create separate incentive arrangements (including
using multiple years of data, varying thresholds, varying
shared savings amounts, and varying shared savings limits) for
different categories of qualifying ACOs to reflect variation in
average annual attributable expenditures and other matters the
Secretary deems appropriate.
``(2) Encouragement of participation of smaller
organizations.--In order to encourage the participation of
smaller accountable care organizations under the pilot program,
the Secretary may limit a qualifying ACO's exposure to high
cost patients under the program.
``(3) 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.
``(4) Antidiscrimination limitation.--The Secretary shall
not enter into an agreement with an entity to provide health
care items or services under the pilot program, or with an
entity to administer the program, unless such entity guarantees
that it will not deny, limit, or condition the coverage or
provision of benefits under the program, for individuals
eligible to be enrolled under such program, based on any health
status-related factor described in section 2702(a)(1) of the
Public Health Service Act.
``(5) Funding.--For purposes of administering and carrying
out the pilot program, other than for payments for items and
services furnished under this title and incentive payments
under subsection (c)(1), in addition to funds otherwise
appropriated, there are appropriated to the Secretary for the
Center for Medicare & Medicaid Services Program Management
Account $25,000,000 for each of fiscal years 2010 through 2014
and $20,000,000 for fiscal year 2015. Amounts appropriated
under this paragraph for a fiscal year shall be available until
expended.
``(6) No duplication in payments to physicians in multiple
pilots.--The Secretary shall not make payments under this
section to any physician group that is paid under section 1866F
(relating to medical homes) or section 1866G (relating to
independence at home).''.
SEC. 1302. MEDICAL HOME PILOT PROGRAM.
(a) In General.--Title XVIII of the Social Security Act is amended
by inserting after section 1866E, as inserted by section 1301, the
following new section:
``medical home pilot program
``Sec. 1866F. (a) Establishment and Medical Home Models.--
``(1) Establishment of pilot program.--The Secretary shall
establish a medical home pilot program (in this section
referred to as the `pilot program') for the purpose of
evaluating the feasibility and advisability of reimbursing
qualified patient-centered medical homes for furnishing medical
home services (as defined under subsection (b)(1)) to
beneficiaries (as defined in subsection (b)(4)) and to targeted
high need beneficiaries (as defined in subsection (c)(1)(C)).
``(2) Scope.--Subject to subsection (g), the Secretary
shall set specific goals for the number of practices and
communities, and the number of patients served, under the pilot
program in the initial tests to ensure that the pilot program
is of sufficient size and scope to--
``(A) test the approach involved in a variety of
settings, including urban, rural, and underserved
areas; and
``(B) subject to subsection (e)(1), disseminate
such approach rapidly on a national basis.
To the extent that the Secretary finds a medical home model to
be successful in improving quality and reducing costs, the
Secretary shall implement such model on as large a geographic
scale as practical and economical.
``(3) Models of medical homes in the pilot program.--The
pilot program shall evaluate each of the following medical home
models:
``(A) Independent patient-centered medical home
model.--Independent patient-centered medical home model
under subsection (c).
``(B) Community-based medical home model.--
Community-based medical home model under subsection
(d).
``(4) Participation of nurse practitioners and physician
assistants.--
``(A) Nothing in this section shall be construed as
preventing a nurse practitioner from leading a patient
centered medical home so long as--
``(i) all the requirements of this section
are met; and
``(ii) the nurse practitioner is acting in
a manner that is consistent with State law.
``(B) Nothing in this section shall be construed as
preventing a physician assistant from participating in
a patient centered medical home so long as--
``(i) all the requirements of this section
are met; and
``(ii) the physician assistant is acting in
a manner that is consistent with State law.
``(b) Definitions.--For purposes of this section:
``(1) Patient-centered medical home services.--The term
`patient-centered medical home services' means services that--
``(A) provide beneficiaries with direct and ongoing
access to a primary care or principal care physician or
nurse practitioner who accepts responsibility for
providing first contact, continuous and comprehensive
care to such beneficiary;
``(B) coordinate the care provided to a beneficiary
by a team of individuals at the practice level across
office, provider of services, and home settings led by
a primary care or principal care physician or nurse
practitioner, as needed and appropriate;
``(C) provide for all the patient's health care
needs or take responsibility for appropriately
arranging care with other qualified physicians or
providers for all stages of life;
``(D) provide continuous access to care and
communication with participating beneficiaries;
``(E) provide support for patient self-management,
proactive and regular patient monitoring, support for
family caregivers, use patient-centered processes, and
coordination with community resources;
``(F) integrate readily accessible, clinically
useful information on participating patients that
enables the practice to treat such patients
comprehensively and systematically; and
``(G) implement evidence-based guidelines and apply
such guidelines to the identified needs of
beneficiaries over time and with the intensity needed
by such beneficiaries.
``(2) Primary care.--The term `primary care' means health
care that is provided by a physician, nurse practitioner, or
physician assistant who practices in the field of family
medicine, general internal medicine, geriatric medicine, or
pediatric medicine.
``(3) Principal care.--The term `principal care' means
integrated, accessible health care that is provided by a
physician who is a medical specialist or subspecialist that
addresses the majority of the personal health care needs of
patients with chronic conditions requiring the specialist's or
subspecialist's expertise, and for whom the specialist or
subspecialist assumes care management.
``(4) Beneficiaries.--The term `beneficiaries' means, with
respect to a qualifying medical home, an individual who--
``(A) is enrolled under part B and entitled to
benefits under part A;
``(B) is not enrolled in a Medicare Advantage plan
under part C or a PACE program under section 1894; and
``(C) meets such other criteria as the Secretary
determines appropriate.
``(c) Independent Patient-centered Medical Home Model.--
``(1) In general.--
``(A) Payment authority.--Under the independent
patient-centered medical home model under this
subsection, the Secretary shall make payments for
medical home services furnished by an independent
patient-centered medical home (as defined in
subparagraph (B)) pursuant to paragraph (3) for
targeted high need beneficiaries (as defined in
subparagraph (C)).
``(B) Independent patient-centered medical home
defined.--In this section, the term `independent
patient-centered medical home' means a physician-
directed or nurse-practitioner-directed practice that
is qualified under paragraph (2) as--
``(i) providing beneficiaries with patient-
centered medical home services; and
``(ii) meets such other requirements as the
Secretary may specify.
``(C) Targeted high need beneficiary defined.--For
purposes of this subsection, the term `targeted high
need beneficiary' means a beneficiary who, based on a
risk score as specified by the Secretary, is generally
within the upper 50th percentile of Medicare
beneficiaries.
``(D) Beneficiary election to participate.--The
Secretary shall determine an appropriate method of
ensuring that beneficiaries have agreed to participate
in the pilot program.
``(E) Implementation.--The pilot program under this
subsection shall begin no later than 12 months after
the date of the enactment of this section and shall
operate for 5 years.
``(2) Qualification process for patient-centered medical
homes.--The Secretary shall establish a process for practices
to qualify as medical homes.
``(3) Payment.--
``(A) Establishment of methodology.--The Secretary
shall establish a methodology for the payment for
medical home services furnished by independent patient-
centered medical homes. Under such methodology, the
Secretary shall adjust payments to medical homes based
on beneficiary risk scores to ensure that higher
payments are made for higher risk beneficiaries.
``(B) Per beneficiary per month payments.--Under
such payment methodology, the Secretary shall pay
independent patient-centered medical homes a monthly
fee for each targeted high need beneficiary who
consents to receive medical home services through such
medical home.
``(C) Prospective payment.--The fee under
subparagraph (B) shall be paid on a prospective basis.
``(D) Amount of payment.--In determining the amount
of such fee, the Secretary shall consider the
following:
``(i) The clinical work and practice
expenses involved in providing the medical home
services provided by the independent patient-
centered medical home (such as providing
increased access, care coordination, population
disease management, and teaching self-care
skills for managing chronic illnesses) for
which payment is not made under this title as
of the date of the enactment of this section.
``(ii) Allow for differential payments
based on capabilities of the independent
patient-centered medical home.
``(iii) Use appropriate risk-adjustment in
determining the amount of the per beneficiary
per month payment under this paragraph in a
manner that ensures that higher payments are
made for higher risk beneficiaries.
``(4) Encouraging participation of variety of practices.--
The pilot program under this subsection shall be designed to
include the participation of physicians in practices with fewer
than 10 full-time equivalent physicians, as well as physicians
in larger practices, particularly in underserved and rural
areas, as well as federally qualified health centers, and rural
health centers.
``(d) Community-based Medical Home Model.--
``(1) In general.--
``(A) Authority for payments.--Under the community-
based medical home model under this subsection (in this
section referred to as the `CBMH model'), the Secretary
shall make payments for the furnishing of medical home
services by a community-based medical home (as defined
in subparagraph (B)) pursuant to paragraph (5)(B) for
beneficiaries.
``(B) Community-based medical home defined.--In
this section, the term `community-based medical home'
means a nonprofit community-based or State-based
organization or a State that is certified under
paragraph (2) as meeting the following requirements:
``(i) The organization provides
beneficiaries with medical home services.
``(ii) The organization provides medical
home services under the supervision of and in
close collaboration with the primary care or
principal care physician, nurse practitioner,
or physician assistant designated by the
beneficiary as his or her community-based
medical home provider.
``(iii) The organization employs community
health workers, including nurses or other non-
physician practitioners, lay health workers, or
other persons as determined appropriate by the
Secretary, that assist the primary or principal
care physician, nurse practitioner, or
physician assistant in chronic care management
activities such as teaching self-care skills
for managing chronic illnesses, transitional
care services, care plan setting, nutritional
counseling, medication therapy management
services for patients with multiple chronic
diseases, or help beneficiaries access the
health care and community-based resources in
their local geographic area.
``(iv) The organization meets such other
requirements as the Secretary may specify.
``(2) Qualification process for community-based medical
homes.--The Secretary shall establish a process to provide for
the review and qualification of community-based medical homes
pursuant to criteria established by the Secretary.
``(3) Duration.--The pilot program for community-based
medical homes under this subsection shall start no later than 2
years after the date of the enactment of this section. Each
demonstration site under the pilot program shall operate for a
period of up to 5 years after the initial implementation phase,
without regard to the receipt of a initial implementation
funding under paragraph (6).
``(4) Preference.--In selecting sites for the CBMH model,
the Secretary shall give preference to applications which seek
to eliminate health disparities, as defined in section 3171 of
the Public Health Service Act and may give preference to any of
the following:
``(A) Applications that propose to coordinate
health care items and services under this title for
chronically ill beneficiaries who rely, for primary
care, on small physician or nurse practitioner
practices, federally qualified health centers, rural
health clinics, or other settings with limited
resources and scope of services.
``(B) Applications that include other third-party
payors that furnish medical home services for
chronically ill patients covered by such third-party
payors.
``(C) Applications from States that propose to use
the medical home model to coordinate health care
services for--
``(i) individuals enrolled under this
title;
``(ii) individuals enrolled under title
XIX; and
``(iii) full-benefit dual eligible
individuals (as defined in section 1935(c)(6)),
with chronic diseases across a variety of health care
settings.
``(5) Payments.--
``(A) Establishment of methodology.--The Secretary
shall establish a methodology for the payment for
medical home services furnished under the CBMH model.
``(B) Per beneficiary per month payments.--Under
such payment methodology, the Secretary shall make two
separate monthly payments for each beneficiary who
consents to receive medical home services through such
medical home, as follows:
``(i) Payment to community-based
organization.--One monthly payment to a
community-based or State-based organization or
State.
``(ii) Payment to primary or principal care
practice.--One monthly payment to the primary
or principal care practice for such
beneficiary.
``(C) Prospective payment.--The payments under
subparagraph (B) shall be paid on a prospective basis.
``(D) Amount of payment.--In determining the amount
of such payment under subparagraph (B), the Secretary
shall consider the following:
``(i) The clinical work and practice
expenses involved in providing the medical home
services provided by the primary or principal
care practice (such as providing increased
access, care coordination, care planning,
population disease management, and teaching
self-care skills for managing chronic
illnesses) for which payment is not made under
this title as of the date of the enactment of
this section.
``(ii) Use appropriate risk-adjustment in
determining the amount of the per beneficiary
per month payment under this paragraph.
``(iii) In the case of the models described
in subparagraphs (B) and (C) of paragraph (4),
the Secretary may determine an appropriate
payment amount.
``(6) Initial implementation funding.--The Secretary may
make available initial implementation funding to a non-profit
community based or State-based organization or a State that is
participating in the pilot program under this subsection. Such
organization shall provide the Secretary with a detailed
implementation plan that includes how such funds will be used.
The Secretary shall select a territory of the United States as
one of the locations in which to implement the pilot program
under this subsection, unless no organization in a territory is
able to comply with the requirements under paragraph (1)(B).
``(e) Expansion of Program.--
``(1) Evaluation of cost and quality.--The Secretary shall
evaluate the pilot program to determine--
``(A) the extent to which medical homes result in--
``(i) improvement in the quality and
coordination of items and services under this
title, particularly with regard to the care of
complex patients;
``(ii) improvement in reducing health
disparities;
``(iii) reductions in preventable
hospitalizations;
``(iv) prevention of readmissions;
``(v) reductions in emergency room visits;
``(vi) improvement in health outcomes,
including patient functional status where
applicable;
``(vii) improvement in patient
satisfaction;
``(viii) improved efficiency of care such
as reducing duplicative diagnostic tests and
laboratory tests; and
``(ix) reductions in health care
expenditures; and
``(B) the feasability and advisability of
reimbursing medical homes for medical home services
under this title on a permanent basis.
``(2) Report.--Not later than 60 days after the date of
completion of the evaluation under paragraph (1), the Secretary
shall submit to Congress and make available to the public a
report on the findings of the evaluation under paragraph (1)
and the extent to which standards for the certification of
medical homes need to be periodically updated.
``(3) Expansion of program.--
``(A) In general.--Subject to the results of the
evaluation under paragraph (1) and subparagraph (B),
the Secretary may issue regulations to implement, on a
permanent basis, one or more models, if, and to the
extent that such model or models, are beneficial to the
program under this title, including that such
implementation will improve quality of care, as
determined by the Secretary.
``(B) Certification requirement.--The Secretary may
not issue such regulations unless the Chief Actuary of
the Centers for Medicare & Medicaid Services certifies
that the expansion of the components of the pilot
program described in subparagraph (A) would result in
estimated spending under this title that would be no
more than the level of spending that the Secretary
estimates would otherwise be spent under this title in
the absence of such expansion.
``(C) Updated standards.--The Secretary shall
periodically review and update the standards for
qualification as an independent patient centered
medical home and as a community based medical home and
shall establish a process for ensuring that medical
homes meet such updated standards, as applicable
``(f) Administrative Provisions.--
``(1) No duplication in payments for individuals in medical
homes.--During any month, the Secretary may not make payments
under this section under more than one model or through more
than one medical home under any model for the furnishing of
medical home services to an individual.
``(2) No effect on payment for medical visits.--Payments
made under this section are in addition to, and have no effect
on the amount of, payment for medical visits made under this
title
``(3) Administration.--Chapter 35 of title 44, United
States Code shall not apply to this section.
``(4) No duplication in physician pilot participation.--The
Secretary shall not make payments to an independent or
community based medical home both under this section and
section 1866E or 1866G, unless the pilot program under this
section has been implemented on a permanent basis under
subsection (e)(3).
``(5) Waiver.--The Secretary may waive such provisions of
this title and title XI in the manner the Secretary determines
necessary in order to implement this section.
``(g) Funding.--
``(1) Operational costs.--For purposes of administering and
carrying out the pilot program (including the design,
implementation, technical assistance for and evaluation of such
program), in addition to funds otherwise available, there shall
be transferred from the Federal Supplementary Medical Insurance
Trust Fund under section 1841 to the Secretary for the Centers
for Medicare & Medicaid Services Program Management Account
$6,000,000 for each of fiscal years 2010 through 2014. Amounts
appropriated under this paragraph for a fiscal year shall be
available until expended.
``(2) Patient-centered medical home services.--In addition
to funds otherwise available, there shall be available to the
Secretary for the Centers for Medicare & Medicaid Services,
from the Federal Supplementary Medical Insurance Trust Fund
under section 1841--
``(A) $200,000,000 for each of fiscal years 2010
through 2014 for payments for medical home services
under subsection (c)(3); and
``(B) $125,000,000 for each of fiscal years 2012
through 2016, for payments under subsection (d)(5).
Amounts available under this paragraph for a fiscal year shall
be available until expended.
``(3) Initial implementation.--In addition to funds
otherwise available, there shall be available to the Secretary
for the Centers for Medicare & Medicaid Services, from the
Federal Supplementary Medical Insurance Trust Fund under
section 1841, $2,500,000 for each of fiscal years 2010 through
2012, under subsection (d)(6). Amounts available under this
paragraph for a fiscal year shall be available until expended.
``(h) Treatment of TRHCA Medicare Medical Home Demonstration
Funding.--
``(1) In addition to funds otherwise available for payment
of medical home services under subsection (c)(3), there shall
also be available the amount provided in subsection (g) of
section 204 of division B of the Tax Relief and Health Care Act
of 2006 (42 U.S.C. 1395b-1 note), as added by section 133 of
the Medicare Improvements for Patients and Providers Act of
2008 (Public Law 110-275).
``(2) Notwithstanding section 1302(c) of the Affordable
Health Care for America Act, in addition to funds provided in
paragraph (1) and subsection (g)(2)(A), the funding for medical
home services that would otherwise have been available if such
section 204 medical home demonstration had been implemented
(without regard to subsection (g) of such section) shall be
available to the independent patient-centered medical home
model described in subsection (c).''.
(b) Effective Date.--The amendment made by this section shall apply
to services furnished on or after the date of the enactment of this
Act.
(c) Conforming Repeal.--Section 204 of division B of the Tax Relief
and Health Care Act of 2006 (42 U.S.C. 1395b-1 note), as amended by
section 133(a)(2) of the Medicare Improvements for Patients and
Providers Act of 2008 (Public Law 110-275), is repealed.
SEC. 1303. PAYMENT INCENTIVE FOR SELECTED PRIMARY CARE SERVICES.
(a) In General.--Section 1833 of the Social Security Act is amended
by inserting after subsection (o) the following new subsection:
``(p) Primary Care Payment Incentives.--
``(1) In general.--In the case of primary care services (as
defined in paragraph (2)) furnished on or after January 1,
2011, by a primary care practitioner (as defined in paragraph
(3)) for which amounts are payable under section 1848, in
addition to the amount otherwise paid under this part there
shall also be paid to the practitioner (or to an employer or
facility in the cases described in clause (A) of section
1842(b)(6)) (on a monthly or quarterly basis) from the Federal
Supplementary Medical Insurance Trust Fund an amount equal 5
percent (or 10 percent if the practitioner predominately
furnishes such services in an area that is designated (under
section 332(a)(1)(A) of the Public Health Service Act) as a
primary care health professional shortage area.
``(2) Primary care services defined.--In this subsection,
the term `primary care services'--
``(A) mean evaluation and management services,
without regard to the specialty of the physician
furnishing the services, that are procedure codes (for
services covered under this title) for--
``(i) services in the category designated
Evaluation and Management in the Health Care
Common Procedure Coding System (established by
the Secretary under section 1848(c)(5) as of
December 31, 2009, and as subsequently modified
by the Secretary); and
``(ii) preventive services (as defined in
section 1861(iii) for which payment is made
under this section; and
``(B) includes services furnished by another health
care professional that would be described in
subparagraph (A) if furnished by a physician.
``(3) Primary care practitioner defined.--In this
subsection, the term `primary care practitioner'--
``(A) means a physician or other health care
practitioner (including a nurse practitioner) who--
``(i) specializes in family medicine,
general internal medicine, general pediatrics,
geriatrics, or obstetrics and gynecology; and
``(ii) has allowed charges for primary care
services that account for at least 50 percent
of the physician's or practitioner's total
allowed charges under section 1848, as
determined by the Secretary for the most recent
period for which data are available; and
``(B) includes a physician assistant who is under
the supervision of a physician described in
subparagraph (A).
``(4) Limitation on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise, respecting--
``(A) any determination or designation under this
subsection;
``(B) the identification of services as primary
care services under this subsection; and
``(C) the identification of a practitioner as a
primary care practitioner under this subsection.
``(5) Coordination with other payments.--
``(A) With other primary care incentives.--The
provisions of this subsection shall not be taken into
account in applying subsections (m) and (u) and any
payment under such subsections shall not be taken into
account in computing payments under this subsection.
``(B) With quality incentives.--Payments under this
subsection shall not be taken into account in
determining the amounts that would otherwise be paid
under this part for purposes of section
1834(g)(2)(B).''.
(b) Conforming Amendments.--
(1) Section 1833(m) of such Act (42 U.S.C. 1395l(m)) is
amended by redesignating paragraph (4) as paragraph (5) and by
inserting after paragraph (3) the following new paragraph:
``(4) The provisions of this subsection shall not be taken into
account in applying subsections (m) or (u) and any payment under such
subsections shall not be taken into account in computing payments under
this subsection.''.
(2) Section 1848(m)(5)(B) of such Act (42 U.S.C. 1395w-
4(m)(5)(B)) is amended by inserting ``, (p),'' after ``(m)''.
(3) Section 1848(o)(1)(B)(iv) of such Act (42 U.S.C. 1395w-
4(o)(1)(B)(iv)) is amended by inserting ``primary care'' before
``health professional shortage area''.
SEC. 1304. INCREASED REIMBURSEMENT RATE FOR CERTIFIED NURSE-MIDWIVES.
(a) In General.--Section 1833(a)(1)(K) of the Social Security Act
(42 U.S.C.1395l(a)(1)(K)) is amended by striking ``(but in no event''
and all that follows through ``performed by a physician)''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to services furnished on or after January 1, 2011.
SEC. 1305. COVERAGE AND WAIVER OF COST-SHARING FOR PREVENTIVE SERVICES.
(a) Medicare Covered Preventive Services Defined.--Section 1861 of
the Social Security Act (42 U.S.C. 1395x), as amended by section
1233(a)(1)(B), is amended by adding at the end the following new
subsection:
``Medicare Covered Preventive Services
``(iii)(1) Subject to the succeeding provisions of this subsection,
the term `Medicare covered preventive services' means the following:
``(A) Prostate cancer screening tests (as defined in
subsection (oo)).
``(B) Colorectal cancer screening tests (as defined in
subsection (pp).
``(C) Diabetes outpatient self-management training services
(as defined in subsection (qq)).
``(D) Screening for glaucoma for certain individuals (as
described in subsection (s)(2)(U)).
``(E) Medical nutrition therapy services for certain
individuals (as described in subsection (s)(2)(V)).
``(F) An initial preventive physical examination (as
defined in subsection (ww)).
``(G) Cardiovascular screening blood tests (as defined in
subsection (xx)(1)).
``(H) Diabetes screening tests (as defined in subsection
(yy)).
``(I) Ultrasound screening for abdominal aortic aneurysm
for certain individuals (as described in subsection
(s)(2)(AA)).
``(J) Federally approved and recommended vaccines and their
administration as described in subsection (s)(10).
``(K) Screening mammography (as defined in subsection
(jj)).
``(L) Screening pap smear and screening pelvic exam (as
defined in subsection (nn)).
``(M) Bone mass measurement (as defined in subsection
(rr)).
``(N) Kidney disease education services (as defined in
subsection (ggg)).
``(O) Additional preventive services (as defined in
subsection (ddd)).
``(2) With respect to specific Medicare covered preventive
services, the limitations and conditions described in the provisions
referenced in paragraph (1) with respect to such services shall
apply.''.
(b) Payment and Elimination of Cost-sharing.--
(1) In general.--
(A) In general.--Section 1833(a) of the Social
Security Act (42 U.S.C. 1395l(a)) is amended by adding
after and below paragraph (9) the following:
``With respect to Medicare covered preventive services, in any case in
which the payment rate otherwise provided under this part is computed
as a percent of less than 100 percent of an actual charge, fee schedule
rate, or other rate, such percentage shall be increased to 100
percent.''.
(B) Application to sigmoidoscopies and
colonoscopies.--Section 1834(d) of such Act (42 U.S.C.
1395m(d)) is amended--
(i) in paragraph (2)(C), by amending clause
(ii) to read as follows:
``(ii) No coinsurance.--In the case of a
beneficiary who receives services described in
clause (i), there shall be no coinsurance
applied.''; and
(ii) in paragraph (3)(C), by amending
clause (ii) to read as follows:
``(ii) No coinsurance.--In the case of a
beneficiary who receives services described in
clause (i), there shall be no coinsurance
applied.''.
(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)) is amended by striking ``screening
mammography (as defined in section 1861(jj)) and
diagnostic mammography'' and inserting ``diagnostic
mammograms and Medicare covered preventive services (as
defined in section 1861(iii)(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'' after the semicolon at the end;
(ii) in subparagraph (G), by adding ``and''
at the end; and
(iii) by adding at the end the following
new subparagraph:
``(H) with respect to additional preventive
services (as defined in section 1861(ddd)) furnished by
an outpatient department of a hospital, the amount
determined under paragraph (1)(W);''.
(3) Waiver of application of deductible for all preventive
services.--The first sentence of section 1833(b) of the Social
Security Act (42 U.S.C. 1395l(b)) is amended--
(A) in clause (1), by striking ``items and services
described in section 1861(s)(10)(A)'' and inserting
``Medicare covered preventive services (as defined in
section 1861(iii))'';
(B) by inserting ``and'' before ``(4)''; and
(C) by striking clauses (5) through (8).
(4) Application to providers of services.--Section
1866(a)(2)(A)(ii) of such Act (42 U.S.C. 1395cc(a)(2)(A)(ii))
is amended by inserting ``other than for Medicare covered
preventive services and'' after ``for such items and services
(''.
(c) Effective Date.--The amendments made by this section shall
apply to services furnished on or after January 1, 2011.
(d) Preventive Services.--
(1) Report to congress on barriers to preventive
services.--Not later than 12 months after the date of the
enactment of this Act, the Secretary of Health and Human
Services shall report to Congress on barriers, if any, facing
Medicare beneficiaries in accessing the benefit to abdominal
aortic aneurysm screening and other preventative services
through the Welcome to Medicare Physical Exam.
(2) Abdominal aortic aneurysm screen access.--The Secretary
shall, to the extent practical, identify and implement policies
promoting proper use of abdominal aortic aneurysm screening
among Medicare beneficiaries at risk for such aneurysms.
SEC. 1306. WAIVER OF DEDUCTIBLE FOR COLORECTAL CANCER SCREENING TESTS
REGARDLESS OF CODING, SUBSEQUENT DIAGNOSIS, OR ANCILLARY
TISSUE REMOVAL.
(a) In General.--Section 1833 of the Social Security Act (42 U.S.C.
1395l(b)), as amended by section 1305(b), is further amended--
(1) in subsection (a), in the sentence added by section
1305(b)(1)(A), by inserting ``(including services described in
the last sentence of section 1833(b))'' after ``preventive
services''; and
(2) in subsection (b), by adding at the end the following
new sentence: ``Clause (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.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to items and services furnished on or after January 1, 2011.
SEC. 1307. EXCLUDING CLINICAL SOCIAL WORKER SERVICES FROM COVERAGE
UNDER THE MEDICARE SKILLED NURSING FACILITY PROSPECTIVE
PAYMENT SYSTEM AND CONSOLIDATED PAYMENT.
(a) In General.--Section 1888(e)(2)(A)(ii) of the Social Security
Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting ``clinical
social worker services,'' after ``qualified psychologist services,''.
(b) Conforming Amendment.--Section 1861(hh)(2) of the Social
Security Act (42 U.S.C. 1395x(hh)(2)) is amended by striking ``and
other than services furnished to an inpatient of a skilled nursing
facility which the facility is required to provide as a requirement for
participation''.
(c) Effective Date.--The amendments made by this section shall
apply to items and services furnished on or after October 1, 2010.
SEC. 1308. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES AND
MENTAL HEALTH COUNSELOR SERVICES.
(a) Coverage of Marriage and Family Therapist Services.--
(1) Coverage of services.--Section 1861(s)(2) of the Social
Security Act (42 U.S.C. 1395x(s)(2)), as amended by section
1235, is amended--
(A) in subparagraph (EE), by striking ``and'' at
the end;
(B) in subparagraph (FF), by adding ``and'' at the
end; and
(C) by adding at the end the following new
subparagraph:
``(GG) marriage and family therapist services (as
defined in subsection (jjj));''.
(2) Definition.--Section 1861 of the Social Security Act
(42 U.S.C. 1395x), as amended by sections 1233 and 1305, is
amended by adding at the end the following new subsection:
``Marriage and Family Therapist Services
``(jjj)(1) The term `marriage and family therapist services' means
services performed by a marriage and family therapist (as defined in
paragraph (2)) for the diagnosis and treatment of mental illnesses,
which the marriage and family therapist is legally authorized to
perform under State law (or the State regulatory mechanism provided by
State law) of the State in which such services are performed, as would
otherwise be covered if furnished by a physician or as incident to a
physician's professional service, but only if no facility or other
provider charges or is paid any amounts with respect to the furnishing
of such services.
``(2) The term `marriage and family therapist' means an individual
who--
``(A) possesses a master's or doctoral degree which
qualifies for licensure or certification as a marriage and
family therapist pursuant to State law;
``(B) after obtaining such degree has performed at least 2
years of clinical supervised experience in marriage and family
therapy; and
``(C) is licensed or certified as a marriage and family
therapist in the State in which marriage and family therapist
services are performed.''.
(3) Provision for payment under part b.--Section
1832(a)(2)(B) of the Social Security Act (42 U.S.C.
1395k(a)(2)(B)) is amended by adding at the end the following
new clause:
``(v) marriage and family therapist
services;''.
(4) Amount of payment.--
(A) In general.--Section 1833(a)(1) of the Social
Security Act (42 U.S.C. 1395l(a)(1)) is amended--
(i) by striking ``and'' before ``(W)''; and
(ii) by inserting before the semicolon at
the end the following: ``, and (X) with respect
to marriage and family therapist services under
section 1861(s)(2)(GG), the amounts paid shall
be 80 percent of the lesser of the actual
charge for the services or 75 percent of the
amount determined for payment of a psychologist
under clause (L)''.
(B) Development of criteria with respect to
consultation with a health care professional.--The
Secretary of Health and Human Services shall, taking
into consideration concerns for patient
confidentiality, develop criteria with respect to
payment for marriage and family therapist services for
which payment may be made directly to the marriage and
family therapist under part B of title XVIII of the
Social Security Act (42 U.S.C. 1395j et seq.) under
which such a therapist must agree to consult with a
patient's attending or primary care physician or nurse
practitioner in accordance with such criteria.
(5) Exclusion of marriage and family therapist services
from skilled nursing facility prospective payment system.--
Section 1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C.
1395yy(e)(2)(A)(ii)), as amended by section 1307(a), is amended
by inserting ``marriage and family therapist services (as
defined in subsection (jjj)(1)),'' after ``clinical social
worker services,''.
(6) Coverage of marriage and family therapist services
provided in rural health clinics and federally qualified health
centers.--Section 1861(aa)(1)(B) of the Social Security Act (42
U.S.C. 1395x(aa)(1)(B)) is amended by striking ``or by a
clinical social worker (as defined in subsection (hh)(1)),''
and inserting ``, by a clinical social worker (as defined in
subsection (hh)(1)), or by a marriage and family therapist (as
defined in subsection (jjj)(2)),''.
(7) Inclusion of marriage and family therapists as
practitioners for assignment of claims.--Section 1842(b)(18)(C)
of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)) is
amended by adding at the end the following new clause:
``(vii) A marriage and family therapist (as defined in
section 1861(jjj)(2)).''.
(b) Coverage of Mental Health Counselor Services.--
(1) Coverage of services.--Section 1861(s)(2) of the Social
Security Act (42 U.S.C. 1395x(s)(2)), as previously amended, is
further amended--
(A) in subparagraph (FF), by striking ``and'' at
the end;
(B) in subparagraph (GG), by inserting ``and'' at
the end; and
(C) by adding at the end the following new
subparagraph:
``(HH) mental health counselor services (as defined in
subsection (kkk)(1));''.
(2) Definition.--Section 1861 of the Social Security Act
(42 U.S.C. 1395x), as previously amended, is amended by adding
at the end the following new subsection:
``Mental Health Counselor Services
``(kkk)(1) The term `mental health counselor services' means
services performed by a mental health counselor (as defined in
paragraph (2)) for the diagnosis and treatment of mental illnesses
which the mental health counselor is legally authorized to perform
under State law (or the State regulatory mechanism provided by the
State law) of the State in which such services are performed, as would
otherwise be covered if furnished by a physician or as incident to a
physician's professional service, but only if no facility or other
provider charges or is paid any amounts with respect to the furnishing
of such services.
``(2) The term `mental health counselor' means an individual who--
``(A) possesses a master's or doctor's degree which
qualifies the individual for licensure or certification for the
practice of mental health counseling in the State in which the
services are performed;
``(B) after obtaining such a degree has performed at least
2 years of supervised mental health counselor practice; and
``(C) is licensed or certified as a mental health counselor
or professional counselor by the State in which the services
are performed.''.
(3) Provision for payment under part b.--Section
1832(a)(2)(B) of the Social Security Act (42 U.S.C.
1395k(a)(2)(B)), as amended by subsection (a)(3), is further
amended--
(A) by striking ``and'' at the end of clause (iv);
(B) by adding ``and'' at the end of clause (v); and
(C) by adding at the end the following new clause:
``(vi) mental health counselor services;''.
(4) Amount of payment.--
(A) In general.--Section 1833(a)(1) of the Social
Security Act (42 U.S.C. 1395l(a)(1)), as amended by
subsection (a), is further amended--
(i) by striking ``and'' before ``(X)''; and
(ii) by inserting before the semicolon at
the end the following: ``, and (Y), with
respect to mental health counselor services
under section 1861(s)(2)(HH), the amounts paid
shall be 80 percent of the lesser of the actual
charge for the services or 75 percent of the
amount determined for payment of a psychologist
under clause (L)''.
(B) Development of criteria with respect to
consultation with a physician.--The Secretary of Health
and Human Services shall, taking into consideration
concerns for patient confidentiality, develop criteria
with respect to payment for mental health counselor
services for which payment may be made directly to the
mental health counselor under part B of title XVIII of
the Social Security Act (42 U.S.C. 1395j et seq.) under
which such a counselor must agree to consult with a
patient's attending or primary care physician in
accordance with such criteria.
(5) Exclusion of mental health counselor services from
skilled nursing facility prospective payment system.--Section
1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C.
1395yy(e)(2)(A)(ii)), as amended by section 1307(a) and
subsection (a), is amended by inserting ``mental health
counselor services (as defined in section 1861(kkk)(1)),''
after ``marriage and family therapist services (as defined in
subsection (jjj)(1)),''.
(6) Coverage of mental health counselor services provided
in rural health clinics and federally qualified health
centers.--Section 1861(aa)(1)(B) of the Social Security Act (42
U.S.C. 1395x(aa)(1)(B)), as amended by subsection (a), is
amended by striking ``or by a marriage and family therapist (as
defined in subsection (jjj)(2)),'' and inserting ``by a
marriage and family therapist (as defined in subsection
(jjj)(2)), or a mental health counselor (as defined in
subsection (kkk)(2)),''.
(7) Inclusion of mental health counselors as practitioners
for assignment of claims.--Section 1842(b)(18)(C) of the Social
Security Act (42 U.S.C. 1395u(b)(18)(C)), as amended by
subsection (a)(7), is amended by adding at the end the
following new clause:
``(viii) A mental health counselor (as defined in section
1861(kkk)(2)).''.
(c) Effective Date.--The amendments made by this section shall
apply to items and services furnished on or after January 1, 2011.
SEC. 1309. 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, 2011''.
SEC. 1310. EXPANDING ACCESS TO VACCINES.
(a) In General.--Paragraph (10) of section 1861(s) of the Social
Security Act (42 U.S.C. 1395w(s)) is amended to read as follows:
``(10) federally approved and recommended vaccines (as
defined in subsection (lll)) and their respective
administration;''.
(b) Federally Approved and Recommended Vaccines Defined.--Section
1861 of such Act is further amended by adding at the end the following
new subsection:
``Federally Approved and Recommended Vaccines
``(lll) The term `federally approved and recommended vaccine' means
a vaccine that--
``(1) is licensed under section 351 of the Public Health
Service Act, approved under the Federal Food, Drug, and
Cosmetic Act, or authorized for emergency use under section 564
of the Federal, Food, Drug, and Cosmetic Act; and
``(2) is recommended by the Director of the Centers for
Disease Control and Prevention.''.
(c) Conforming Amendments.--
(1) Section 1833 of such Act (42 U.S.C. 1395l) is amended,
in each of subsections (a)(1)(B), (a)(2)(G), and (a)(3)(A), by
striking ``1861(s)(10)(A)'' and inserting ``1861(s)(10)'' each
place it appears.
(2) Section 1842(o)(1)(A)(iv) of such Act (42 U.S.C.
1395u(o)(1)(A)(iv)) is amended--
(A) by striking ``subparagraph (A) or (B) of''; and
(B) by inserting before the period the following:
``and before January 1, 2011, and influenza vaccines
furnished on or after January 1, 2011''.
(3) Section 1847A(c)(6) of such Act (42 U.S.C. 1395w-
3a(c)(6)) is amended--
(A) in subparagraph (D)(i), by inserting ``,
including a vaccine furnished on or after January 1,
2010''; and
(B) by the following new paragraph:
``(H) Implementation.--Chapter 35 of title 44,
United States Code shall not apply to manufacturer
provision of information pursuant to section
1927(b)(3)(A)(iii) or subsection (f)(2) for purposes of
implementation of this section.''.
(4) Section 1860D-2(e)(1) of such Act (42 U.S.C. 1395w-
102(e)(1)) is amended by striking ``such term includes a
vaccine'' and all that follows through ``its administration)
and''.
(5) Section 1861(ww)(2)(A) of such Act (42 U.S.C.
1395x(ww)(2)(A))) is amended by striking ``Pneumococcal,
influenza, and hepatitis B vaccine and administration'' and
inserting ``federally approved or authorized vaccines (as
defined in subsection (lll)) and their respective
administration''.
(6) Section 1927(b)(3)(A)(iii) of such Act (42 U.S.C.
1396r-8(b)(3)(A)(iii)) is amended, in the matter following
subclause (III), by inserting ``(A)(iv) (including influenza
vaccines furnished on or after January 1, 2011),'' after
``described in subparagraph''.
(7) Section 1847A(f) of such Act (42 U.S.C. 1395w-3a(f)) is
amended--
(A) by striking ``For'' and inserting ``(1) In
general.--For'';
(B) by indenting paragraph (1), as redesignated in
subparagraph (A), 2 ems to the left; and--
(C) by adding at the end the following new
paragraph:
``(2) Treatment of certain manufacturers.--In the case of a
manufacturer of a drug or biological described in subparagraphs
(A)(iv), (C), (D), (E), or (G) of section 1842(o)(1) that does
not have a rebate agreement under section 1927(a), no payment
may be made under this part for such drug or biological if such
manufacturer does not submit the information described in
section 1927(b)(3)(A)(iii) in the same manner as if the
manufacturer had such a rebate agreement in effect.
Subparagraphs (C) and (D) of section 1927(b)(3) shall apply to
information reported pursuant to the previous sentence in the
same manner as such subparagraphs apply with respect to
information reported pursuant to such section.''.''.
(d) Effective Dates.--The amendments made--
(1) by this section (other than by subsection (c)(6)) shall
apply to vaccines administered on or after January 1, 2011; and
(2) by subsection (c)(6) shall apply to calendar quarters
beginning on or after January 1, 2010.
SEC. 1311. EXPANSION OF MEDICARE-COVERED PREVENTIVE SERVICES AT
FEDERALLY QUALIFIED HEALTH CENTERS.
(a) 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 services described
in section 1861(iii); and''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply not later than January 1, 2011.
SEC. 1312. INDEPENDENCE AT HOME DEMONSTRATION PROGRAM.
Title XVIII of the Social Security Act is amended by inserting
after section 1866F, as inserted by section 1302, the following new
section:
``independence at home medical practice demonstration program
``Sec. 1866G. (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) includes at least 200 applicable
beneficiaries as defined in subsection (d);
``(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.
``(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.--
``(A) In general.--An independence at home medical
practice participating in the demonstration program
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) Development of quality performance
standards.--The Secretary shall develop quality
performance standards for independence at home medical
practices participating in the demonstration program.
``(c) Shared Savings Payment Methodology.--
``(1) Establishment of target spending level.--The
Secretary shall establish annual target spending levels for
items and services covered under parts A and B furnished to
applicable beneficiaries by qualifying independence at home
medical practices under this section. The Secretary may set an
aggregate target spending level for all qualifying practices,
or may set different target spending levels for groups of
practices or a single practice. Such target spending levels may
be determined on a per capita basis and shall take into account
normal variation in expenditures for items and services covered
under parts A and B furnished to such beneficiaries. The target
shall also be adjusted for the size of the practice, number of
practices included in the target spending level,
characteristics of applicable beneficiaries and such other
factors as the Secretary determines appropriate. The Secretary
may periodically adjust or rebase the target spending level
under this paragraph.
``(2) Shared savings amounts.--
``(A) In general.--Subject to subparagraph (B),
qualifying independence at home medical practices are
eligible to receive an incentive payment under this
section if aggregate expenditures for a year for
applicable beneficiaries are less than the target
spending level for qualifying independence at home
medical practices 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
total payments for applicable beneficiaries under parts
A and B for such year are estimated to be less than 5
percent less than the target spending level for such
year, as determined by the Secretary.
``(B) Apportionment of savings.--The Secretary
shall designate how, and to what extent, an incentive
payment under this section is to be apportioned among
qualifying independence at home medical practices,
taking into account the size of the practice,
characteristics of the individuals enrolled in each
practice, performance on quality performance measures,
and such other factors as the Secretary determines
appropriate.
``(3) Savings to the medicare program.--The Secretary shall
limit incentive payments to each qualifying independence at
home medical practice under this paragraph, with respect to a
year, as necessary to ensure that the aggregate expenditures
for items and services under parts A and B with respect to
applicable beneficiaries for such independence at home medical
practice (inclusive of shared savings payments) do not exceed
the amount that the Secretary estimates would be expended for
such items and services for such beneficiaries during such year
(taking into account normal variation in expenditures and other
factors the Secretary deems appropriate) if the demonstration
program under this section were not implemented, minus 5
percent.
``(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
not 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 1866D or section 1866E.
``(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 1866D or section 1866E.
``(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) Number of practices.--
``(A) In general.--Subject to subparagraph (B), the
Secretary shall enter into agreements with as many
independence at home medial practices as practicable
and consistent with this subsection to test the
potential of the independence at home medical practice
model under this section in order to achieve the
results described in subsection (a) across practices
serving varying numbers of applicable beneficiaries.
``(B) Limitation.--In selecting qualified
independence at home medial practices to participate
under the demonstration program, the Secretary shall
limit the number of applicable beneficiaries that may
participate in the demonstration program to 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) Following 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 shared savings 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 $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) Antidiscrimination Limitation.--The Secretary shall not enter
into an agreement with an entity to provide health care items or
services under the demonstration program unless such entity guarantees
that for individuals eligible to be enrolled in such program, the
entity will not deny, limit, or condition the coverage or provision of
benefits to which the individual would have otherwise been entitled to
on the basis of health status if not included in this program.
``(j) Termination.--The Secretary may terminate an agreement with
an independence at home medical practice if such practice does not
receive incentive payments under subsection (c)(2) or consistently
fails to meet quality standards.''.
SEC. 1313. RECOGNITION OF CERTIFIED DIABETES EDUCATORS AS CERTIFIED
PROVIDERS FOR PURPOSES OF MEDICARE DIABETES OUTPATIENT
SELF-MANAGEMENT TRAINING SERVICES.
(a) In General.--Section 1861(qq) of the Social Security Act (42
U.S.C. 1395x(qq)) is amended--
(1) in paragraph (1), by inserting ``or by a certified
diabetes educator (as defined in paragraph (3))'' after
``paragraph (2)(B)''; and
(2) by adding at the end the following new paragraphs:
``(3) For purposes of paragraph (1), the term `certified
diabetes educator' means an individual who--
``(A) is licensed or registered by the State in
which the services are performed as a health care
professional;
``(B) specializes in teaching individuals with
diabetes to develop the necessary skills and knowledge
to manage the individual's diabetic condition; and
``(C) is certified as a diabetes educator by a
recognized certifying body (as defined in paragraph
(4)).
``(4)(A) For purposes of paragraph (3)(C), the term
`recognized certifying body' means--
``(i) the National Certification Board for Diabetes
Educators, or
``(ii) a certifying body for diabetes educators,
which is recognized by the Secretary as authorized to
grant certification of diabetes educators for purposes
of this subsection pursuant to standards established by
the Secretary, if the Secretary determines such Board
or body, respectively, meets the requirement of
subparagraph (B).
``(B) The National Certification Board for Diabetes
Educators or a certifying body for diabetes educators meets the
requirement of this subparagraph, with respect to the
certification of an individual, if the Board or body,
respectively, is incorporated and registered to do business in
the United States and requires as a condition of such
certification each of the following:
``(i) The individual has a qualifying credential in
a specified health care profession.
``(ii) The individual has professional practice
experience in diabetes self-management training that
includes a minimum number of hours and years of
experience in such training.
``(iii) The individual has successfully completed a
national certification examination offered by such
entity.
``(iv) The individual periodically renews
certification status following initial
certification.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to diabetes outpatient self-management training services
furnished on or after the first day of the first calendar year that is
at least 6 months after the date of the enactment of this Act.
TITLE IV--QUALITY
Subtitle A--Comparative Effectiveness Research
SEC. 1401. COMPARATIVE EFFECTIVENESS RESEARCH.
(a) In General.--Title XI of the Social Security Act is amended by
adding at the end the following new part:
``Part D--Comparative Effectiveness Research
``comparative effectiveness research
``Sec. 1181. (a) Center for Comparative Effectiveness Research
Established.--
``(1) In general.--The Secretary shall establish within the
Agency for Healthcare Research and Quality a Center for
Comparative Effectiveness Research (in this section referred to
as the `Center') to conduct, support, and synthesize research
(including research conducted or supported under section 1013
of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003) with respect to the outcomes,
effectiveness, and appropriateness of health care services and
procedures in order to identify the manner in which diseases,
disorders, and other health conditions can most effectively and
appropriately be prevented, diagnosed, treated, and managed
clinically.
``(2) Duties.--The Center shall--
``(A) conduct, support, and synthesize research
relevant to the comparative effectiveness of the full
spectrum of health care items, services and systems,
including pharmaceuticals, medical devices, medical and
surgical procedures, and other medical interventions;
``(B) conduct and support systematic reviews of
clinical research, including original research
conducted subsequent to the date of the enactment of
this section;
``(C) continuously develop rigorous scientific
methodologies for conducting comparative effectiveness
studies, and use such methodologies appropriately;
``(D) submit to the Comparative Effectiveness
Research Commission, the Secretary, and Congress
appropriate relevant reports described in subsection
(d)(2);
``(E) not later than one year after the date of the
enactment of this section, enter into an arrangement
under which the Institute of Medicine of the National
Academy of Sciences shall conduct an evaluation and
report on standards of evidence for highly credible
research;
``(F) encourage, as appropriate, the development
and use of clinical registries and the development of
clinical effectiveness research data networks from
electronic health records, post marketing drug and
medical device surveillance efforts, and other forms of
electronic health data; and
``(G) appoint clinical perspective advisory panels
for research priorities under this section, which shall
consult with patients and other stakeholders and advise
the Center on research questions, methods, and evidence
gaps in terms of clinical outcomes for the specific
research inquiry to be examined with respect to such
priority to ensure that the information produced from
such research is clinically relevant to decisions made
by clinicians and patients at the point of care.
``(3) Powers.--
``(A) Obtaining official data.--The Center 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 Center, the
head of such department or agency shall furnish that
information to the Center on an agreed upon schedule.
``(B) Data collection.--In order to carry out its
functions, the Center shall--
``(i) 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;
``(ii) carry out, or award grants or
contracts for, original research and
experimentation, where existing information is
inadequate; and
``(iii) adopt procedures allowing any
interested party to submit information for the
use by the Center in making reports and
recommendations.
In carrying out clause (ii), the Center may award
grants or contracts (or provide for intergovernmental
transfers, as applicable) to private entities and
governmental agencies with experience in conducting
comparative effectiveness research, such as the
National Institutes of Health and other relevant
Federal health agencies.
``(C) Access of gao to information.--The
Comptroller General shall have unrestricted access to
all deliberations, records, and nonproprietary data of
the Center and Commission under subsection (b),
immediately upon request.
``(D) Periodic audit.--The Center and Commission
under subsection (b) shall be subject to periodic audit
by the Comptroller General.
``(b) Comparative Effectiveness Research Commission.--
``(1) In general.--There is established an independent
Comparative Effectiveness Research Commission (in this section
referred to as the `Commission') to advise the Center and
evaluate the activities carried out by the Center under
subsection (a) to ensure such activities result in highly
credible research and information resulting from such research.
``(2) Duties.--The Commission shall--
``(A)(i) recommend to the Center national
priorities for research described in subsection (a)
which shall take into account--
``(I) disease incidence, prevalence, and
burden in the United States;
``(II) evidence gaps in terms of clinical
outcomes;
``(III) variations in practice, delivery,
and outcomes by geography, treatment site,
provider type, disability, variation in age
group (including children, adolescents, adults,
and seniors), racial and ethnic background,
gender, genetic and molecular subtypes, and
other appropriate populations or
subpopulations; and
``(IV) the potential for new evidence
concerning certain categories, health care
services, or treatments to improve patient
health and well-being, and the quality of care;
and
``(ii) in making such recommendations consult with
a broad array of public and private stakeholders,
including patients and health care providers and
payers;
``(B) monitor the appropriateness of use of the
CERTF described in subsection (g) with respect to the
timely production of comparative effectiveness research
recommended to be a national priority under
subparagraph (A);
``(C) identify highly credible research methods and
standards of evidence for such research to be
considered by the Center;
``(D) review the methodologies developed by the
center under subsection (a)(2)(C);
``(E) support forums to increase stakeholder
awareness and permit stakeholder feedback on the
efforts of the Center to advance methods and standards
that promote highly credible research;
``(F) make recommendations to the Center for
policies that would allow for public access of data
produced under this section, in accordance with
appropriate privacy and proprietary practices, while
ensuring that the information produced through such
data is timely and credible;
``(G) make recommendations to the Center for the
priority for periodic reviews of previous comparative
effectiveness research and studies conducted by the
Center under subsection (a);
``(H) at least annually review the processes of the
Center and make reports to Congress and the President
regarding research conducted, supported, or synthesized
by the Center to confirm that the information produced
by such research is objective, credible, consistent
with standards of evidence developed under this
section, and developed through a transparent process
that includes consultations with appropriate
stakeholders;
``(I) make recommendations to the Center for the
broad dissemination, consistent with subsection (e), of
the findings of research conducted and supported under
this section that enables clinicians, patients,
consumers, and payers to make more informed health care
decisions that improve quality and value; and
``(J) at least twice each year, hold a public
meeting with an opportunity for stakeholder input.
The reports under subparagraph (H) shall not be submitted to
the Office of Management and Budget or to any other Federal
agency or executive department for any purpose prior to
transmittal to Congress and the President. Such reports shall
be published on the public internet website of the Commission
after the date of such transmittal.
``(3) Composition of commission.--
``(A) In general.--The members of the Commission
shall consist of--
``(i) the Director of the Agency for
Healthcare Research and Quality or their
designee;
``(ii) the Chief Medical Officer of the
Centers for Medicare & Medicaid Services or
their designee;
``(iii) the Director of the National
Institutes of Health or their designee; and
``(iv) 16 additional members who shall
represent broad constituencies of stakeholders
including clinicians, patients, researchers,
third-party payers, and consumers of Federal
and State beneficiary programs.
Of such members, at least 10 shall be practicing
physicians, health care practitioners, consumers, or
patients.
``(B) Qualifications.--
``(i) Diverse representation of
perspectives.--The members of the Commission
shall represent a broad range of perspectives
and shall collectively have experience in the
following areas:
``(I) Epidemiology.
``(II) Health services research.
``(III) Bioethics.
``(IV) Decision sciences.
``(V) Health disparities.
``(VI) Health economics.
``(ii) Diverse representation of health
care community.--At least one member shall
represent each of the following health care
communities:
``(I) Patients.
``(II) Health care consumers.
``(III) Practicing Physicians,
including surgeons.
``(IV) Other health care
practitioners engaged in clinical care.
``(V) Organizations with proven
expertise in racial and ethnic minority
health research.
``(VI) Employers.
``(VII) Public payers.
``(VIII) Insurance plans.
``(IX) Clinical researchers who
conduct research on behalf of
pharmaceutical or device manufacturers.
``(C) Limitation.--No more than 3 of the Members of
the Commission may be representatives of pharmaceutical
or device manufacturers and such representatives shall
be clinical researchers described under subparagraph
(B)(ii)(IX).
``(4) Appointment.--The Comptroller General shall appoint
the members of the Commission.
``(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. The Chairman shall serve as an
ex officio member of the National Advisory Council of the
Agency for Health Care Research and Quality under section
931(c)(3)(B) of the Public Health Service Act.
``(6) Terms.--
``(A) In general.--Except as provided in
subparagraph (B), each member of the Commission shall
be appointed for a term of 4 years.
``(B) Terms of initial appointees.--Of the members
first appointed--
``(i) 8 shall be appointed for a term of 4
years; and
``(ii) 8 shall be appointed for a term of 3
years.
``(7) 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 title 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 Director of the Commission.
``(8) Director and staff; experts and consultants.--Subject
to such review as the Comptroller General deems necessary to
assure the efficient administration of the Commission, the
Commission may--
``(A) appoint and set the compensation for an
Executive Director (subject to the approval of the
Comptroller General) and such other personnel as
Federal employees under section 2105 of title 5, United
States Code, 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);
``(B) seek such assistance and support as may be
required in the performance of its duties from
appropriate Federal departments and agencies;
``(C) 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));
``(D) make advance, progress, and other payments
which relate to the work of the Commission;
``(E) provide transportation and subsistence for
persons serving without compensation; and
``(F) prescribe such rules and regulations as it
deems necessary with respect to the internal
organization and operation of the Commission.
``(9) Obtaining official data.--The Commission may secure
directly from any department or agency of the United States
information necessary to enable the Commission to carry out
this section. Upon request of the Chairman of the Commission,
the head of such department or agency shall furnish the
information to the Commission on an agreed upon schedule.
``(10) Availability of reports.--The Commission shall
transmit to the Secretary a copy of each report submitted under
this subsection and shall make such reports available to the
public.
``(11) Coordination.--To enhance effectiveness and
coordination, the Secretary is encouraged, to the greatest
extent possible, to seek coordination between the Commission
and the National Advisory Council of the Agency for Healthcare
Research and Quality.
``(12) Conflicts of interest.--
``(A) In general.--In appointing the members of the
Commission or a clinical perspective advisory panel
described in subsection (a)(2)(G), the Comptroller
General or the Secretary, respectively, shall take into
consideration any financial interest (as defined in
subparagraph (D)), consistent with this paragraph, and
develop a plan for managing any identified conflicts.
``(B) Evaluation and criteria.--When considering an
appointment to the Commission or a clinical perspective
advisory panel described subsection (a)(2)(G), the
Comptroller General or the Secretary, respectively,
shall review the expertise of the individual and the
financial disclosure report filed by the individual
pursuant to the Ethics in Government Act of 1978 for
each individual under consideration for the
appointment, so as to reduce the likelihood that an
appointed individual will later require a written
determination as referred to in section 208(b)(1) of
title 18, United States Code, a written certification
as referred to in section 208(b)(3) of title 18, United
States Code, or a waiver as referred to in subparagraph
(D)(iii) for service on the Commission at a meeting of
the Commission.
``(C) Disclosures; prohibitions on participation;
waivers.--
``(i) Disclosure of financial interest.--
Prior to a meeting of the Commission or a
clinical perspective advisory panel described
in subsection (a)(2)(G) regarding a `particular
matter' (as that term is used in section 208 of
title 18, United States Code), each member of
the Commission or the clinical perspective
advisory panel who is a full-time Government
employee or special Government employee shall
disclose to the Comptroller General or
Secretary, respectively, financial interests in
accordance with requiring a waiver under
section 208(b) of title 18, United States Code,
or other interests as deemed relevant by the
Secretary.
``(ii) Prohibitions on participation.--
Except as provided under clause (iii), a member
of the Commission or a clinical perspective
advisory panel described in subsection
(a)(2)(G) may not participate with respect to a
particular matter considered in meeting of the
Commission or the clinical perspective advisory
panel if such member has a financial interest
that could be affected by the advice given to
the Secretary with respect to such matter,
excluding interests exempted in regulations
issued by the Director of the Office of
Government Ethics as too remote or
inconsequential to affect the integrity of the
services of the Government officers or
employees to which such regulations apply.
``(iii) Waiver.--If the Comptroller General
or Secretary, as applicable, determines it
necessary to afford the Commission or a
clinical perspective advisory panel described
in subsection (a)(2)(G) essential expertise,
the Comptroller General or Secretary,
respectively, may grant a waiver of the
prohibition in clause (ii) to permit a member
described in such subparagraph to--
``(I) participate as a non-voting
member with respect to a particular
matter considered in a meeting of the
Commission or a clinical perspective
advisory panel, respectively; or
``(II) participate as a voting
member with respect to a particular
matter considered in a meeting of the
Commission.
``(iv) Limitation on waivers and other
exceptions.--
``(I) Determination of allowable
exceptions for the commission.--The
number of waivers granted to members of
the Commission cannot exceed one-half
of the total number of members for the
Commission.
``(II) Prohibition on voting status
on clinical perspective advisory
panels.--No voting member of any
clinical perspective advisory panel
shall be in receipt of a waiver. No
more than two nonvoting members of any
clinical perspective advisory panel
shall receive a waiver.
``(D) Financial interest defined.--For purposes of
this paragraph, the term `financial interest' means a
financial interest under section 208(a) of title 18,
United States Code.
``(13) Application of faca.--The Federal Advisory Committee
Act (other than section 14 of such Act) shall apply to the
Commission to the extent that the provisions of such Act do not
conflict with the requirements of this subsection.
``(c) Research Requirements.--Any research conducted, supported, or
synthesized under this section shall meet the following requirements:
``(1) Ensuring transparency, credibility, and access.--
``(A) The establishment of a research agenda by the
Center shall be informed by the national priorities for
research recommended under subsection (b)(2)(A).
``(B) The establishment of the agenda and conduct
of the research shall be insulated from inappropriate
political or stakeholder influence.
``(C) Methods of conducting such research shall be
scientifically based.
``(D) Consistent with applicable law, all aspects
of the prioritization of research, conduct of the
research, and development of conclusions based on the
research shall be transparent to all stakeholders.
``(E) Consistent with applicable law, the process
and methods for conducting such research shall be
publicly documented and available to all stakeholders.
``(F) Throughout the process of such research, the
Center shall provide opportunities for all stakeholders
involved to review and provide public comment on the
methods and findings of such research.
``(G) Such research shall consider advice given to
the Center by the clinical perspective advisory panel
for the particular national research priority.
``(2) Stakeholder input.--
``(A) In general.--The Commission shall consult
with patients, health care providers, health care
consumer representatives, and other appropriate
stakeholders with an interest in the research through a
transparent process recommended by the Commission.
``(B) Specific areas of consultation.--Consultation
shall include where deemed appropriate by the
Commission--
``(i) recommending research priorities and
questions;
``(ii) recommending research methodologies;
and
``(iii) advising on and assisting with
efforts to disseminate research findings.
``(C) Ombudsman.--The Secretary shall designate a
patient ombudsman. The ombudsman shall--
``(i) serve as an available point of
contact for any patients with an interest in
proposed comparative effectiveness studies by
the Center; and
``(ii) ensure that any comments from
patients regarding proposed comparative
effectiveness studies are reviewed by the
Center.
``(3) Taking into account potential differences.--Research
shall--
``(A) be designed, as appropriate, to take into
account the potential for differences in the
effectiveness of health care items, services, and
systems used with various subpopulations such as racial
and ethnic minorities, women, different age groups
(including children, adolescents, adults, and seniors),
individuals with disabilities, and individuals with
different comorbidities and genetic and molecular
subtypes; and--
``(B) seek, as feasible and appropriate, to include
members of such subpopulations as subjects in the
research.
``(d) Public Access to Comparative Effectiveness Information.--
``(1) In general.--Not later than 90 days after receipt by
the Center or Commission, as applicable, of a relevant report
described in paragraph (2) made by the Center, Commission, or
clinical perspective advisory panel under this section,
appropriate information contained in such report shall be
posted on the official public Internet site of the Center and
of the Commission, as applicable.
``(2) Relevant reports described.--For purposes of this
section, a relevant report is each of the following submitted
by the Center or a grantee or contractor of the Center:
``(A) Any interim or progress reports as deemed
appropriate by the Secretary.
``(B) Stakeholder comments.
``(C) A final report.
``(e) Dissemination and Incorporation of Comparative Effectiveness
Information.--
``(1) Dissemination.--The Center shall provide for the
dissemination of appropriate findings produced by research
supported, conducted, or synthesized under this section to
health care providers, patients, vendors of health information
technology focused on clinical decision support, relevant
expert organizations (as defined in subsection (i)(3)(A)), and
Federal and private health plans, and other relevant
stakeholders. In disseminating such findings the Center shall--
``(A) convey findings of research so that they are
comprehensible and useful to patients and providers in
making health care decisions;
``(B) discuss findings and other considerations
specific to certain sub-populations, risk factors, and
comorbidities as appropriate;
``(C) include considerations such as limitations of
research and what further research may be needed, as
appropriate;
``(D) not include any data that the dissemination
of which would violate the privacy of research
participants or violate any confidentiality agreements
made with respect to the use of data under this
section; and
``(E) assist the users of health information
technology focused on clinical decision support to
promote the timely incorporation of such findings into
clinical practices and promote the ease of use of such
incorporation.
``(2) Dissemination protocols and strategies.--The Center
shall develop protocols and strategies for the appropriate
dissemination of research findings in order to ensure effective
communication of findings and the use and incorporation of such
findings into relevant activities for the purpose of informing
higher quality and more effective and efficient decisions
regarding medical items and services. In developing and
adopting such protocols and strategies, the Center shall
consult with stakeholders concerning the types of dissemination
that will be most useful to the end users of information and
may provide for the utilization of multiple formats for
conveying findings to different audiences, including
dissemination to individuals with limited English proficiency.
``(f) Reports to Congress.--
``(1) Annual reports.--Beginning not later than one year
after the date of the enactment of this section, the Director
of the Agency of Healthcare Research and Quality shall submit
to Congress an annual report on the activities of the Center,
as well as the research, conducted under this section. Each
such report shall include a discussion of the Center's
compliance with subsection (c)(3)(B), including any reasons for
lack of compliance with such subsection.
``(2) Recommendation for fair share per capita amount for
all-payer financing.--Beginning not later than December 31,
2011, the Secretary shall submit to Congress an annual
recommendation for a fair share per capita amount described in
subsection (c)(1) of section 9511 of the Internal Revenue Code
of 1986 for purposes of funding the CERTF under such section.
``(3) Analysis and review.--Not later than December 31,
2013, the Secretary, in consultation with the Commission, shall
submit to Congress a report on all activities conducted or
supported under this section as of such date. Such report shall
include an evaluation of the overall costs of such activities
and an analysis of the backlog of any research proposals
approved by the Center but not funded.
``(g) Funding of Comparative Effectiveness Research.--For fiscal
year 2010 and each subsequent fiscal year, amounts in the Comparative
Effectiveness Research Trust Fund (referred to in this section as the
`CERTF') under section 9511 of the Internal Revenue Code of 1986 shall
be available in accordance with such section, without the need for
further appropriations and without fiscal year limitation, to carry out
this section.
``(h) Construction.--
``(1) Coverage.--Nothing in this section shall be
construed--
``(A) to permit the Center or Commission 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.
``(2) Reports and findings.--None of the reports submitted
under this section or research findings disseminated by the
Center or Commission shall be construed as mandates, for
payment, coverage, or treatment.
``(3) Protecting the physician-patient relationship.--
Nothing in this section shall be construed to authorize any
Federal officer or employee to exercise any supervision or
control over the practice of medicine.
``(i) Consultation With Relevant Expert Organizations.--
``(1) Consultation prior to initiation of research.--Prior
to recommending priorities or initiating research described in
this section, the Commission or the Center shall consult with
the relevant expert organizations responsible for standards and
protocols of clinical excellence. Such consultation shall be
consistent with the processes established under subsection
(c)(2).
``(2) Consultation in dissemination of research.--Any
dissemination of research from the Commission or the Center and
findings made by the Commission or the Center shall be
consistent with processes established under subsection (e) and
shall--
``(A) be based upon evidence-based medicine; and
``(B) take into consideration standards and
protocols of clinical excellence developed by relevant
expert organizations.
``(3) Definitions.--For purposes of this subsection:
``(A) Relevant expert organizations.--The term
`relevant expert organization' means an organization
with expertise in the rigorous application of evidence-
based scientific methods for the design of clinical
studies, the interpretation of clinical data, and the
development of national clinical practice guidelines,
including a voluntary health organization, clinical
specialty, or other professional organization that
represents physicians based on the field of medicine in
which each such physician practices or is board
certified.
``(B) Standards and protocols of clinical
excellence.--The term `standards and protocols of
clinical excellence' means clinical or practice
guidelines that consist of a set of directions or
principles that is based on evidence and is designed to
assist a health care practitioner with decisions about
appropriate diagnostic, therapeutic, or other clinical
procedures for specific clinical circumstances.
``(j) Research May Not Be Used to Deny or Ration Care.--Nothing in
this section shall be construed to make more stringent or otherwise
change the standards or requirements for coverage of items and services
under this Act.''.
(b) Comparative Effectiveness Research Trust Fund; Financing for
the Trust Fund.--For the provision establishing a Comparative
Effectiveness Research Trust Fund and financing such Trust Fund, see
section 1802.
Subtitle B--Nursing Home Transparency
PART 1--IMPROVING TRANSPARENCY OF INFORMATION ON SKILLED NURSING
FACILITIES, NURSING FACILITIES, AND OTHER LONG-TERM CARE FACILITIES
SEC. 1411. 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 (as defined in paragraph
(6)(B)) shall have the information described in paragraph (3)
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 1411(b) of the Affordable Health Care for
America 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 (4)(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 (4)(A).
``(2) Public availability of information.--During the
period described in paragraph (1)(A), a facility shall--
``(A) make the information described in paragraph
(3) available to the public upon request and update
such information as may be necessary to reflect changes
in such information; and
``(B) post a notice of the availability of such
information in the lobby of the facility in a prominent
manner.
``(3) 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 date of start of service of each
such person or entity; and
``(III) each person or entity who
is an additional disclosable party of
the facility.
``(iii) A description of the organizational
structure and the relationship of each person
and entity described in subclauses (II) and
(III) of clause (ii) 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
Secretary may allow, to the extent practicable, such
Form or such information to meet the requirements of
paragraph (1) and to be submitted in a manner specified
by the Secretary.
``(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.
``(4) 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 regulations
requiring a facility to report the information
described in paragraph (3) to the Secretary in a
standardized format, and such other regulations as are
necessary to carry out this subsection. Such
regulations shall specify the frequency of reporting,
as determined by the Secretary. Such final regulations
shall also require--
``(i) the reporting of such information on
or after the first day of the first calendar
quarter beginning after the date that is 90
days after the date on which such final
regulations are published in the Federal
Register; and--
``(ii) the certification, as a condition of
participation under the program under title
XVIII or XIX, that such information is 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).
``(5) 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.
``(6) Definitions.--In this subsection:
``(A) Additional disclosable party.--The term
`additional disclosable party' means, with respect to a
facility, any person or entity who, through ownership
interest, partnership interest, contract, or
otherwise--
``(i) directly or indirectly exercises
operational, financial, administrative, or
managerial control or direction 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;
``(iii) lends funds or provides a financial
guarantee to the facility in an amount which is
equal to or exceeds $50,000; or
``(iv) provides management or
administrative services, 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)(4)(A) of the Social Security Act, as
added by subsection (a), are published in the Federal Register, the
information reported in accordance with such final regulations shall be
made available to the public in accordance with procedures established
by the Secretary of Health and Human Services.
(a) Conforming Amendments.--
(1) 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).
(2) 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).
SEC. 1412. ACCOUNTABILITY REQUIREMENTS.
(a) Effective Compliance and Ethics Programs.--
(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 1411(c)(1), is amended by adding at the end the
following new subparagraph:
``(C) Compliance and ethics programs.--
``(i) Requirement.--On or after the first
day of the first calendar quarter beginning
after the date that is 1 year after the date on
which regulations developed under clause (ii)
are published in the Federal Register, a
skilled nursing facility shall, with respect to
the entity that operates or controls 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 such
regulations.
``(ii) Development of regulations.--
``(I) In general.--Not later than
the date that is 2 years after the date
of the enactment of this subparagraph,
the Secretary, in consultation 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.
``(II) Design of regulations.--Such
regulations with respect to specific
elements or formality of a program may
vary with the size of the organization,
such that larger organizations should
have a more formal and rigorous program
and include established written
policies defining the standards and
procedures to be followed by its
employees. Such requirements shall
specifically apply to the corporate
level management of multi-unit nursing
home chains.
``(III) Evaluation.--Not later than
3 years after the date on which
compliance and ethics programs
established under this subparagraph are
in operation pursuant to clause (i),
the Secretary shall complete an
evaluation of such programs. Such
evaluation shall determine if such
programs led to changes in deficiency
citations, changes in quality
performance, or changes in other
metrics of resident 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.
``(iii) Requirements for compliance and
ethics programs.--In this subparagraph, the
term `compliance and ethics program' means,
with respect to a skilled nursing facility, a
program of the operating organization that--
``(I) 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
``(II) includes at least the
required components specified in clause
(iv).
``(iv) Required components of program.--The
required components of a compliance and ethics
program of an organization are the following:
``(I) The organization must have
established compliance standards and
procedures to be followed by its
employees, contractors, and other
agents that are reasonably capable of
reducing the prospect of criminal,
civil, and administrative violations
under this Act.
``(II) 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.
``(III) 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.
``(IV) 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.
``(V) 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.
``(VI) 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.
``(VII) 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 repayment of any funds to
which it was not entitled and any
necessary modification to its program
to prevent and detect criminal, civil,
and administrative violations under
this Act.
``(VIII) The organization must
periodically undertake reassessment of
its compliance program to identify
changes necessary to reflect changes
within the organization and its
facilities.
``(v) Coordination.--The provisions of this
subparagraph shall apply with respect to a
skilled nursing facility in lieu of section
1874(d).''.
(2) Nursing facilities.--Section 1919(d)(1) of the Social
Security Act (42 U.S.C. 1396r(d)(1)), as amended by section
1411(c)(2), is amended by adding at the end the following new
subparagraph:
``(C) Compliance and ethics program.--
``(i) Requirement.--On or after the first
day of the first calendar quarter beginning
after the date that is 1 year after the date on
which regulations developed under clause (ii)
are published in the Federal Register, a
skilled nursing facility shall, with respect to
the entity that operates or controls 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 such
regulations.
``(iii) Development of regulations.--
``(I) In general.--Not later than
the date that is 2 years after the date
of the enactment of this subparagraph,
the Secretary, in consultation 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.
``(II) Design of regulations.--Such
regulations with respect to specific
elements or formality of a program may
vary with the size of the organization,
such that larger organizations should
have a more formal and rigorous program
and include established written
policies defining the standards and
procedures to be followed by its
employees. Such requirements shall
specifically apply to the corporate
level management of multi-unit nursing
home chains.
``(III) Evaluation.--Not later than
3 years after the date on which
compliance and ethics programs
established under this subparagraph are
in operation pursuant to clause (i),
the Secretary shall complete an
evaluation of such programs. Such
evaluation shall determine if such
programs led to changes in deficiency
citations, changes in quality
performance, or changes in other
metrics of resident 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.
``(v) Requirements for compliance and
ethics programs.--In this subparagraph, the
term `compliance and ethics program' means,
with respect to a nursing facility, a program
of the operating organization that--
``(I) 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
``(II) includes at least the
required components specified in clause
(iv).
``(vi) Required components of program.--The
required components of a compliance and ethics
program of an organization are the following:
``(I) 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.
``(II) Specific individuals within
high-level personnel of the
organization must have been assigned
overall responsibility to oversee
compliance with such standards and
procedures and has sufficient resources
and authority to assure such
compliance.
``(III) 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.
``(IV) 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.
``(V) 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.
``(VI) 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.
``(VII) 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 repayment of any funds to
which it was not entitled and any
necessary modification to its program
to prevent and detect criminal, civil,
and administrative violations under
this Act.
``(VIII) The organization must
periodically undertake reassessment of
its compliance program to identify
changes necessary to reflect changes
within the organization and its
facilities.
``(vii) Coordination.--The provisions of
this subparagraph shall apply with respect to a
nursing facility in lieu of section
1902(a)(77).''.
(b) Quality Assurance and Performance Improvement Program.--
(1) Skilled nursing facilities.--Section 1819(b)(1)(B) of
the Social Security Act (42 U.S.C. 1396r(b)(1)(B)) is amended--
(A) by striking ``assurance'' and inserting
``assurance and quality assurance and performance
improvement program'';
(B) by designating the matter beginning with ``A
skilled nursing facility'' as a clause (i) with the
heading ``In general.--'' and the appropriate
indentation;
(C) in clause (i) (as so designated by subparagraph
(B)), by redesignating clauses (i) and (ii) as
subclauses (I) and (II), respectively; and
(D) by adding at the end the following new clause:
``(ii) Quality assurance and performance
improvement program.--
``(I) In general.--Not later than
December 31, 2011, the Secretary shall
establish and implement a quality
assurance and performance improvement
program (in this clause referred to as
the `QAPI program') for skilled nursing
facilities, including multi-unit chains
of such facilities. Under the QAPI
program, the Secretary shall establish
standards relating to such facilities
and provide technical assistance to
such 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 subclause (II), a
skilled nursing 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
clause (i).
``(II) Regulations.--The Secretary
shall promulgate regulations to carry
out this clause.''.
(2) Nursing facilities.--Section 1919(b)(1)(B) of the
Social Security Act (42 U.S.C. 1396r(b)(1)(B)) is amended--
(A) by striking ``assurance'' and inserting
``assurance and quality assurance and performance
improvement program'';
(B) by designating the matter beginning with ``A
nursing facility'' as a clause (i) with the heading
``In general.--'' and the appropriate indentation; and
(C) by adding at the end the following new clause:
``(ii) Quality assurance and performance
improvement program.--
``(I) In general.--Not later than
December 31, 2011, the Secretary shall
establish and implement a quality
assurance and performance improvement
program (in this clause referred to as
the `QAPI program') for nursing
facilities, including multi-unit chains
of such facilities. Under the QAPI
program, the Secretary shall establish
standards relating to such facilities
and provide technical assistance to
such 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 subclause (II), a
nursing 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
clause (i).
``(II) Regulations.--The Secretary
shall promulgate regulations to carry
out this clause.''.
(3) Proposal to revise quality assurance and performance
improvement programs.--The Secretary shall implement policies
that modify and strengthen quality assurance and performance
improvement programs in skilled nursing facilities and nursing
facilities on a periodic basis, as determined by the Secretary.
(4) Facility plan.--Not later than 1 year after the date on
which the regulations are promulgated under subclause (II) of
clause (ii) of sections 1819(b)(1)(B) and 1919(b)(1)(B) of the
Social Security Act, as added by paragraphs (1) and (2), a
skilled nursing facility and a nursing facility must submit to
the Secretary a plan for the facility to meet the standards
under such regulations and implement such best practices,
including how to coordinate the implementation of such plan
with quality assessment and assurance activities conducted
under clause (i) of such sections.
(c) GAO Study on Nursing Facility Undercapitalization.--
(1) In general.--The Comptroller General of the United
States shall conduct a study that examines the following:
(A) The extent to which corporations that own or
operate large numbers of nursing facilities, taking
into account ownership type (including private equity
and control interests), are undercapitalizing such
facilities.
(B) The effects of such undercapitalization on
quality of care, including staffing and food costs, at
such facilities.
(C) Options to address such undercapitalization,
such as requirements relating to surety bonds,
liability insurance, or minimum capitalization.
(2) Report.--Not later than 18 months after the date of the
enactment of this Act, the Comptroller General shall submit to
Congress a report on the study conducted under paragraph (1).
(3) Nursing facility.--In this subsection, the term
``nursing facility'' includes a skilled nursing facility.
SEC. 1413. 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, easily
accessible, readily understandable to consumers of
long-term care services, and searchable:
``(i) Information that is reported to the
Secretary under section 1124(c)(4).
``(ii) Information on the `Special Focus
Facility program' (or a successor program)
established by the Centers for Medicare and
Medicaid Services, according to procedures
established by the Secretary. Such procedures
shall provide for the inclusion of information
with respect to, and the names and locations
of, those facilities that, since the previous
quarter--
``(I) were newly enrolled in the
program;
``(II) are enrolled in the program
and have failed to significantly
improve;
``(III) are enrolled in the program
and have significantly improved;
``(IV) have graduated from the
program; and
``(V) have closed voluntarily or no
longer participate under this title.
``(iii) 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 subsection
(b)(8)(C), 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.
``(iv) 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.
``(v) The standardized complaint form
developed under subsection (f)(8), 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.
``(vi) Summary information on the number,
type, severity, and outcome of substantiated
complaints.
``(vii) The number of adjudicated instances
of criminal violations by employees of a
nursing 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
``(viii) The number of civil monetary
penalties levied against the facility,
employees, contractors, and other agents.
``(ix) Any other information that the
Secretary determines appropriate.
The facility shall not make available under clause (iv)
identifying information on complainants or residents.
``(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) and (A)(iii) is included on
such website (or a successor website) not later
than 1 year after the dates on which the data
are submitted to the Secretary pursuant to
section 1124(c)(4) and subsection (b)(8)(C),
respectively.
``(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 recommendation made respecting a skilled
nursing facility (including any enforcement actions
taken by the State or any Federal enforcement action
recommended 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
such Act 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 a poor compliance
history or that 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 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, easily
accessible, readily understandable to consumers of
long-term care services, and searchable:
``(i) Information that is reported to the
Secretary under section 1124(c)(4)
``(ii) Information on the `Special Focus
Facility program' (or a successor program)
established by the Centers for Medicare &
Medicaid Services, according to procedures
established by the Secretary. Such procedures
shall provide for the inclusion of information
with respect to, and the names and locations
of, those facilities that, since the previous
quarter--
``(I) were newly enrolled in the
program;
``(II) are enrolled in the program
and have failed to significantly
improve;
``(III) are enrolled in the program
and have significantly improved;
``(IV) have graduated from the
program; and
``(V) have closed voluntarily or no
longer participate under this title.
``(iii) 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 subsection
(b)(8)(C)(ii), 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.
``(iv) 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.
``(v) The standardized complaint form
developed under subsection (f)(10), 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.
``(vi) Summary information on the number,
type, severity, and outcome of substantiated
complaints.
``(vii) The number of adjudicated instances
of criminal violations by employees of a
nursing facility--
``(I) that were committed inside of
the facility; and
``(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.
``(viii) the number of civil monetary
penalties levied against the facility,
employees, contractors, and other agents.
``(ix) Any other information that the
Secretary determines appropriate.
The facility shall not make available under clause (ii)
identifying information about complainants or
residents.
``(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) and (A)(iii) is included on
such website (or a successor website) not later
than 1 year after the dates on which the data
are submitted to the Secretary pursuant to
section 1124(c)(4) and subsection (b)(8)(C),
respectively.
``(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 recommendation made respecting a nursing
facility (including any enforcement actions taken by
the State or any Federal enforcement action recommended
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
such Act 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 a poor compliance history or
that 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
sections 1411 and 1412, is amended by adding at the end the
following new subparagraph:
``(D) 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 sections
1411 and 1412, is amended by adding at the end the following
new subparagraph:
``(D) 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)).
SEC. 1414. 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 no more than two years after the redesign of the report
specified in subparagraph (2), skilled nursing facilities
shall--
``(A) 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); and
``(B) take into account agency and contract staff
in a manner to be determined by the Administrator.
``(2) Modification of form.--The Secretary, in consultation
with private sector accountants experienced with skilled
nursing facility cost reports, shall redesign such reports to
meet the requirement of paragraph (1) not later than 2 years
after the date of the enactment of this subsection.
``(3) Categorization by functional accounts.--Beginning
with cost reports submitted under paragraph (1) , the
Secretary, working in consultation with the Medicare Payment
Advisory Commission, the Inspector General of the Department of
Health and Human Services, and other expert parties the
Secretary determines appropriate, shall categorize the
expenditures listed on cost reports, as modified under
paragraph (1), submitted by skilled nursing facilities,
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. 1415. STANDARDIZED COMPLAINT FORM.
(a) Skilled Nursing Facilities.--
(1) Development by the secretary.--Section 1819(f) of the
Social Security Act (42 U.S.C. 1395i-3(f)), as amended by
section 1413(a)(3), is amended by adding at the end the
following new paragraph:
``(9) Standardized complaint form.--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 skilled nursing
facility.''.
(2) State requirements.--Section 1819(e) of the Social
Security Act (42 U.S.C. 1395i-3(e)) is amended by adding at the
end the following new paragraph:
``(6) Complaint processes and whistle-blower protection.--
``(A) Complaint forms.--The State must make the
standardized complaint form developed under subsection
(f)(9) available upon request to--
``(i) a resident of a skilled nursing
facility;
``(ii) any person acting on the resident's
behalf; and
``(iii) any person who works at a skilled
nursing facility or is a representative of such
a worker.
``(B) Complaint resolution process.--The State must
establish a complaint resolution process in order to
ensure that a resident, the legal representative of a
resident of a skilled nursing facility, or other
responsible party is not retaliated against if the
resident, legal representative, or responsible party
has complained, in good faith, about the quality of
care or other issues relating to the skilled nursing
facility, that the legal representative of a resident
of a skilled nursing facility or other responsible
party is not denied access to such resident or
otherwise retaliated against if such representative
party has complained, in good faith, about the quality
of care provided by the facility or other issues
relating to the facility, and that a person who works
at a skilled nursing facility is not retaliated against
if the worker has complained, in good faith, about
quality of care or services or an issue relating to the
quality of care or services provided at the facility,
whether the resident, legal representative, other
responsible party, or worker used the form developed
under subsection (f)(9) or some other method for
submitting the complaint. 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;
``(iii) deadlines for responding to a
complaint and for notifying the complainant of
the outcome of the investigation; and
``(iv) procedures to ensure that the
identity of the complainant will be kept
confidential.
``(C) Whistleblower protection.--
``(i) Prohibition against retaliation.--No
person who works at a skilled nursing facility
may be penalized, discriminated, or retaliated
against with respect to any aspect of
employment, including discharge, promotion,
compensation, terms, conditions, or privileges
of employment, or have a contract for services
terminated, because the person (or anyone
acting at the person's request) complained, in
good faith, about the quality of care or
services provided by a skilled nursing facility
or about other issues relating to quality of
care or services, whether using the form
developed under subsection (f)(9) or some other
method for submitting the complaint.
``(ii) Retaliatory reporting.--A skilled
nursing facility may not file a complaint or a
report against a person who works (or has
worked at the facility) with the appropriate
State professional disciplinary agency because
the person (or anyone acting at the person's
request) complained in good faith, as described
in clause (i).
``(iii) Relief.--Any person aggrieved by a
violation of clause (i) or clause (ii) may, in
a civil action, obtain all appropriate relief,
including reinstatement, reimbursement of lost
wages, compensation, and benefits, and
exemplary damages where warranted, and such
other relief as the court deems appropriate, as
well as costs of suit and reasonable attorney
and expert witness fees.
``(iv) Rights not waivable.--The rights
protected by this paragraph may not be
diminished by contract or other agreement, and
nothing in this paragraph shall be construed to
diminish any greater or additional protection
provided by Federal or State law or by contract
or other agreement.
``(v) Requirement to post notice of
employee rights.--Each skilled nursing facility
shall post conspicuously in an appropriate
location a sign (in a form specified by the
Secretary) specifying the rights of persons
under this paragraph and including a statement
that an employee may file a complaint with the
Secretary against a skilled nursing facility
that violates the provisions of this paragraph
and information with respect to the manner of
filing such a complaint.
``(D) Rule of construction.--Nothing in this
paragraph shall be construed as preventing a resident
of a skilled nursing 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 subsection (f)(9)
(including submitting a complaint orally).
``(E) Good faith defined.--For purposes of this
paragraph, an individual shall be deemed to be acting
in good faith with respect to the filing of a complaint
if the individual reasonably believes--
``(i) the information reported or disclosed
in the complaint is true; and
``(ii) the violation of this title has
occurred or may occur in relation to such
information.''.
(b) Nursing Facilities.--
(1) Development by the secretary.--Section 1919(f) of the
Social Security Act (42 U.S.C. 1395i-3(f)), as amended by
section 1413(b), is amended by adding at the end the following
new paragraph:
``(11) Standardized complaint form.--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 nursing
facility.''.
(2) State requirements.--Section 1919(e) of the Social
Security Act (42 U.S.C. 1395i-3(e)) is amended by adding at the
end the following new paragraph:
``(8) Complaint processes and whistleblower protection.--
``(A) Complaint forms.--The State must make the
standardized complaint form developed under subsection
(f)(11) available upon request to--
``(i) a resident of a nursing facility;
``(ii) any person acting on the resident's
behalf; and
``(iii) any person who works at a nursing
facility or a representative of such a worker.
``(B) Complaint resolution process.--The State must
establish a complaint resolution process in order to
ensure that a resident, the legal representative of a
resident of a nursing facility, or other responsible
party is not retaliated against if the resident, legal
representative, or responsible party has complained, in
good faith, about the quality of care or other issues
relating to the nursing facility, that the legal
representative of a resident of a nursing facility or
other responsible party is not denied access to such
resident or otherwise retaliated against if such
representative party has complained, in good faith,
about the quality of care provided by the facility or
other issues relating to the facility, and that a
person who works at a nursing facility is not
retaliated against if the worker has complained, in
good faith, about quality of care or services or an
issue relating to the quality of care or services
provided at the facility, whether the resident, legal
representative, other responsible party, or worker used
the form developed under subsection (f)(11) or some
other method for submitting the complaint. 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;
``(iii) deadlines for responding to a
complaint and for notifying the complainant of
the outcome of the investigation; and
``(iv) procedures to ensure that the
identity of the complainant will be kept
confidential.
``(C) Whistleblower protection.--
``(i) Prohibition against retaliation.--No
person who works at a nursing facility may be
penalized, discriminated, or retaliated against
with respect to any aspect of employment,
including discharge, promotion, compensation,
terms, conditions, or privileges of employment,
or have a contract for services terminated,
because the person (or anyone acting at the
person's request) complained, in good faith,
about the quality of care or services provided
by a nursing facility or about other issues
relating to quality of care or services,
whether using the form developed under
subsection (f)(11) or some other method for
submitting the complaint.
``(ii) Retaliatory reporting.--A nursing
facility may not file a complaint or a report
against a person who works (or has worked at
the facility with the appropriate State
professional disciplinary agency because the
person (or anyone acting at the person's
request) complained in good faith, as described
in clause (i).
``(iii) Relief.--Any person aggrieved by a
violation of clause (i) or clause (ii) may, in
a civil action, obtain all appropriate relief,
including reinstatement, reimbursement of lost
wages, compensation, and benefits, and
exemplary damages where warranted, and such
other relief as the court deems appropriate, as
well as costs of suit and reasonable attorney
and expert witness fees.
``(iv) Rights not waivable.--The rights
protected by this paragraph may not be
diminished by contract or other agreement, and
nothing in this paragraph shall be construed to
diminish any greater or additional protection
provided by Federal or State law or by contract
or other agreement.
``(v) Requirement to post notice of
employee rights.--Each nursing facility shall
post conspicuously in an appropriate location a
sign (in a form specified by the Secretary)
specifying the rights of persons under this
paragraph and including a statement that an
employee may file a complaint with the
Secretary against a nursing facility that
violates the provisions of this paragraph and
information with respect to the manner of
filing such a complaint.
``(D) Rule of construction.--Nothing in this
paragraph shall be construed as preventing a resident
of a nursing 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 subsection (f)(11)
(including submitting a complaint orally).
``(E) Good faith defined.--For purposes of this
paragraph, an individual shall be deemed to be acting
in good faith with respect to the filing of a complaint
if the individual reasonably believes--
``(i) the information reported or disclosed
in the complaint is true; and
``(ii) the violation of this title has
occurred or may occur in relation to such
information.''.
(c) Effective Date.--The amendments made by this section shall take
effect 1 year after the date of the enactment of this Act.
SEC. 1416. ENSURING STAFFING ACCOUNTABILITY.
(a) Skilled Nursing Facilities.--Section 1819(b)(8) of the Social
Security Act (42 U.S.C. 1395i-3(b)(8)) is amended by adding at the end
the following new subparagraph:
``(C) Submission of staffing information based on
payroll data in a uniform format.--On and after the
first day of the first calendar quarter beginning after
the date that is 2 years after the date of enactment of
this subparagraph, 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
skilled nursing 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--
``(i) 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);
``(ii) include resident census data and
information on resident case mix;
``(iii) include a regular reporting
schedule; and
``(iv) include information on employee
turnover and tenure and on the hours of care
provided by each category of certified
employees referenced in clause (i) per resident
per day.
Nothing in this subparagraph 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
subparagraph with respect to agency and contract staff
shall be kept separate from information on employee
staffing.''.
(b) Nursing Facilities.--Section 1919(b)(8) of the Social Security
Act (42 U.S.C. 1396r(b)(8)) is amended by adding at the end the
following new subparagraph:
``(C) Submission of staffing information based on
payroll data in a uniform format.--On and after the
first day of the first calendar quarter beginning after
the date that is 2 years after the date of enactment of
this subparagraph, 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
nursing 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--
``(i) 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);
``(ii) include resident census data and
information on resident case mix;
``(iii) include a regular reporting
schedule; and
``(iv) include information on employee
turnover and tenure and on the hours of care
provided by each category of certified
employees referenced in clause (i) per resident
per day.
Nothing in this subparagraph 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
subparagraph with respect to agency and contract staff
shall be kept separate from information on employee
staffing.''.
SEC. 1417. 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''). 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 subsections (b)(3)(A) and
(b)(6), respectively, of such section 307. The program under this
subsection shall contain the following modifications to such pilot
program:
(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);
(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
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 or other background checks on the prospective
employee through such means as the Secretary determines
appropriate 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; and
(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.
(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 or other
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.
Background checks and screenings under this
subsection shall be valid for a period of no
longer than 2 years, as determined by the State
and approved by the Secretary.
(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).
(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).
(6) Definitions.--Under the nationwide program:
(A) 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 nursing home level of
care conveyed by State licensure or State
definition.
(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.
(B) 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.
(7) Evaluation and report.--
(A) Evaluation.--The Inspector General of the
Department of Health and Human Services shall conduct
an evaluation of the nationwide program. Such
evaluation shall include--
(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 and identify
the most efficient, effective, and economical
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 such
facilities or providers;
(iv) an assessment of the impact of the
program on reducing the number of incidents of
neglect, abuse, and misappropriation of
resident property to the extent practicable;
and
(v) an evaluation of other aspects of the
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, including costs for the Department of Health and Human
Services to administer and evaluate the program, 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.--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.
PART 2--TARGETING ENFORCEMENT
SEC. 1421. 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 to
read as follows:
``(ii) Authority with respect to civil
money penalties.--
``(I) Amount.--The Secretary may
impose a civil money penalty in the
applicable per instance or per day
amount (as defined in subclause (II)
and (III)) for each day or instance,
respectively, of noncompliance (as
determined appropriate by the
Secretary).
``(II) Applicable per instance
amount.--In this clause, the term
`applicable per instance amount'
means--
``(aa) in the case where
the deficiency is found to be a
direct proximate cause of death
of a resident of the facility,
an amount not to exceed
$100,000.
``(bb) in each case of a
deficiency where the facility
is cited for actual harm or
immediate jeopardy, an amount
not less than $3,050 and not
more than $25,000; and
``(cc) in each case of any
other deficiency, an amount not
less than $250 and not to
exceed $3050.
``(III) Applicable per day
amount.--In this clause, the term
`applicable per day amount' means--
``(aa) in each case of a
deficiency where the facility
is cited for actual harm or
immediate jeopardy, an amount
not less than $3,050 and not
more than $25,000 and
``(bb) in each case of any
other deficiency, an amount not
less than $250 and not to
exceed $3,050.
``(IV) Reduction of civil money
penalties in certain circumstances.--
Subject to subclauses (V) and (VI), 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.
``(V) Prohibition on reduction for
certain deficiencies.--
``(aa) Repeat
deficiencies.--The Secretary
may not reduce under subclause
(IV) the amount of a penalty if
the deficiency is a repeat
deficiency.
``(bb) Certain other
deficiencies.--The Secretary
may not reduce under subclause
(IV) the amount of a penalty if
the penalty is imposed for a
deficiency described in
subclause (II)(aa) or (III)(aa)
and the actual harm or
widespread harm immediately
jeopardizes the health or
safety of a resident or
residents of the facility, or
if the penalty is imposed for a
deficiency described in
subclause (II)(bb).
``(VI) Limitation on aggregate
reductions.--The aggregate reduction in
a penalty under subclause (IV) may not
exceed 35 percent on the basis of self-
reporting, on the basis of a waiver of
an appeal (as provided for under
regulations under section 488.436 of
title 42, Code of Federal Regulations),
or on the basis of both.
``(VII) Collection of civil money
penalties.--In the case of a civil
money penalty imposed under this
clause, the Secretary--
``(aa) subject to item
(cc), shall, not later than 30
days after the date of
imposition of the penalty,
provide the opportunity for the
facility to participate in an
independent informal dispute
resolution process, established
by the State survey agency,
which generates a written
record prior to the collection
of such penalty, but such
opportunity shall not affect
the responsibility of the State
survey agency for making final
recommendations for such
penalties;
``(bb) in the case where
the penalty is imposed for each
day of noncompliance, shall not
impose a penalty 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 under quality
assurance programs, the
appointment of temporary
management, and other
activities approved by the
Secretary).
``(VIII) Procedure.--The provisions
of section 1128A (other than
subsections (a) and (b) and except to
the extent that such provisions require
a hearing prior to the imposition of a
civil money penalty) shall apply to a
civil money penalty under this clause
in the same manner as such provisions
apply to a penalty or proceeding under
section 1128A(a).''.
(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),''after ``(i),''.
(b) Nursing Facilities.--
(1) Penalties imposed by the state.--
(A) In general.--Section 1919(h)(2) of the Social
Security Act (42 U.S.C. 1396r(h)(2)) is amended--
(i) in subparagraph (A)(ii), by striking
the first sentence and inserting the following:
``A civil money penalty in accordance with
subparagraph (G).''; and
(ii) by adding at the end the following new
subparagraph:
``(G) Civil money penalties.--
``(i) In general.--The State may impose a
civil money penalty under subparagraph (A)(ii)
in the applicable per instance or per day
amount (as defined in subclause (II) and (III))
for each day or instance, respectively, of
noncompliance (as determined appropriate by the
Secretary).
``(ii) Applicable per instance amount.--In
this subparagraph, the term `applicable per
instance amount' means--
``(I) in the case where the
deficiency is found to be a direct
proximate cause of death of a resident
of the facility, an amount not to
exceed $100,000.
``(II) in each case of a deficiency
where the facility is cited for actual
harm or immediate jeopardy, an amount
not less than $3,050 and not more than
$25,000; and
``(III) in each case of any other
deficiency, an amount not less than
$250 and not to exceed $3050.
``(iii) Applicable per day amount.--In this
subparagraph, the term `applicable per day
amount' means--
``(I) in each case of a deficiency
where the facility is cited for actual
harm or immediate jeopardy, an amount
not less than $3,050 and not more than
$25,000 and
``(II) in each case of any other
deficiency, an amount not less than
$250 and not to exceed $3,050.
``(iv) Reduction of civil money penalties
in certain circumstances.--Subject to clauses
(v) and (vi), in the case where a facility
self-reports and promptly corrects a deficiency
for which a penalty was imposed under
subparagraph (A)(ii) not later than 10 calendar
days after the date of such imposition, the
State may reduce the amount of the penalty
imposed by not more than 50 percent.
``(v) Prohibition on reduction for certain
deficiencies.--
``(I) Repeat deficiencies.--The
State may not reduce under clause (iv)
the amount of a penalty if the State
had reduced a penalty imposed on the
facility in the preceding year under
such clause with respect to a repeat
deficiency.
``(II) Certain other
deficiencies.--The State may not reduce
under clause (iv) the amount of a
penalty if the penalty is imposed for a
deficiency described in clause (ii)(II)
or (iii)(I) and the actual harm or
widespread harm that immediately
jeopardizes the health or safety of a
resident or residents of the facility,
or if the penalty is imposed for a
deficiency described in clause (ii)(I).
``(III) Limitation on aggregate
reductions.--The aggregate reduction in
a penalty under clause (iv) may not
exceed 35 percent on the basis of self-
reporting, on the basis of a waiver of
an appeal (as provided for under
regulations under section 488.436 of
title 42, Code of Federal Regulations),
or on the basis of both.
``(vi) Collection of civil money
penalties.--In the case of a civil money
penalty imposed under subparagraph (A)(ii), the
State--
``(I) subject to subclause (III),
shall, not later than 30 days after the
date of imposition of the penalty,
provide the opportunity for the
facility to participate in an
independent informal dispute resolution
process, established by the State
survey agency, which generates a
written record prior to the collection
of such penalty, but such opportunity
shall not affect the responsibility of
the State survey agency for making
final recommendations for such
penalties;
``(II) in the case where the
penalty is imposed for each day of
noncompliance, shall not impose a
penalty 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 subclause (I)
is completed;
``(III) 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 State on the
earlier of the date on which the
informal dispute resolution process
under subclause (I) is completed or the
date that is 90 days after the date of
the imposition of the penalty;
``(IV) may provide that such
amounts collected are kept in such
account pending the resolution of any
subsequent appeals;
``(V) 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
``(VI) in the case where all such
appeals are unsuccessful, may provide
that such funds collected shall be used
for the purposes described in the
second sentence of subparagraph
(A)(ii).''.
(B) Conforming amendment.--The second sentence of
section 1919(h)(2)(A)(ii) of the Social Security Act
(42 U.S.C. 1396r(h)(2)(A)(ii)) is amended by inserting
before the period at the end the following: ``, and
some portion of such funds 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, providing technical
assistance to facilities under quality assurance
programs, the appointment of temporary management, and
other activities approved by the Secretary)''.
(2) Penalties imposed by the secretary.--
(A) In general.--Section 1919(h)(3)(C)(ii) of the
Social Security Act (42 U.S.C. 1396r(h)(3)(C)) is
amended to read as follows:
``(ii) Authority with respect to civil
money penalties.--
``(I) Amount.--Subject to subclause
(II), the Secretary may impose a civil
money penalty in an amount not to
exceed $10,000 for each day or each
instance of noncompliance (as
determined appropriate by the
Secretary).
``(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) Prohibition on reduction
for 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.
``(IV) Collection of civil money
penalties.--In the case of a civil
money penalty imposed under this
clause, the Secretary--
``(aa) subject to item
(bb), shall, not later than 30
days after the date of
imposition of the penalty,
provide the opportunity for the
facility 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, shall not
impose a penalty 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 under quality
assurance programs, the
appointment of temporary
management, and other
activities approved by the
Secretary).
``(V) Procedure.--The provisions of
section 1128A (other than subsections
(a) and (b) and except to the extent
that such provisions require a hearing
prior to the imposition of a civil
money penalty) shall apply to a civil
money penalty under this clause in the
same manner as such provisions apply to
a penalty or proceeding under section
1128A(a).''.
(B) Conforming amendment.--Section 1919(h)(8) of
the Social Security Act (42 U.S.C. 1396r(h)(5)(8)) is
amended by inserting ``and in paragraph (3)(C)(ii)''
after ``paragraph (2)(A)''.
(c) Effective Date.--The amendments made by this section shall take
effect 1 year after the date of the enactment of this Act.
SEC. 1422. NATIONAL INDEPENDENT MONITOR PILOT PROGRAM.
(a) Establishment.--
(1) In general.--The Secretary, in consultation with the
Inspector General of the Department of Health and Human
Services, shall establish a pilot program (in this section
referred to as the ``pilot program'') to develop, test, and
implement use of an independent monitor 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 pilot program 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 pilot
program for a two-year period.
(4) Implementation.--The Secretary shall implement the
pilot program not later than one year after the date of the
enactment of this Act.
(b) Requirements.--The Secretary shall evaluate chains selected to
participate in the pilot program based on criteria selected by the
Secretary, including where evidence suggests that one or more
facilities of the chain are experiencing serious safety and quality of
care problems. Such criteria may include the evaluation of a chain that
includes one or more facilities participating in the ``Special Focus
Facility'' program (or a successor program) or one or more facilities
with a record of repeated serious safety and quality of care
deficiencies.
(c) Responsibilities of the Independent Monitor.--An independent
monitor that enters into a contract with the Secretary to participate
in the conduct of such program 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) undertake sustained oversight of the chain, whether
publicly or privately held, to involve the owners of the chain
and the principal business partners of such owners in
facilitating 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 pilot program
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 the date of 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) involved, 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 pilot program. 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 pilot program.
(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) Facility.--The term ``facility'' means a skilled
nursing facility or a nursing facility.
(2) 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)).
(3) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services, acting through the Assistant
Secretary for Planning and Evaluation.
(4) 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 Inspector General of the Department of
Health and Human Services shall evaluate the pilot program.
Such evaluation shall--
(A) determine whether the independent monitor
program should be established on a permanent basis; and
(B) if the Inspector General determines that the
independent monitor program should be established on a
permanent basis, recommend appropriate procedures and
mechanisms for such establishment.
(2) Report.--Not later than 180 days after the completion
of the pilot program, the Inspector General shall submit to
Congress and the Secretary a report containing the results of
the evaluation conducted under paragraph (1), together with
recommendations for such legislation and administrative action
as the Inspector General determines appropriate.
SEC. 1423. NOTIFICATION OF FACILITY CLOSURE.
(a) Skilled Nursing Facilities.--
(1) In general.--Section 1819(c) of the Social Security Act
(42 U.S.C. 1395i-3(c)) is amended by adding at the end the
following new paragraph:
``(7) Notification of facility closure.--
``(A) In general.--Any individual who is the
administrator of a skilled nursing facility must--
``(i) 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 subclause (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;
``(ii) ensure that the facility does not
admit any new residents on or after the date on
which such written notification is submitted;
and
``(iii) 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 and best interests of
each resident.
``(B) Relocation.--
``(i) 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.
``(ii) 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 subparagraph (A) during the
period beginning on the date such notification
is submitted and ending on the date on which
the resident is successfully relocated.''.
(2) Conforming amendments.--Section 1819(h)(4) of the
Social Security Act (42 U.S.C. 1395i-3(h)(4)) is amended--
(A) in the first sentence, by striking ``the
Secretary shall terminate'' and inserting ``the
Secretary, subject to subsection (c)(7), shall
terminate''; and
(B) in the second sentence, by striking
``subsection (c)(2)'' and inserting ``paragraphs (2)
and (7) of subsection (c)''.
(b) Nursing Facilities.--
(1) In general.--Section 1919(c) of the Social Security Act
(42 U.S.C. 1396r(c)) is amended by adding at the end the
following new paragraph:
``(9) Notification of facility closure.--
``(A) In general.--Any individual who is an
administrator of a nursing facility must--
``(i) 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 subclause (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;
``(ii) ensure that the facility does not
admit any new residents on or after the date on
which such written notification is submitted;
and
``(iii) 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 and best interests of
each resident.
``(B) Relocation.--
``(i) 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.
``(ii) 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 subparagraph (A) during the
period beginning on the date such notification
is submitted and ending on the date on which
the resident is successfully relocated.''.
(c) Effective Date.--The amendments made by this section shall take
effect 1 year after the date of the enactment of this Act.
PART 3--IMPROVING STAFF TRAINING
SEC. 1431. DEMENTIA AND ABUSE PREVENTION TRAINING.
(a) Skilled Nursing Facilities.--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 resident abuse prevention training)''
after ``curriculum''.
(b) Nursing Facilities.--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 resident abuse prevention training)'' after
``curriculum''.
(c) Effective Date.--The amendments made by this section shall take
effect 1 year after the date of the enactment of this Act.
SEC. 1432. STUDY AND REPORT ON TRAINING REQUIRED FOR CERTIFIED NURSE
AIDES AND SUPERVISORY STAFF.
(a) Study.--
(1) In general.--The Secretary shall conduct a study on the
content of training for certified nurse aides and supervisory
staff of skilled nursing facilities and nursing facilities. The
study shall include an analysis of the following:
(A) Whether the number of initial training hours
for certified nurse aides required under sections
1819(f)(2)(A)(i)(II) and 1919(f)(2)(A)(i)(II) of the
Social Security Act (42 U.S.C. 1395i-3(f)(2)(A)(i)(II);
1396r(f)(2)(A)(i)(II)) should be increased from 75 and,
if so, what the required number of initial training
hours should be, including any recommendations for the
content of such training (including training related to
dementia).
(B) Whether requirements for ongoing training under
such sections 1819(f)(2)(A)(i)(II) and
1919(f)(2)(A)(i)(II) should be increased from 12 hours
per year, including any recommendations for the content
of such training.
(2) Consultation.--In conducting the analysis under
paragraph (1)(A), the Secretary shall consult with States that,
as of the date of the enactment of this Act, require more than
75 hours of training for certified nurse aides.
(3) Definitions.--In this section:
(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, acting through
the Assistant Secretary for Planning and Evaluation.
(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.
1395(a)).
(b) Report.--Not later than 2 years after the date of the 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. 1433. QUALIFICATION OF DIRECTOR OF FOOD SERVICES OF A SKILLED
NURSING FACILITY OR NURSING FACILITY.
(a) Medicare.--Section 1819(b)(4)(A) of the Social Security Act (42
U.S.C. 1395i-3(b)(4)(A)) is amended by adding at the end the following:
``With respect to meeting the staffing requirement imposed by the
Secretary to carry out clause (iv), the full-time director of food
services of the facility, if not a qualified dietitian (as defined in
section 483.35(a)(2) of title 42, Code of Federal Regulations, as in
effect as of the date of the enactment of this sentence), shall be a
Certified Dietary Manager meeting the requirements of the Certifying
Board for Dietary Managers, or a Dietetic Technician, Registered
meeting the requirements of the Commission on Dietetic Registration or
have equivalent military, academic, or other qualifications (as
specified by the Secretary).''.
(b) Medicaid.--Section 1919(b)(4)(A) of the Social Security Act (42
U.S.C. 1396r(b)(4)(A)) is amended by adding at the end the following:
``With respect to meeting the staffing requirement imposed by the
Secretary to carry out clause (iv), the full-time director of food
services of the facility, if not a qualified dietitian (as defined in
section 483.35(a)(2) of title 42, Code of Federal Regulations, as in
effect as of the date of the enactment of this sentence), shall be a
Certified Dietary Manager meeting the requirements of the Certifying
Board for Dietary Managers, or a Dietetic Technician, Registered
meeting the requirements of the Commission on Dietetic Registration or
have equivalent military, academic, or other qualifications (as
specified by the Secretary).''.
(c) Effective Date.--The amendments made by this section shall take
effect on the date that is 180 days after the date of enactment of this
Act.
Subtitle C--Quality Measurements
SEC. 1441. ESTABLISHMENT OF NATIONAL PRIORITIES FOR QUALITY
IMPROVEMENT.
Title XI of the Social Security Act, as amended by section 1401(a),
is further amended by adding at the end the following new part:
``Part E--Quality Improvement
``establishment of national priorities for performance improvement
``Sec. 1191. (a) Establishment of National Priorities by the
Secretary.--The Secretary shall establish and periodically update, not
less frequently than triennially, national priorities for performance
improvement.
``(b) Recommendations for National Priorities.--In establishing and
updating national priorities under subsection (a), the Secretary shall
solicit and consider recommendations from multiple outside
stakeholders.
``(c) Considerations in Setting National Priorities.--With respect
to such priorities, the Secretary shall ensure that priority is given
to areas in the delivery of health care services in the United States
that--
``(1) contribute to a large burden of disease, including
those that address the health care provided to patients with
prevalent, high-cost chronic diseases;
``(2) have the greatest potential to decrease morbidity and
mortality in this country, including those that are designed to
eliminate harm to patients;
``(3) have the greatest potential for improving the
performance, affordability, and patient-centeredness of health
care, including those due to variations in care;
``(4) address health disparities across groups and areas;
and
``(5) have the potential for rapid improvement due to
existing evidence, standards of care or other reasons.
``(d) Definitions.--In this part:
``(1) Consensus-based entity.--The term `consensus-based
entity' means an entity with a contract with the Secretary
under section 1890.
``(2) Quality measure.--The term `quality measure' means a
national consensus standard for measuring the performance and
improvement of population health, or of institutional providers
of services, physicians, and other health care practitioners in
the delivery of health care services.
``(e) Funding.--
``(1) 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 such proportion as the
Secretary determines appropriate), of $2,000,000, for the
activities under this section for each of the fiscal years 2010
through 2014.
``(2) Authorization of appropriations.--For purposes of
carrying out the provisions of this section, in addition to
funds otherwise available, out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the Secretary
of Health and Human Services $2,000,000 for each of the fiscal
years 2010 through 2014.''.
SEC. 1442. DEVELOPMENT OF NEW QUALITY MEASURES; GAO EVALUATION OF DATA
COLLECTION PROCESS FOR QUALITY MEASUREMENT.
Part E of title XI of the Social Security Act, as added by section
1441, is amended by adding at the end the following new sections:
``SEC. 1192. DEVELOPMENT OF NEW QUALITY MEASURES.
``(a) Agreements With Qualified Entities.--
``(1) In general.--The Secretary shall enter into
agreements with qualified entities to develop quality measures
for the delivery of health care services in the United States.
``(2) Form of agreements.--The Secretary may carry out
paragraph (1) by contract, grant, or otherwise.
``(3) Recommendations of consensus-based entity.--In
carrying out this section, the Secretary shall--
``(A) seek public input; and
``(B) take into consideration recommendations of
the consensus-based entity with a contract with the
Secretary under section 1890(a).
``(b) Determination of Areas Where Quality Measures Are Required.--
Consistent with the national priorities established under this part and
with the programs administered by the Centers for Medicare & Medicaid
Services and in consultation with other relevant Federal agencies, the
Secretary shall determine areas in which quality measures for assessing
health care services in the United States are needed.
``(c) Development of Quality Measures.--
``(1) Patient-centered and population-based measures.--In
entering into agreements under subsection (a), the Secretary
shall give priority to the development of quality measures that
allow the assessment of--
``(A) health outcomes, presence of impairment, and
functional status of patients;
``(B) the continuity and coordination of care and
care transitions for patients across providers and
health care settings, including end of life care;
``(C) patient experience and patient engagement;
``(D) the safety, effectiveness, and timeliness of
care;
``(E) health disparities including those associated
with individual race, ethnicity, age, gender, place of
residence or language; and
``(F) the efficiency and resource use in the
provision of care.
``(2) Use of funds.--An entity that enters into an
agreement under subsection (a) shall develop quality measures
that--
``(A) to the extent feasible, have the ability to
be collected through the use of health information
technologies supporting better delivery of health care
services; and
``(B) are available free of charge to users for the
use of such measures.
``(3) Availability of measures.--The Secretary shall make
quality measures developed under this section available to the
public.
``(4) Testing of proposed measures.--The Secretary may use
amounts made available under subsection (f) to fund the testing
of proposed quality measures by qualified entities. Testing
funded under this paragraph shall include testing of the
feasibility and usability of proposed measures.
``(5) Updating of endorsed measures.--The Secretary may use
amounts made available under subsection (f) to fund the
updating (and testing, if applicable) by consensus-based
entities of quality measures that have been previously endorsed
by such an entity as new evidence is developed, in a manner
consistent with section 1890(b)(3).
``(d) Qualified Entities.--Before entering into agreements with a
qualified entity, the Secretary shall ensure that the entity is a
public, private, or academic institution with technical expertise in
the area of health quality measurement.
``(e) Application for Grant.--A grant may be made under this
section only if an application for the grant is submitted 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 section.
``(f) Funding.--
``(1) 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 such proportion as the
Secretary determines appropriate), of $25,000,000, to the
Secretary for purposes of carrying out this section for each of
the fiscal years 2010 through 2014.
``(2) Authorization of appropriations.--For purposes of
carrying out the provisions of this section, in addition to
funds otherwise available, out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the Secretary
of Health and Human Services $25,000,000 for each of the fiscal
years 2010 through 2014.
``SEC. 1193. GAO EVALUATION OF DATA COLLECTION PROCESS FOR QUALITY
MEASUREMENT.
``(a) GAO Evaluations.--The Comptroller General of the United
States shall conduct periodic evaluations of the implementation of the
data collection processes for quality measures used by the Secretary.
``(b) Considerations.--In carrying out the evaluation under
subsection (a), the Comptroller General shall determine--
``(1) whether the system for the collection of data for
quality measures provides for validation of data as relevant
and scientifically credible;
``(2) whether data collection efforts under the system use
the most efficient and cost-effective means in a manner that
minimizes administrative burden on persons required to collect
data and that adequately protects the privacy of patients'
personal health information and provides data security;
``(3) whether standards under the system provide for an
appropriate opportunity for physicians and other clinicians and
institutional providers of services to review and correct
findings; and
``(4) the extent to which quality measures are consistent
with section 1192(c)(1) or result in direct or indirect costs
to users of such measures.
``(c) Report.--The Comptroller General shall submit reports to
Congress and to the Secretary containing a description of the findings
and conclusions of the results of each such evaluation.''.
SEC. 1443. MULTI-STAKEHOLDER PRE-RULEMAKING INPUT INTO SELECTION OF
QUALITY MEASURES.
Section 1808 of the Social Security Act (42 U.S.C. 1395b-9) is
amended by adding at the end the following new subsection:
``(d) Multi-stakeholder Pre-rulemaking Input Into Selection of
Quality Measures.--
``(1) List of measures.--Not later than December 1 before
each year (beginning with 2011), the Secretary shall make
public a list of measures being considered for selection for
quality measurement by the Secretary in rulemaking with respect
to payment systems under this title beginning in the payment
year beginning in such year and for payment systems beginning
in the calendar year following such year, as the case may be.
``(2) Consultation on selection of endorsed quality
measures.--A consensus-based entity that has entered into a
contract under section 1890 shall, as part of such contract,
convene multi-stakeholder groups to provide recommendations on
the selection of individual or composite quality measures, for
use in reporting performance information to the public or for
use in public health care programs.
``(3) Multi-stakeholder input.--Not later than February 1
of each year (beginning with 2011), the consensus-based entity
described in paragraph (2) shall transmit to the Secretary the
recommendations of multi-stakeholder groups provided under
paragraph (2). Such recommendations shall be included in the
transmissions the consensus-based entity makes to the Secretary
under the contract provided for under section 1890.
``(4) Requirement for transparency in process.--
``(A) In general.--In convening multi-stakeholder
groups under paragraph (2) with respect to the
selection of quality measures, the consensus-based
entity described in such paragraph shall provide for an
open and transparent process for the activities
conducted pursuant to such convening.
``(B) Selection of organizations participating in
multi-stakeholder groups.--The process under paragraph
(2) shall ensure that the selection of representatives
of multi-stakeholder groups includes provision for
public nominations for, and the opportunity for public
comment on, such selection.
``(5) Use of input.--The respective proposed rule shall
contain a summary of the recommendations made by the multi-
stakeholder groups under paragraph (2), as well as other
comments received regarding the proposed measures, and the
extent to which such proposed rule follows such recommendations
and the rationale for not following such recommendations.
``(6) Multi-stakeholder groups.--For purposes of this
subsection, the term `multi-stakeholder groups' means, with
respect to a quality measure, a voluntary collaborative of
organizations representing persons interested in or affected by
the use of such quality measure, such as the following:
``(A) Hospitals and other institutional providers.
``(B) Physicians.
``(C) Health care quality alliances.
``(D) Nurses and other health care practitioners.
``(E) Health plans.
``(F) Patient advocates and consumer groups.
``(G) Employers.
``(H) Public and private purchasers of health care
items and services.
``(I) Labor organizations.
``(J) Relevant departments or agencies of the
United States.
``(K) Biopharmaceutical companies and manufacturers
of medical devices.
``(L) Licensing, credentialing, and accrediting
bodies.
``(7) Funding.--
``(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
such proportion as the Secretary determines
appropriate), of $1,000,000, to the Secretary for
purposes of carrying out this subsection for each of
the fiscal years 2010 through 2014.
``(B) Authorization of appropriations.--For
purposes of carrying out the provisions of this
subsection, in addition to funds otherwise available,
out of any funds in the Treasury not otherwise
appropriated, there are appropriated to the Secretary
of Health and Human Services $1,000,000 for each of the
fiscal years 2010 through 2014.''.
SEC. 1444. APPLICATION OF QUALITY MEASURES.
(a) Inpatient Hospital Services.--Section 1886(b)(3)(B) of such Act
(42 U.S.C. 1395ww(b)(3)(B)) is amended by adding at the end the
following new clause:
``(x)(I) Subject to subclause (II), for purposes of reporting data
on quality measures for inpatient hospital services furnished during
fiscal year 2012 and each subsequent fiscal year, the quality measures
specified under clause (viii) shall be measures selected by the
Secretary from measures that have been endorsed by the entity with a
contract with the Secretary under section 1890(a).
``(II) In the case of a specified area or medical topic determined
appropriate by the Secretary for which a feasible and practical quality
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. The Secretary shall submit such a non-endorsed measure to
the entity for consideration for endorsement. If the entity considers
but does not endorse such a measure and if the Secretary does not
phase-out use of such measure, the Secretary shall include the
rationale for continued use of such a measure in rulemaking.''.
(b) Outpatient Hospital Services.--Section 1833(t)(17) of such Act
(42 U.S.C. 1395l(t)(17)) is amended by adding at the end the following
new subparagraph:
``(F) Use of endorsed quality measures.--The
provisions of clause (x) of section 1886(b)(3)(C) shall
apply to quality measures for covered OPD services
under this paragraph in the same manner as such
provisions apply to quality measures for inpatient
hospital services.''.
(c) Physicians' Services.--Section 1848(k)(2)(C)(ii) of such Act
(42 U.S.C. 1395w-4(k)(2)(C)(ii)) is amended by adding at the end the
following: ``The Secretary shall submit such a non-endorsed measure to
the entity for consideration for endorsement. If the entity considers
but does not endorse such a measure and if the Secretary does not
phase-out use of such measure, the Secretary shall include the
rationale for continued use of such a measure in rulemaking.''.
(d) Renal Dialysis Services.--Section 1881(h)(2)(B)(ii) of such Act
(42 U.S.C. 1395rr(h)(2)(B)(ii)) is amended by adding at the end the
following: ``The Secretary shall submit such a non-endorsed measure to
the entity for consideration for endorsement. If the entity considers
but does not endorse such a measure and if the Secretary does not
phase-out use of such measure, the Secretary shall include the
rationale for continued use of such a measure in rulemaking.''.
(e) Endorsement of Standards.--Section 1890(b)(2) of the Social
Security Act (42 U.S.C. 1395aaa(b)(2)) is amended by adding after and
below subparagraph (B) the following:
``If the entity does not endorse a measure, such entity shall
explain the reasons and provide suggestions about changes to
such measure that might make it a potentially endorsable
measure.''.
(f) Effective Date.--Except as otherwise provided, the amendments
made by this section shall apply to quality measures applied for
payment years beginning with 2012 or fiscal year 2012, as the case may
be.
SEC. 1445. CONSENSUS-BASED ENTITY FUNDING.
Section 1890(d) of the Social Security Act (42 U.S.C. 1395aaa(d))
is amended by striking ``for each of fiscal years 2009 through 2012''
and inserting ``for fiscal year 2009, and $12,000,000 for each of the
fiscal years 2010 through 2012''
Subtitle D--Physician Payments Sunshine Provision
SEC. 1451. REPORTS ON FINANCIAL RELATIONSHIPS BETWEEN MANUFACTURERS AND
DISTRIBUTORS OF COVERED DRUGS, DEVICES, BIOLOGICALS, OR
MEDICAL SUPPLIES UNDER MEDICARE, MEDICAID, OR CHIP AND
PHYSICIANS AND OTHER HEALTH CARE ENTITIES AND BETWEEN
PHYSICIANS AND OTHER HEALTH CARE ENTITIES.
(a) In General.--Part A of title XI of the Social Security Act (42
U.S.C. 1301 et seq.), as amended by section 1631(a), is further amended
by inserting after section 1128G the following new section:
``SEC. 1128H. FINANCIAL REPORTS ON PHYSICIANS' FINANCIAL RELATIONSHIPS
WITH MANUFACTURERS AND DISTRIBUTORS OF COVERED DRUGS,
DEVICES, BIOLOGICALS, OR MEDICAL SUPPLIES UNDER MEDICARE,
MEDICAID, OR CHIP AND WITH ENTITIES THAT BILL FOR
SERVICES UNDER MEDICARE.
``(a) Reporting of Payments or Other Transfers of Value.--
``(1) In general.--Except as provided in this subsection,
not later than March 31, 2011, and annually thereafter, each
applicable manufacturer or distributor 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:
``(A) With respect to the covered recipient, the
recipient's name, business address, physician
specialty, and national provider identifier.
``(B) With respect to the payment or other transfer
of value, other than a drug sample--
``(i) its value and date;
``(ii) the name of the related drug,
device, or supply, if available, to the level
of specificity available; and
``(iii) a description of its form,
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 (as defined
by the Secretary).
``(C) With respect to a drug sample, the name,
number, date, and dosage units of the sample.
``(2) Aggregate reporting.--Information submitted by an
applicable manufacturer or distributor under paragraph (1)
shall include the aggregate amount of all payments or other
transfers of value provided by the manufacturer or distributor
to covered recipients (and to entities or individuals at the
request of or designated on behalf of a covered recipient)
during the year involved, including all payments and transfers
of value regardless of whether such payments or transfer of
value were individually disclosed.
``(3) Special rule for certain payments or other transfers
of value.--In the case where an applicable manufacturer or
distributor 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 manufacturer or distributor shall
disclose that payment or other transfer of value under the name
of the covered recipient.
``(4) Delayed reporting for payments made pursuant to
product development agreements.--In the case of a payment or
other transfer of value made to a covered recipient by an
applicable manufacturer or distributor pursuant to a product
development agreement for services furnished in connection with
the development of a new drug, device, biological, or medical
supply, the applicable manufacturer or distributor may report
the value and recipient of such payment or other transfer of
value in the first reporting period under this subsection in
the next reporting deadline after the earlier of the following:
``(A) The date of the approval or clearance of the
covered drug, device, biological, or medical supply by
the Food and Drug Administration.
``(B) Two calendar years after the date such
payment or other transfer of value was made.
``(5) Delayed reporting for payments made pursuant to
clinical investigations.--In the case of a payment or other
transfer of value made to a covered recipient by an applicable
manufacturer or distributor in connection with a clinical
investigation regarding a new drug, device, biological, or
medical supply, the applicable manufacturer or distributor may
report as required under this section in the next reporting
period under this subsection after the earlier of the
following:
``(A) The date that the clinical investigation is
registered on the website maintained by the National
Institutes of Health pursuant to section 671 of the
Food and Drug Administration Amendments Act of 2007.
``(B) Two calendar years after the date such
payment or other transfer of value was made.
``(6) Confidentiality.--Information described in paragraph
(4) or (5) 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 or after the date on which the information is made
available to the public under such paragraph.
``(7) Physicians in self-insured health plans.--Nothing in
this subsection shall be construed to require the disclosure of
a payment or other transfer of value to a physician by a self-
insured health plan.
``(b) Reporting of Ownership Interest by Physicians.--
``(1) Hospitals and other entities that bill medicare.--Not
later than March 31 of each year (beginning with 2011), each
hospital or other health care entity (not including a Medicare
Advantage organization) that bills the Secretary under part A
or part B of title XVIII for services shall report on the
ownership shares (other than ownership shares described in
section 1877(c)) of each physician who, directly or indirectly,
owns an interest in the entity.
``(2) Additional physician ownership.--Not later than March
31 of each year (beginning with 2011), in addition to the
requirement under subsection (a)(1), any applicable
manufacturer, applicable group purchasing organization, or
applicable distributor 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, applicable group purchasing
organization or applicable distributor 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 (iii) of paragraph (a)(1)(B), and information
described in subsection (f)(8)(A) and (f)(8)(B).
``(D) Any other information regarding the ownership
or investment interest the Secretary determines
appropriate.
``(3) Definitions.--In this subsection:
``(A) Physician.--The term `physician' includes a
physician's immediate family members (as defined for
purposes of section 1877(a)).
``(B) Applicable group purchasing organization.--
The term `applicable group purchasing organization'
means any organization or other entity (as defined by
the Secretary) that purchases, arranges for, or
negotiates the purchase of a covered drug, device,
biological, or medical supply.
``(4) Study of practice patterns in advanced diagnostic
imaging and radiation oncology services.--The Comptroller
General of the United States shall conduct a study to evaluate
the extent of use of physician self-referral arrangements and
the effects of such arrangements on the cost of providing
advanced diagnostic imaging and radiation oncology services to
Medicare beneficiaries under title XVIII. The study shall be
completed and submitted to Congress not later than July 1,
2011.
``(c) Public Availability.--
``(1) In general.--The Secretary shall establish procedures
to ensure that, not later than September 30, 2011, and on June
30 of each year beginning thereafter, the information submitted
under subsections (a) and (b), other than information regard
drug samples, with respect to the preceding calendar year is
made available through an Internet website that--
``(A) is searchable and is in a format that is
clear and understandable;
``(B) contains information that is presented by the
name of the applicable manufacturer or distributor, the
name of the covered recipient, the business address of
the covered recipient, the specialty (if applicable) 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)(B)(ii), the nature of the payment or other
transfer of value, indicated (as appropriate) under
subsection (a)(1)(B)(iii), and the name of the covered
drug, device, biological, or medical supply, as
applicable;
``(C) contains information that is able to be
easily aggregated and downloaded;
``(D) contains a description of any enforcement
actions taken to carry out this section, including any
penalties imposed under subsection (d), during the
preceding year;
``(E) contains background information on industry-
physician relationships;
``(F) in the case of information submitted with
respect to a payment or other transfer of value
described in subsection (a)(5), lists such information
separately from the other information submitted under
subsection (a) and designates such separately listed
information as funding for clinical research;
``(G) contains any other information the Secretary
determines would be helpful to the average consumer;
and
``(H) provides the covered recipient an opportunity
to submit corrections to the information made available
to the public with respect to the covered recipient.
``(2) Accuracy of reporting.--The accuracy of the
information that is submitted under subsections (a) and (b) and
made available under paragraph (1) shall be the responsibility
of the reporting entity reporting under subsection (a) or (b),
as applicable. The Secretary shall establish procedures to
ensure that the covered recipient is provided with an
opportunity to submit corrections to the applicable reporting
entity with regard to information made public with respect to
the covered recipient and, under such procedures, the
corrections shall be transmitted to the Secretary.
``(3) Special rule for drug samples.--Information relating
to drug samples provided under subsection (a) shall not be made
available to the public by the Secretary but may be made
available outside the Department of Health and Human Services
by the Secretary for research or legitimate business purposes
pursuant to data use agreements.
``(4) Special rule for national provider identifiers.--
Information relating to national provider identifiers provided
under subsection (a) shall not be made available to the public
by the Secretary but may be made available outside the
Department of Health and Human Services by the Secretary for
research or legitimate business purposes pursuant to data use
agreements.
``(d) Penalties for Noncompliance.--
``(1) Failure to report.--
``(A) In general.--Subject to subparagraph (B),
except as provided in paragraph (2), any reporting
entity that fails to submit information required under
subsection (a) or (b), as applicable, in a timely
manner in accordance with regulations promulgated to
carry out such applicable 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 a reporting entity, shall not exceed
$150,000.
``(2) Knowing failure to report.--
``(A) In general.--Subject to subparagraph (B), any
reporting entity that knowingly fails to submit
information required under subsection (a) or (b), as
applicable, in a timely manner in accordance with
regulations promulgated to carry out such applicable
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) or (b) by an applicable reporting entity
shall not exceed $1,000,000, or, if greater, 0.1
percentage of the total annual revenues of the
reporting entity.
``(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.
``(4) Enforcement through state attorneys general.--The
attorney general of a State, after providing notice to the
Secretary of an intent to proceed under this paragraph in a
specific case and providing the Secretary with an opportunity
to bring an action under this subsection and the Secretary
declining such opportunity, may proceed under this subsection
against an applicable manufacturer or distributor in the State.
``(e) Annual Report to Congress.--Not later than April 1 of each
year beginning with 2011, the Secretary shall submit to Congress a
report that includes the following:
``(1) The information submitted under this section during
the preceding year, aggregated for each applicable reporting
entity that submitted such information during such year.
``(2) A description of any enforcement actions taken to
carry out this section, including any penalties imposed under
subsection (d), during the preceding year.
``(f) Definitions.--In this section:
``(1) Applicable distributor.--The term `applicable
distributor' means--
``(A) any entity, other than an applicable group
purchasing organization, that buys and resells, or
receives a commission or other similar form of payment,
from another seller, for selling or arranging for the
sale of a covered drug, device, biological, or medical
supply; or
``(B) any entity under common ownership with such
an entity described in subparagraph (A) and which
provides assistance or support to such entity so
described with respect to the production, preparation,
propagation, compounding, conversion, processing,
marketing, or distribution of a covered drug, device,
biological, or medical supply.
Such term does not include a wholesale pharmaceutical
distributor.
``(2) Applicable manufacturer.--The term `applicable
manufacturer' means any entity which is engaged in the
production, preparation, propagation, compounding, conversion,
processing, marketing, or manufacturer-direct distribution of a
covered drug, device, biological, or medical supply (or any
entity under common ownership with such entity and which
provides assistance or support to such entity with respect to
the production, preparation, propagation, compounding,
conversion, processing, marketing, or distribution or a covered
drug, device, biological, or medical supply). For purposes of
this section only, such term does not include a retail pharmacy
licensed under State law.
``(3) Clinical investigation.--The term `clinical
investigation' means any experiment involving one or more human
subjects, or materials derived from human subjects, in which a
drug or device is administered, dispensed, or used.
``(4) Covered drug, device, biological, or medical
supply.--The term `covered' means, with respect to a drug,
device, biological, or medical supply, such a drug, device,
biological, 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).
``(5) Covered recipient.--The term `covered recipient'
means the following:
``(A) A physician.
``(B) A physician group practice.
``(C) Any other prescriber of a covered drug,
device, biological, or medical supply.
``(D) A pharmacy or pharmacist.
``(E) A health insurance issuer, group health plan,
or other entity offering a health benefits plan,
including any employee of such an issuer, plan, or
entity.
``(F) A pharmacy benefit manager, including any
employee of such a manager.
``(G) A hospital.
``(H) A medical school.
``(I) A sponsor of a continuing medical education
program.
``(J) A patient advocacy or disease specific group.
``(K) A organization of health care professionals.
``(L) A biomedical researcher.
``(M) A group purchasing organization.
``(6) Employee.--The term `employee' has the meaning given
such term in section 1877(h)(2).
``(7) Knowingly.--The term `knowingly' has the meaning
given such term in section 3729(b) of title 31, United States
Code.
``(8) Payment or other transfer of value.--
``(A) In general.--The term `payment or other
transfer of value' means a transfer of anything of
value for or of any of the following:
``(i) Gift, food, or entertainment.
``(ii) Travel or trip.
``(iii) Honoraria.
``(iv) Research funding or grant.
``(v) Education or conference funding.
``(vi) Consulting fees.
``(vii) Ownership or investment interest
and royalties or license fee.
``(B) Inclusions.--Subject to subparagraph (C), the
term `payment or other transfer of value' includes any
compensation, gift, honorarium, speaking fee,
consulting fee, travel, services, dividend, profit
distribution, stock or stock option grant, or any
ownership or investment interest held by a physician in
a manufacturer (excluding a dividend or other profit
distribution from, or ownership or investment interest
in, a publicly traded security or mutual fund (as
described in section 1877(c))).
``(C) Exclusions.--The term `payment or other
transfer of value' does not include the following:
``(i) Any payment or other transfer of
value provided by an applicable manufacturer or
distributor to a covered recipient where the
amount transferred to, requested by, or
designated on behalf of the covered recipient
does not exceed $5.
``(ii) 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.
``(iii) 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.
``(iv) 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.
``(v) In-kind items used for the provision
of charity care.
``(vi) 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)).
``(vii) Compensation paid by an applicable
manufacturer or distributor to a covered
recipient who is directly employed by and works
solely for such manufacturer or distributor.
``(viii) Payments made to a covered
recipient by an applicable manufacturer or by a
health plan affiliated with an applicable
manufacturer for medical care provided to
employees of such manufacturer or their
dependents.
``(ix) Any discount (including a rebate).
``(x) Any payment or other transfer of
value that is made to a covered recipient
indirectly through an entity other than the
applicable manufacturer in connection with an
activity or service--
``(I) in which the applicable
manufacturer is unaware of the identity
of the covered recipient and is not
using such activity or service to
market its product to the covered
recipient; and
``(II) that is not designed to
market or promote the product to the
covered recipient.
``(xi) 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.
``(9) Physician.--The term `physician' has the meaning
given that term in section 1861(r). For purposes of this
section, such term does not include a physician who is an
employee of the applicable manufacturer that is required to
submit information under subsection (a).
``(10) Reporting entity.--The term `reporting entity'
means--
``(A) with respect to the reporting requirement
under subsection (a), an applicable manufacturer or
distributor of a covered drug, device, biological, or
medical supply required to report under such
subsection; and
``(B) with respect to the reporting requirement
under subsection (b), a hospital, other health care
entity, applicable manufacturer, applicable
distributor, or applicable group purchasing
organization required to report physician ownership
under such subsection.
``(g) Annual Reports to States.--Not later than April 1 of each
year beginning with 2011, the Secretary shall submit to States a report
that includes a summary of the information submitted under subsections
(a), (b), and (e) during the preceding year with respect to covered
recipients or other hospitals and entities in the State.
``(h) Relation to State Laws.--
``(1) In general.--Effective on January 1, 2011, subject to
paragraph (2), the provisions of this section shall preempt any
law or regulation of a State or of a political subdivision of a
State that requires an applicable manufacturer and applicable
distributor (as such terms are defined in subsection (f)) to
disclose or report, in any format, the type of information
(described in subsection (a)) regarding a payment or other
transfer of value provided by the manufacturer to a covered
recipient (as so defined).
``(2) No preemption of additional requirements.--Paragraph
(1) shall not preempt any statute or regulation of a State or
political subdivision of a State that requires any of the
following:
``(A) The disclosure or reporting of information
not of the type required to be disclosed or reported
under this section.
``(B) The disclosure or reporting, in any format,
of information described in subsection (f)(8)(C),
except in the case of information described in clause
(i) of subsection (f)(8)(C).
``(C) The disclosure or reporting, in any format,
of the type of information by any person or entity
other than an applicable manufacturer (as so defined)
or a covered recipient (as defined in subsection (f)).
``(D) The disclosure or reporting, in any format,
of the type of information required to be disclosed or
reported under this section to a Federal, State, or
local governmental agency for public health
surveillance, investigation, or other public health
purposes or health oversight purposes.
Nothing in paragraph (1) shall be construed to limit the
discovery or admissibility of information described in this
paragraph in a criminal, civil, or administrative
proceeding.''.
(b) Availability of Information From the Disclosure of Financial
Relationship Report (DFRR).--The Secretary of Health and Human Services
shall submit to Congress a report on the full results of the Disclosure
of Physician Financial Relationships surveys required pursuant to
section 5006 of the Deficit Reduction Act of 2005. Such report shall be
submitted to Congress not later than the date that is 6 months after
the date such surveys are collected and shall be made publicly
available on an Internet website of the Department of Health and Human
Services.
(c) GAO Report.--Not later than December 31, 2012, the Comptroller
General of the United States shall submit to Congress a report on
section 1128H of the Social Security Act, as added by subsection (a).
Such report shall address the extent to which important transfers of
value are being adequately reported under such section (including
unreported transfers required by such section as well as transfers not
required to be reported by such section), the impact on States of the
federal preemption provision under subsection (h) of such section,
whether changes have occurred in the pattern of payments as a result of
efforts to evade reporting requirements, a description of the financial
relationships subject to delayed reporting under subsection (a) of such
section, and any recommended improvements to the collection or the
analysis of data reported under such section.
Subtitle E--Public Reporting on Health Care-Associated Infections
SEC. 1461. REQUIREMENT FOR PUBLIC REPORTING BY HOSPITALS AND AMBULATORY
SURGICAL CENTERS ON HEALTH CARE-ASSOCIATED INFECTIONS.
(a) In General.--Title XI of the Social Security Act is amended by
inserting after section 1138 the following section:
``SEC. 1138A. REQUIREMENT FOR PUBLIC REPORTING BY HOSPITALS AND
AMBULATORY SURGICAL CENTERS ON HEALTH CARE-ASSOCIATED
INFECTIONS.
``(a) Reporting Requirement.--
``(1) In general.--The Secretary shall provide that a
hospital (as defined in subsection (g)) or ambulatory surgical
center meeting the requirements of titles XVIII or XIX may
participate in the programs established under such titles only
if, in accordance with this section, the hospital or center
reports such information on health care-associated infections
that develop in the hospital or center (and such demographic
information associated with such infections) as the Secretary
specifies.
``(2) Reporting protocols.-- Such information shall be
reported in accordance with reporting protocols established by
the Secretary through the Director of the Centers for Disease
Control and Prevention (in this section referred to as the
`CDC') and to the National Healthcare Safety Network of the CDC
or under such another reporting system of such Centers as
determined appropriate by the Secretary in consultation with
such Director.
``(3) Coordination with hit.--The Secretary, through the
Director of the CDC and the Office of the National Coordinator
for Health Information Technology, shall ensure that the
transmission of information under this subsection is
coordinated with systems established under the HITECH Act,
where appropriate.
``(4) Procedures to ensure the validity of information.--
The Secretary shall establish procedures regarding the validity
of the information submitted under this subsection in order to
ensure that such information is appropriately compared across
hospitals and centers. Such procedures shall address failures
to report as well as errors in reporting.
``(5) Implementation.--Not later than 1 year after the date
of enactment of this section, the Secretary, through the
Director of CDC, shall promulgate regulations to carry out this
section.
``(b) Public Posting of Information.--The Secretary shall promptly
post, on the official public Internet site of the Department of Health
and Human Services, the information reported under subsection (a). Such
information shall be set forth in a manner that allows for the
comparison of information on health care-associated infections--
``(1) among hospitals and ambulatory surgical centers; and
``(2) by demographic information.
``(c) Annual Report to Congress.--On an annual basis the Secretary
shall submit to the Congress a report that summarizes each of the
following:
``(1) The number and types of health care-associated
infections reported under subsection (a) in hospitals and
ambulatory surgical centers during such year.
``(2) Factors that contribute to the occurrence of such
infections, including health care worker immunization rates.
``(3) Based on the most recent information available to the
Secretary on the composition of the professional staff of
hospitals and ambulatory surgical centers, the number of
certified infection control professionals on the staff of
hospitals and ambulatory surgical centers.
``(4) The total increases or decreases in health care costs
that resulted from increases or decreases in the rates of
occurrence of each such type of infection during such year.
``(5) Recommendations, in coordination with the Center for
Quality Improvement established under section 931 of the Public
Health Service Act, for best practices to eliminate the rates
of occurrence of each such type of infection in hospitals and
ambulatory surgical centers.
``(d) Non-preemption of State Laws.--Nothing in this section shall
be construed as preempting or otherwise affecting any provision of
State law relating to the disclosure of information on health care-
associated infections or patient safety procedures for a hospital or
ambulatory surgical center.
``(e) Health Care-associated Infection.--For purposes of this
section:
``(1) In general.--The term `health care-associated
infection' means an infection that develops in a patient who
has received care in any institutional setting where health
care is delivered and is related to receiving health care.
``(2) Related to receiving health care.--The term `related
to receiving health care', with respect to an infection, means
that the infection was not incubating or present at the time
health care was provided.
``(f) Application to Critical Access Hospitals.--For purposes of
this section, the term `hospital' includes a critical access hospital,
as defined in section 1861(mm)(1).''.
(b) Effective Date.--With respect to section 1138A of the Social
Security Act (as inserted by subsection (a) of this section), the
requirement under such section that hospitals and ambulatory surgical
centers submit reports takes effect on such date (not later than 2
years after the date of the enactment of this Act) as the Secretary of
Health and Human Services shall specify. In order to meet such
deadline, the Secretary may implement such section through guidance or
other instructions.
(c) GAO Report.--Not later than 18 months after the date of the
enactment of this Act, the Comptroller General of the United States
shall submit to Congress a report on the program established under
section 1138A of the Social Security Act, as inserted by subsection
(a). Such report shall include an analysis of the appropriateness of
the types of information required for submission, compliance with
reporting requirements, the success of the validity procedures
established, and any conflict or overlap between the reporting required
under such section and any other reporting systems mandated by either
the States or the Federal Government.
(d) Report on Additional Data.--Not later than 18 months after the
date of the enactment of this Act, the Secretary of Health and Human
Services shall submit to the Congress a report on the appropriateness
of expanding the requirements under such section to include additional
information (such as health care worker immunization rates), in order
to improve health care quality and patient safety.
TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION
SEC. 1501. DISTRIBUTION OF UNUSED 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 ``and paragraph (8)''
after ``this paragraph''; and
(4) by adding at the end the following new paragraph:
``(8) Additional redistribution of unused residency
positions.--
``(A) Reductions in limit based on unused
positions.--
``(i) Programs subject to reduction.--If a
hospital's reference resident level (specified
in clause (ii)) is less than the otherwise
applicable resident limit (as defined in
subparagraph (C)(ii)), effective for portions
of cost reporting periods occurring on or after
July 1, 2011, the otherwise applicable resident
limit shall be reduced by 90 percent of the
difference between such otherwise applicable
resident limit and such reference resident
level.
``(ii) Reference resident level.--
``(I) In general.--Except as
otherwise provided in a subsequent
subclause, the reference resident level
specified in this clause for a hospital
is 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) Use of most recent
accounting period to recognize
expansion of existing programs.--If a
hospital submits a timely request to
increase its resident level due to an
expansion, or planned expansion, of an
existing residency training program
that is not reflected on the most
recent settled or submitted cost
report, after audit and subject to the
discretion of the Secretary, subject to
subclause (IV), the reference resident
level for such hospital is the resident
level that includes the additional
residents attributable to such
expansion or establishment, as
determined by the Secretary. The
Secretary is authorized to determine an
alternative reference resident level
for a hospital that submitted to the
Secretary a timely request, before the
start of the 2009-2010 academic year,
for an increase in its reference
resident level due to a planned
expansion.
``(III) Special provider
agreement.--In the case of a hospital
described in paragraph (4)(H)(v), the
reference resident level specified in
this clause is the limitation
applicable under subclause (I) of such
paragraph.
``(IV) Previous redistribution.--
The reference resident level specified
in this clause for a hospital shall be
increased to the extent required to
take into account an increase in
resident positions made available to
the hospital under paragraph (7)(B)
that are not otherwise taken into
account under a previous subclause.
``(iii) Affiliation.--The provisions of
clause (i) shall be applied to hospitals which
are members of the same affiliated group (as
defined by the Secretary under paragraph
(4)(H)(ii)) and to the extent the hospitals can
demonstrate that they are filling any
additional resident slots allocated to other
hospitals through an affiliation agreement, the
Secretary shall adjust the determination of
available slots accordingly, or which the
Secretary otherwise has permitted the resident
positions (under section 402 of the Social
Security Amendments of 1967) to be aggregated
for purposes of applying the resident position
limitations under this subsection.
``(B) Redistribution.--
``(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 estimated aggregate
number of increases in the otherwise applicable
resident limit under this subparagraph may not
exceed the Secretary's estimate of the
aggregate reduction in such limits attributable
to subparagraph (A).
``(ii) Requirements for qualifying
hospitals.--A hospital is not a qualifying
hospital for purposes of this paragraph unless
the following requirements are met:
``(I) Maintenance of primary care
resident level.--The hospital maintains
the number of primary care residents at
a level that is not less than the base
level of primary care residents
increased by the number of additional
primary care resident positions
provided to the hospital under this
subparagraph. For purposes of this
subparagraph, the `base level of
primary care residents' for a hospital
is the level of such residents as of a
base period (specified by the
Secretary), determined without regard
to whether such positions were in
excess of the otherwise applicable
resident limit for such period but
taking into account the application of
subclauses (II) and (III) of
subparagraph (A)(ii).
``(II) Dedicated assignment of
additional resident positions to
primary care.--The hospital assigns all
such additional resident positions for
primary care residents.
``(III) Accreditation.--The
hospital's residency programs in
primary care are fully accredited or,
in the case of a residency training
program not in operation as of the base
year, the hospital is actively applying
for such accreditation for the program
for such additional resident positions
(as determined by the Secretary).
``(iii) Considerations in redistribution.--
In determining for which qualifying hospitals
the increase in the otherwise applicable
resident limit is provided under this
subparagraph, the Secretary shall take into
account the demonstrated likelihood of the
hospital filling the positions within the first
3 cost reporting periods beginning on or after
July 1, 2011, made available under this
subparagraph, as determined by the Secretary.
``(iv) Priority for certain hospitals.--In
determining for which qualifying hospitals the
increase in the otherwise applicable resident
limit is provided under this subparagraph, the
Secretary shall distribute the increase to
qualifying hospitals based on the following
criteria:
``(I) The Secretary shall give
preference to hospitals that had a
reduction in resident training
positions under subparagraph (A).
``(II) The Secretary shall give
preference to hospitals with 3-year
primary care residency training
programs, such as family practice and
general internal medicine.
``(III) The Secretary shall give
preference to hospitals insofar as they
have in effect formal arrangements (as
determined by the Secretary) that place
greater emphasis upon training in
Federally qualified health centers,
rural health clinics, and other
nonprovider settings, and to hospitals
that receive additional payments under
subsection (d)(5)(F) and emphasize
training in an outpatient department.
``(IV) The Secretary shall give
preference to hospitals with a number
of positions (as of July 1, 2009) in
excess of the otherwise applicable
resident limit for such period.
``(V) The Secretary shall give
preference to hospitals that place
greater emphasis upon training in a
health professional shortage area
(designated under section 332 of the
Public Health Service Act) or a health
professional needs area (designated
under section 2211 of such Act).
``(VI) The Secretary shall give
preference to hospitals in States that
have low resident-to-population ratios
(including a greater preference for
those States with lower resident-to-
population ratios).
``(v) Limitation.--In no case shall more
than 20 full-time equivalent additional
residency positions be made available under
this subparagraph with respect to any hospital.
``(vi) Application of per resident amounts
for primary care.--With respect to additional
residency positions in a hospital attributable
to the increase provided under this
subparagraph, the approved FTE 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.
``(vii) Distribution.--The Secretary shall
distribute the increase in resident training
positions to qualifying hospitals under this
subparagraph not later than July 1, 2011.
``(C) Resident level and limit defined.--In this
paragraph:
``(i) The term `resident level' has the
meaning given such term in paragraph (7)(C)(i).
``(ii) 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).
``(D) Maintenance of primary care resident level.--
In carrying out this paragraph, the Secretary shall
require hospitals that receive additional resident
positions under subparagraph (B)--
``(i) to maintain records, and periodically
report to the Secretary, on the number of
primary care residents in its residency
training programs; and
``(ii) as a condition of payment for a cost
reporting period under this subsection for such
positions, to maintain the level of such
positions at not less than the sum of--
``(I) the base level of primary
care resident positions (as determined
under subparagraph (B)(ii)(I)) before
receiving such additional positions;
and
``(II) the number of such
additional positions.''.
(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 third
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 provision.--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. 1502. INCREASING TRAINING IN NONPROVIDER SETTINGS.
(a) Direct GME.--Section 1886(h)(4)(E) of the Social Security Act
(42 U.S.C. 1395ww(h)) is amended--
(1) by designating the first sentence as a clause (i) with
the heading ``In general.--'' and appropriate indentation;
(2) 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, 2009,
all the time'';
(3) in subclause (I), as inserted by paragraph (1), by
striking the period at the end and inserting ``; and''; and
(A) by inserting after subclause (I), as so
inserted, the following:
``(II) effective for cost reporting
periods beginning on or after July 1,
2009, 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 the
hospital incurs the costs of the
stipends and fringe benefits of the
resident during the time the resident
spends in that setting.
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)(B)(iv)) 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, 2009''; and
(2) by inserting after subclause (I), as inserted by
paragraph (1), the following new subclause:
``(II) Effective for discharges occurring on or after July
1, 2009, all the time spent by an intern or resident in patient
care activities at an entity in a nonprovider setting shall be
counted towards the determination of full-time equivalency if
the 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.''.
(c) OIG Study on Impact on Training.--The Inspector General of the
Department of Health and Human Services shall analyze the data
collected by the Secretary of Health and Human Services from the
records made available to the Secretary under section 1886(h)(4)(E) of
the Social Security Act, as amended by subsection (a), in order to
assess the extent to which there is an increase in time spent by
medical residents in training in nonprovider settings as a result of
the amendments made by this section. Not later than 4 years after the
date of the enactment of this Act, the Inspector General shall submit a
report to Congress on such analysis and assessment.
(d) Demonstration Project for Approved Teaching Health Centers.--
(1) In general.--The Secretary of Health and Human Services
shall conduct a demonstration project under which an approved
teaching health center (as defined in paragraph (3)) would be
eligible for payment under subsections (h) and (k) of section
1886 of the Social Security Act (42 U.S.C. 1395ww) of amounts
for its own direct costs of graduate medical education
activities for primary care residents, as well as for the
direct costs of graduate medical education activities of its
contracting hospital for such residents, in a manner similar to
the manner in which such payments would be made to a hospital
if the hospital were to operate such a program.
(2) Conditions.--Under the demonstration project--
(A) an approved teaching health center shall
contract with an accredited teaching hospital to carry
out the inpatient responsibilities of the primary care
residency program of the hospital involved and is
responsible for payment to the hospital for the
hospital's costs of the salary and fringe benefits for
residents in the program;
(B) the number of primary care residents of the
center shall not count against the contracting
hospital's resident limit; and
(C) the contracting hospital shall agree not to
diminish the number of residents in its primary care
residency training program.
(3) Approved teaching health center defined.--In this
subsection, the term ``approved teaching health center'' means
a nonprovider setting, such as a Federally qualified health
center or rural health clinic (as defined in section 1861(aa)
of the Social Security Act), that develops and operates an
accredited primary care residency program for which funding
would be available if it were operated by a hospital.
SEC. 1503. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC AND SCHOLARLY
ACTIVITIES AND OTHER ACTIVITIES.
(a) Direct GME.--Section 1886(h) of the Social Security Act (42
U.S.C. 1395ww(h)) is amended--
(1) in paragraph (4)(E), as amended by section 1502(a)--
(A) in clause (i), by striking ``Such rules'' and
inserting ``Subject to clause (ii), such rules''; and
(B) by adding at the end the following new clause:
``(ii) 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 nonpatient 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.'';
(2) in paragraph (4), by adding at the end the following
new subparagraph:
``(I) Treatment of certain time in approved medical
residency training programing.--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
(3) 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)), as amended by section 1501(b), is amended by
adding at the end the following new clause:
``(xi)(I) The provisions of subparagraph (I) 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
nonpatient 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; Application.--
(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) Direct gme.--Section 1886(h)(4)(E)(ii) of the Social
Security Act, as added by subsection (a)(1)(B), shall apply to
cost reporting periods beginning on or after July 1, 2008.
(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 on
how the law in effect prior to such date should be interpreted.
(4) 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 or for direct graduate medical education
costs under section 1886(h) of such Act.
SEC. 1504. PRESERVATION OF RESIDENT CAP POSITIONS FROM CLOSED
HOSPITALS.
(a) Direct 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.--The Secretary
shall, by regulation, establish a
process consistent with subclauses (II)
and (III) under which, in the case
where a hospital (other than a hospital
described in clause (v)) with an
approved medical residency program in a
State closes on or after the date that
is 2 years before the date of the
enactment of this clause, the Secretary
shall increase the otherwise applicable
resident limit under this paragraph for
other hospitals in the State in
accordance with this clause.
``(II) Process for hospitals in
certain areas.--In determining for
which hospitals the increase in the
otherwise applicable resident limit
described in subclause (I) is provided,
the Secretary shall establish a process
to provide for such increase to one or
more hospitals located in the State.
Such process shall take into
consideration the recommendations
submitted to the Secretary by the
senior health official (as designated
by the chief executive officer of such
State) if such recommendations are
submitted not later than 180 days after
the date of the hospital closure
involved (or, in the case of a hospital
that closed after the date that is 2
years before the date of the enactment
of this clause, 180 days after such
date of enactment).
``(III) Limitation.--The estimated
aggregate number of increases in the
otherwise applicable resident limits
for hospitals under this clause shall
be equal to the estimated number of
resident positions in the approved
medical residency programs that closed
on or after the date described in
subclause (I).''.
(b) No Effect on Temporary FTE Cap Adjustments.--The amendments
made by this section shall not effect 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) and
shall not affect the application of section 1886(h)(4)(H)(v) of the
Social Security Act.
(c) Conforming Amendments.--
(1) Section 422(b)(2) of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (Public Law 108-
173), as amended by section 1501(c), is amended by striking
``(7) and'' and inserting ``(4)(H)(vi), (7), and''.
(2) Section 1886(h)(7)(E) of the Social Security Act (42
U.S.C. 1395ww(h)(7)(E)) is amended by inserting ``or under
paragraph (4)(H)(vi)'' after ``under this paragraph''.
SEC. 1505. IMPROVING ACCOUNTABILITY FOR APPROVED MEDICAL RESIDENCY
TRAINING.
(a) Specification of Goals for Approved Medical Residency Training
Programs.--Section 1886(h)(1) of the Social Security Act (42 U.S.C.
1395ww(h)(1)) is amended--
(1) by designating the matter beginning with
``Notwithstanding'' as a subparagraph (A) with the heading ``In
general.--'' and with appropriate indentation; and
(2) by adding at the end the following new subparagraph:
``(B) Goals and accountability for approved medical
residency training programs.--The goals of medical
residency training programs are to foster a physician
workforce so that physicians are trained to be able to
do the following:
``(i) Work effectively in various health
care delivery settings, such as nonprovider
settings.
``(ii) Coordinate patient care within and
across settings relevant to their specialties.
``(iii) Understand the relevant cost and
value of various diagnostic and treatment
options.
``(iv) Work in inter-professional teams and
multi-disciplinary team-based models in
provider and nonprovider settings to enhance
safety and improve quality of patient care.
``(v) Be knowledgeable in methods of
identifying systematic errors in health care
delivery and in implementing systematic
solutions in case of such errors, including
experience and participation in continuous
quality improvement projects to improve health
outcomes of the population the physicians
serve.
``(vi) Be meaningful EHR users (as
determined under section 1848(o)(2)) in the
delivery of care and in improving the quality
of the health of the community and the
individuals that the hospital serves.''
(b) GAO Study on Evaluation of Training Programs.--
(1) In general.--The Comptroller General of the United
States shall conduct a study to evaluate the extent to which
medical residency training programs--
(A) are meeting the goals described in section
1886(h)(1)(B) of the Social Security Act, as added by
subsection (a), in a range of residency programs,
including primary care and other specialties; and
(B) have the appropriate faculty expertise to teach
the topics required to achieve such goals.
(2) Report.--Not later than 18 months after the date of the
enactment of this Act, the Comptroller General shall submit to
Congress a report on such study and shall include in such
report recommendations as to how medical residency training
programs could be further encouraged to meet such goals through
means such as--
(A) development of curriculum requirements; and
(B) assessment of the accreditation processes of
the Accreditation Council for Graduate Medical
Education and the American Osteopathic Association and
effectiveness of those processes in accrediting medical
residency programs that meet the goals referred to in
paragraph (1)(A).
TITLE VI--PROGRAM INTEGRITY
Subtitle A--Increased Funding to Fight Waste, Fraud, and Abuse
SEC. 1601. INCREASED FUNDING AND FLEXIBILITY TO FIGHT FRAUD AND ABUSE.
(a) In General.--Section 1817(k) of the Social Security Act (42
U.S.C. 1395i(k)) is amended--
(1) 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
$100,000,000 to such Account from such Trust Fund for each
fiscal year beginning with 2011. 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.''.
(2) in paragraph (4)(A)--
(A) by inserting ``for activities described in
paragraph (3)(C) and'' after ``necessary''; and
(B) by inserting ``until expended'' after
``appropriation''.
(b) 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''.
Subtitle B--Enhanced Penalties for Fraud and Abuse
SEC. 1611. ENHANCED PENALTIES FOR FALSE STATEMENTS ON PROVIDER OR
SUPPLIER ENROLLMENT APPLICATIONS.
(a) In General.--Section 1128A(a) of the Social Security Act (42
U.S.C. 1320a-7a(a)) is amended--
(1) in paragraph (1)(D), by striking all that follows ``in
which the person was excluded'' and inserting ``under Federal
law from the Federal health care program under which the claim
was made, or'';
(2) by striking ``or'' at the end of paragraph (6);
(3) in paragraph (7), by inserting at the end ``or'';
(4) by inserting after paragraph (7) the following new
paragraph:
``(8) 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, including managed care organizations under
title XIX, Medicare Advantage organizations under part C of
title XVIII, prescription drug plan sponsors under part D of
title XVIII, and entities that apply to participate as
providers of services or suppliers in such managed care
organizations and such plans;'';
(5) in the matter following paragraph (8), as inserted by
paragraph (4), by striking ``or in cases under paragraph (7),
$50,000 for each such act)'' and inserting ``in cases under
paragraph (7), $50,000 for each such act, or in cases under
paragraph (8), $50,000 for each false statement, omission, or
misrepresentation of a material fact)''; and
(6) in the second sentence, by striking ``for a lawful
purpose)'' and inserting ``for a lawful purpose, or in cases
under paragraph (8), an assessment of not more than 3 times the
amount claimed as the result of the false statement, omission,
or misrepresentation of material fact claimed by a provider of
services or supplier whose application to participate contained
such false statement, omission, or misrepresentation)''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to acts committed on or after January 1, 2010.
SEC. 1612. ENHANCED PENALTIES FOR SUBMISSION OF FALSE STATEMENTS
MATERIAL TO A FALSE CLAIM.
(a) In General.--Section 1128A(a) of the Social Security Act (42
U.S.C. 1320a-7a(a)), as amended by section 1611, is further amended--
(1) in paragraph (7), by striking ``or'' at the end;
(2) in paragraph (8), by inserting ``or'' at the end; and
(3) by inserting after paragraph (8), the following new
paragraph:
``(9) 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;''; and
(4) in the matter following paragraph (9), as inserted by
paragraph (3)--
(A) by striking ``or in cases under paragraph (8)''
and inserting ``in cases under paragraph (8)''; and
(B) by striking ``a material fact)'' and inserting
``a material fact, in cases under paragraph (9),
$50,000 for each false record or statement)''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to acts committed on or after January 1, 2010.
SEC. 1613. ENHANCED PENALTIES FOR DELAYING INSPECTIONS.
(a) In General.--Section 1128A(a) of the Social Security Act (42
U.S.C. 1320a-7a(a)), as amended by sections 1611 and 1612, is further
amended--
(1) in paragraph (8), by striking ``or'' at the end;
(2) in paragraph (9), by inserting ``or'' at the end;
(3) by inserting after paragraph (9) the following new
paragraph:
``(10) 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
(4) in the matter following paragraph (10), as inserted by
paragraph (3), by inserting ``, or in cases under paragraph
(10), $15,000 for each day of the failure described in such
paragraph'' after ``false record or statement''.
(b) 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--
(1) in subparagraph (A), by inserting ``timely'' before
``inspect''; and
(2) in subparagraph (B), by inserting ``timely'' before
``audit and inspect''.
(c) Effective Date.--The amendments made by subsection (a) shall
apply to violations committed on or after January 1, 2010.
SEC. 1614. ENHANCED HOSPICE PROGRAM SAFEGUARDS.
(a) Medicare.--Part A of title XVIII of the Social Security Act is
amended by inserting after section 1819 the following new section:
``SEC. 1819A. ASSURING QUALITY OF CARE IN HOSPICE CARE.
``(a) In General.--If the Secretary determines on the basis of a
survey or otherwise, that a hospice program that is certified for
participation under this title has demonstrated a substandard quality
of care and failed to meet such other requirements as the Secretary may
find necessary in the interest of the health and safety of the
individuals who are provided care and services by the agency or
organization involved and determines--
``(1) that the deficiencies involved immediately jeopardize
the health and safety of the individuals to whom the program
furnishes items and services, the Secretary shall take
immediate action to remove the jeopardy and correct the
deficiencies through the remedy specified in subsection
(b)(2)(A)(iii) or terminate the certification of the program,
and may provide, in addition, for 1 or more of the other
remedies described in subsection (b)(2)(A); or
``(2) that the deficiencies involved do not immediately
jeopardize the health and safety of the individuals to whom the
program furnishes items and services, the Secretary may--
``(A) impose intermediate sanctions developed
pursuant to subsection (b), in lieu of terminating the
certification of the program; and
``(B) if, after such a period of intermediate
sanctions, the program is still not in compliance with
such requirements, the Secretary shall terminate the
certification of the program.
If the Secretary determines that a hospice program that is
certified for participation under this title is in compliance
with such requirements but, as of a previous period, was not in
compliance with such requirements, the Secretary may provide
for a civil money penalty under subsection (b)(2)(A)(i) for the
days in which it finds that the program was not in compliance
with such requirements.
``(b) Intermediate Sanctions.--
``(1) Development and implementation.--The Secretary shall
develop and implement, by not later than July 1, 2012--
``(A) a range of intermediate sanctions to apply to
hospice programs under the conditions described in
subsection (a), and
``(B) appropriate procedures for appealing
determinations relating to the imposition of such
sanctions.
``(2) Specified sanctions.--
``(A) In general.--The intermediate sanctions
developed under paragraph (1) may include--
``(i) civil money penalties in an amount
not to exceed $10,000 for each day of
noncompliance or, in the case of a per instance
penalty applied by the Secretary, not to exceed
$25,000,
``(ii) denial of all or part of the
payments to which a hospice program would
otherwise be entitled under this title with
respect to items and services furnished by a
hospice program on or after the date on which
the Secretary determines that intermediate
sanctions should be imposed pursuant to
subsection (a)(2),
``(iii) the appointment of temporary
management to oversee the operation of the
hospice program and to protect and assure the
health and safety of the individuals under the
care of the program while improvements are
made,
``(iv) corrective action plans, and
``(v) in-service training for staff.
The provisions of section 1128A (other than subsections
(a) and (b)) shall apply to a civil money penalty under
clause (i) in the same manner as such provisions apply
to a penalty or proceeding under section 1128A(a). The
temporary management under clause (iii) shall not be
terminated until the Secretary has determined that the
program has the management capability to ensure
continued compliance with all requirements referred to
in that clause.
``(B) Clarification.--The sanctions specified in
subparagraph (A) are in addition to sanctions otherwise
available under State or Federal law and shall not be
construed as limiting other remedies, including any
remedy available to an individual at common law.
``(C) Commencement of payment.--A denial of payment
under subparagraph (A)(ii) shall terminate when the
Secretary determines that the hospice program no longer
demonstrates a substandard quality of care and meets
such other requirements as the Secretary may find
necessary in the interest of the health and safety of
the individuals who are provided care and services by
the agency or organization involved.
``(3) Secretarial authority.--The Secretary shall develop
and implement, by not later than July 1, 2011, specific
procedures with respect to the conditions under which each of
the intermediate sanctions developed under paragraph (1) is to
be applied, including the amount of any fines and the severity
of each of these sanctions. Such procedures shall be designed
so as to minimize the time between identification of
deficiencies and imposition of these sanctions and shall
provide for the imposition of incrementally more severe fines
for repeated or uncorrected deficiencies.''.
(b) Application to Medicaid.--Section 1905(o) of the Social
Security Act (42 U.S.C. 1396d(o)) is amended by adding at the end the
following new paragraph:
``(4) The provisions of section 1819A shall apply to a hospice
program providing hospice care under this title in the same manner as
such provisions apply to a hospice program providing hospice care under
title XVIII.''.
(c) Application to CHIP.--Title XXI of the Social Security Act is
amended by adding at the end the following new section:
``SEC. 2114. ASSURING QUALITY OF CARE IN HOSPICE CARE.
``The provisions of section 1819A shall apply to a hospice program
providing hospice care under this title in the same manner such
provisions apply to a hospice program providing hospice care under
title XVIII.''.
SEC. 1615. ENHANCED PENALTIES FOR INDIVIDUALS EXCLUDED FROM PROGRAM
PARTICIPATION.
(a) In General.--Section 1128A(a) of the Social Security Act (42
U.S.C. 1320a-7a(a)), as amended by the previous sections, is further
amended--
(1) by striking ``or'' at the end of paragraph (9);
(2) by inserting ``or'' at the end of paragraph (10);
(3) by inserting after paragraph (10) the following new
paragraph:
``(11) orders or prescribes an item or service, including
without limitation home health care, diagnostic and clinical
lab tests, prescription drugs, durable medical equipment,
ambulance services, physical or occupational therapy, or any
other item or service, during a period when the person has been
excluded from participation in a Federal health care program,
and the person knows or should know that a claim for such item
or service will be presented to such a program;''; and
(4) in the matter following paragraph (11), as inserted by
paragraph (2), by striking ``$15,000 for each day of the
failure described in such paragraph'' and inserting ``$15,000
for each day of the failure described in such paragraph, or in
cases under paragraph (11), $50,000 for each order or
prescription for an item or service by an excluded
individual''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to violations committed on or after January 1, 2010.
SEC. 1616. ENHANCED PENALTIES FOR PROVISION OF FALSE INFORMATION BY
MEDICARE ADVANTAGE AND PART D PLANS.
(a) In General.--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 3 times the amount claimed by such plan or plan sponsor based
upon the misrepresentation or falsified information involved,'' after
``for each such determination,''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to violations committed on or after January 1, 2010.
SEC. 1617. ENHANCED PENALTIES FOR MEDICARE ADVANTAGE AND PART D
MARKETING VIOLATIONS.
(a) In General.--Section 1857(g)(1) of the Social Security Act (42
U.S.C. 1395w--27(g)(1)), as amended by section 1221(b), is amended--
(1) in subparagraph (G), by striking ``or'' at the end;
(2) by inserting after subparagraph (H) the following new
subparagraphs:
``(I) 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;
``(J) 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;
``(K) fails to comply with marketing restrictions
described in subsections (h) and (j) of section 1851 or
applicable implementing regulations or guidance; or
``(L) employs or contracts with any individual or
entity who engages in the conduct described in
subparagraphs (A) through (K) of this paragraph;''; and
(3) 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 (L) of this paragraph.''
(b) Effective Date.--The amendments made by subsection (a) shall
apply to violations committed on or after January 1, 2010.
SEC. 1618. ENHANCED PENALTIES FOR OBSTRUCTION OF PROGRAM AUDITS.
(a) In General.--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)).''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to violations committed on or after January 1, 2010.
SEC. 1619. EXCLUSION OF CERTAIN INDIVIDUALS AND ENTITIES FROM
PARTICIPATION IN MEDICARE AND STATE HEALTH CARE PROGRAMS.
(a) In General.--Section 1128(c) of the Social Security Act, as
previously amended by this division, is further amended--
(1) in the heading, by striking ``and Period'' and
inserting ``Period, and Effect''; and
(2) by adding at the end the following new paragraph:
``(4)(A) For purposes of this Act, subject to subparagraph (C), the
effect of exclusion is that no payment may be made by any Federal
health care program (as defined in section 1128B(f)) with respect to
any item or service furnished--
``(i) by an excluded individual or entity; or
``(ii) at the medical direction or on the prescription of a
physician or other authorized individual when the person
submitting a claim for such item or service knew or had reason
to know of the exclusion of such individual.
``(B) For purposes of this section and sections 1128A and 1128B,
subject to subparagraph (C), an item or service has been furnished by
an individual or entity if the individual or entity directly or
indirectly provided, ordered, manufactured, distributed, prescribed, or
otherwise supplied the item or service regardless of how the item or
service was paid for by a Federal health care program or to whom such
payment was made.
``(C)(i) Payment may be made under a Federal health care program
for emergency items or services (not including items or services
furnished in an emergency room of a hospital) furnished by an excluded
individual or entity, or at the medical direction or on the
prescription of an excluded physician or other authorized individual
during the period of such individual's exclusion.
``(ii) In the case that an individual eligible for benefits under
title XVIII or XIX submits a claim for payment for items or services
furnished by an excluded individual or entity, and such individual
eligible for such benefits did not know or have reason to know that
such excluded individual or entity was so excluded, then,
notwithstanding such exclusion, payment shall be made for such items or
services. In such case the Secretary shall notify such individual
eligible for such benefits of the exclusion of the individual or entity
furnishing the items or services. Payment shall not be made for items
or services furnished by an excluded individual or entity to an
individual eligible for such benefits after a reasonable time (as
determined by the Secretary in regulations) after the Secretary has
notified the individual eligible for such benefits of the exclusion of
the individual or entity furnishing the items or services.
``(iii) In the case that a claim for payment for items or services
furnished by an excluded individual or entity is submitted by an
individual or entity other than an individual eligible for benefits
under title XVIII or XIX or the excluded individual or entity, and the
Secretary determines that the individual or entity that submitted the
claim took reasonable steps to learn of the exclusion and reasonably
relied upon inaccurate or misleading information from the relevant
Federal health care program or its contractor, the Secretary may waive
repayment of the amount paid in violation of the exclusion to the
individual or entity that submitted the claim for the items or services
furnished by the excluded individual or entity. If a Federal health
care program contractor provided inaccurate or misleading information
that resulted in the waiver of an overpayment under this clause, the
Secretary shall take appropriate action to recover the improperly paid
amount from the contractor.''.
SEC. 1620. OIG AUTHORITY TO EXCLUDE FROM FEDERAL HEALTH CARE PROGRAMS
OFFICERS AND OWNERS OF ENTITIES CONVICTED OF FRAUD.
Section 1128(b)(15)(A) of the Social Security Act (42 U.S.C. 1320a-
7(b)(15)(A)) is amended--
(1) in clause (i)--
(A) by striking ``has'' and inserting ``had''; and
(B) by striking ``sanctioned entity and who knows
or should know (as defined in section 1128A(i)(6)) of''
and inserting ``sanctioned entity at the time of, and
who knew or should have known (as defined in section
1128A(i)(6)) of,'' ; and
(2) in clause (ii)--
(A) by striking ``is an officer'' and inserting
``was an officer''; and
(B) by inserting before the period the following:
``at the time of the action constituting the basis for
the conviction or exclusion described in subparagraph
(B)''.
SEC. 1621. 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 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 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 an 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.
(d) Relation to Other Law and Regulation.--Nothing in this section
shall affect the application of section 1128G(c) of the Social Security
Act, as added by section 1641, except, in the case of a health care
provider of services or supplier who is a person (as defined in
paragraph (4) of such section 1128G(c)) who discloses an overpayment
(as defined in such paragraph) to the Secretary of Health and Human
Services pursuant to a SRDP established under this section, the 60-day
period described in paragraph (2) of such section 1128G(c) shall be
extended with respect to the return of an overpayment to the extent
necessary for the Secretary to determine pursuant to the SRDP the
amount due and owing.
Subtitle C--Enhanced Program and Provider Protections
SEC. 1631. ENHANCED CMS PROGRAM PROTECTION AUTHORITY.
(a) In General.--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. ENHANCED PROGRAM AND PROVIDER PROTECTIONS IN THE
MEDICARE, MEDICAID, AND CHIP PROGRAMS.
``(a) Certain Authorized Screening, Enhanced Oversight Periods, and
Enrollment Moratoria.--
``(1) In general.--For periods beginning after January 1,
2011, in the case that the Secretary determines there is a
significant risk of fraudulent activity (as determined by the
Secretary based on relevant complaints, reports, referrals by
law enforcement or other sources, data analysis, trending
information, or claims submissions by providers of services and
suppliers) with respect to a category of provider of services
or supplier of items or services, including a category within a
geographic area, under title XVIII, XIX, or XXI, the Secretary
may impose any of the following requirements with respect to a
provider of services or a supplier (whether such provider or
supplier is initially enrolling in the program or is renewing
such enrollment):
``(A) Screening under paragraph (2).
``(B) Enhanced oversight periods under paragraph
(3).
``(C) Enrollment moratoria under paragraph (4).
In applying this subsection for purposes of title XIX and XXI
the Secretary may require a State to carry out the provisions
of this subsection as a requirement of the State plan under
title XIX or the child health plan under title XXI. Actions
taken and determinations made under this subsection shall not
be subject to review by a judicial tribunal.
``(2) Screening.--For purposes of paragraph (1), the
Secretary shall establish procedures under which screening is
conducted with respect to providers of services and suppliers
described in such paragraph. Such screening may include--
``(A) licensing board checks;
``(B) screening against the list of individuals and
entities excluded from the program under title XVIII,
XIX, or XXI;
``(C) the excluded provider list system;
``(D) background checks; and
``(E) unannounced pre-enrollment or other site
visits.
``(3) Enhanced oversight period.--For purposes of paragraph
(1), the Secretary shall establish procedures to provide for a
period of not less than 30 days and not more than 365 days
during which providers of services and suppliers described in
such paragraph, as the Secretary determines appropriate, would
be subject to enhanced oversight, such as required or
unannounced (or required and unannounced) site visits or
inspections, prepayment review, enhanced review of claims, and
such other actions as specified by the Secretary, under the
programs under titles XVIII, XIX, and XXI. Under such
procedures, the Secretary may extend such period for more than
365 days if the Secretary determines that after the initial
period such additional period of oversight is necessary.
``(4) Moratorium on enrollment of providers and
suppliers.--For purposes of paragraph (1), the Secretary, based
upon a finding of a risk of serious ongoing fraud within a
program under title XVIII, XIX, or XXI, may impose a moratorium
on the enrollment of providers of services and suppliers within
a category of providers of services and suppliers (including a
category within a specific geographic area) under such title.
Such a moratorium may only be imposed if the Secretary makes a
determination that the moratorium would not adversely impact
access of individuals to care under such program.
``(5) Clarification.--Nothing in this subsection shall be
interpreted to preclude or limit the ability of a State to
engage in provider screening or enhanced provider oversight
activities beyond those required by the Secretary.''.
(b) Conforming Amendments.--
(1) Medicaid.--Section 1902(a) of the Social Security Act
(42 U.S.C. 42 U.S.C. 1396a(a)) is amended--
(A) in paragraph (23), by inserting before the
semicolon at the end the following: ``or by a person to
whom or entity to which a moratorium under section
1128G(a)(4) is applied during the period of such
moratorium'';
(B) in paragraph (72); by striking at the end
``and'';
(C) in paragraph (73), by striking the period at
the end and inserting ``; and''; and
(D) by adding after paragraph (73) the following
new paragraph:
``(74) provide that the State will enforce any
determination made by the Secretary under subsection (a) of
section 1128G (relating to a significant risk of fraudulent
activity with respect to a category of provider or supplier
described in such subsection (a) through use of the appropriate
procedures described in such subsection (a)), and that the
State will carry out any activities as required by the
Secretary for purposes of such subsection (a).''.
(2) CHIP.--Section 2102 of such Act (42 U.S.C. 1397bb) is
amended by adding at the end the following new subsection:
``(d) Program Integrity.--A State child health plan shall include a
description of the procedures to be used by the State--
``(1) to enforce any determination made by the Secretary
under subsection (a) of section 1128G (relating to a
significant risk of fraudulent activity with respect to a
category of provider or supplier described in such subsection
through use of the appropriate procedures described in such
subsection); and
``(2) to carry out any activities as required by the
Secretary for purposes of such subsection.''.
(3) Medicare.--Section 1866(j) of such Act (42 U.S.C.
1395cc(j)) is amended by adding at the end the following new
paragraph:
``(3) Program integrity.--The provisions of section
1128G(a) apply to enrollments and renewals of enrollments of
providers of services and suppliers under this title.''.
SEC. 1632. ENHANCED MEDICARE, MEDICAID, AND CHIP PROGRAM DISCLOSURE
REQUIREMENTS RELATING TO PREVIOUS AFFILIATIONS.
(a) In General.--Section 1128G of the Social Security Act, as
inserted by section 1631, is amended by adding at the end the following
new subsection:
``(b) Enhanced Program Disclosure Requirements.--
``(1) Disclosure.--A provider of services or supplier who
submits on or after July 1, 2011, an application for enrollment
and renewing enrollment in a program under title XVIII, XIX, or
XXI shall disclose (in a form and manner determined by the
Secretary) any current affiliation or affiliation within the
previous 10-year period with a provider of services or supplier
that has uncollected debt or with a person or entity that has
been suspended or excluded under such program, subject to a
payment suspension, or has had its billing privileges revoked.
``(2) Enhanced safeguards.--If the Secretary determines
that such previous affiliation of such provider or supplier
poses a risk of fraud, waste, or abuse, the Secretary may apply
such enhanced safeguards as the Secretary determines necessary
to reduce such risk associated with such provider or supplier
enrolling or participating in the program under title XVIII,
XIX, or XXI. Such safeguards may include enhanced oversight,
such as enhanced screening of claims, required or unannounced
(or required and unannounced) site visits or inspections,
additional information reporting requirements, and conditioning
such enrollment on the provision of a surety bond.
``(3) Authority to deny participation.--If the Secretary
determines that there has been at least one such affiliation
and that such affiliation or affiliations, as applicable, of
such provider or supplier poses a serious risk of fraud, waste,
or abuse, the Secretary may deny the application of such
provider or supplier.''.
(b) Conforming Amendments.--
(1) Medicaid.--Paragraph (74) of section 1902(a) of such
Act (42 U.S.C. 1396a(a)), as added by section 1631(b)(1), is
amended--
(A) by inserting ``or subsection (b) of such
section (relating to disclosure requirements)'' before
``, and that the State''; and
(B) by inserting before the period the following:
``and apply any enhanced safeguards, with respect to a
provider or supplier described in such subsection (b),
as the Secretary determines necessary under such
subsection (b)''.
(2) CHIP.--Subsection (d) of section 2102 of such Act (42
U.S.C. 1397bb), as added by section 1631(b)(2), is amended--
(A) in paragraph (1), by striking at the end
``and'';
(B) in paragraph (2) by striking the period at the
end and inserting ``; and''' and
(C) by adding at the end the following new
paragraph:
``(3) to enforce any determination made by the Secretary
under subsection (b) of section 1128G (relating to disclosure
requirements) and to apply any enhanced safeguards, with
respect to a provider or supplier described in such subsection,
as the Secretary determines necessary under such subsection.''.
SEC. 1633. REQUIRED INCLUSION OF PAYMENT MODIFIER FOR CERTAIN
EVALUATION AND MANAGEMENT SERVICES.
Section 1848 of the Social Security Act (42 U.S.C. 1395w-4), as
amended by section 4101 of the HITECH Act (Public Law 111-5), is
amended by adding at the end the following new subsection:
``(p) Payment Modifier for Certain Evaluation and Management
Services.--The Secretary shall establish a payment modifier under the
fee schedule under this section for evaluation and management services
(as specified in section 1842(b)(16)(B)(ii)) that result in the
ordering of additional services (such as lab tests), the prescription
of drugs, the furnishing or ordering of durable medical equipment in
order to enable better monitoring of claims for payment for such
additional services under this title, or the ordering, furnishing, or
prescribing of other items and services determined by the Secretary to
pose a high risk of waste, fraud, and abuse. The Secretary may require
providers of services or suppliers to report such modifier in claims
submitted for payment.''.
SEC. 1634. EVALUATIONS AND REPORTS REQUIRED UNDER MEDICARE INTEGRITY
PROGRAM.
(a) In General.--Section 1893(c) of the Social Security Act (42
U.S.C. 1395ddd(c)) is amended--
(1) in paragraph (3), by striking at the end ``and'';
(2) by redesignating paragraph (4) as paragraph (5); and
(3) by inserting after paragraph (3) the following new
paragraph:
``(4) for the contract year beginning in 2011 and each
subsequent contract year, the entity provides assurances to the
satisfaction of the Secretary that the entity will conduct
periodic evaluations of the effectiveness of the activities
carried out by such entity under the Program and will submit to
the Secretary an annual report on such activities; and''.
(b) Reference to Medicaid Integrity Program.--For a similar
provision with respect to the Medicaid Integrity Program, see section
1752.
SEC. 1635. REQUIRE PROVIDERS AND SUPPLIERS TO ADOPT PROGRAMS TO REDUCE
WASTE, FRAUD, AND ABUSE.
(a) In General.--Section 1866(j) of the Social Security Act (42
U.S.C. 42 U.S.C. 1395cc(j)), as amended by section 1631(d)(3), is
further amended by adding at the end the following new paragraph:
``(4) Compliance programs for providers of services and
suppliers.--
``(A) In general.--The Secretary may not enroll (or
renew the enrollment of) a provider of services or a
supplier (other than a physician or a skilled nursing
facility) under this title if such provider of services
or supplier fails to, subject to subparagraph (E),
establish a compliance program that contains the core
elements established under subparagraph (B) and certify
in a manner determined by the Secretary, that the
provider or suppler has established such a program.
``(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). Such elements may include written
policies, procedures, and standards of conduct, a
designated compliance officer and a compliance
committee; effective training and education pertaining
to fraud, waste, and abuse for the organization's
employees, and contractors; a confidential or anonymous
mechanism, such as a hotline, to receive compliance
questions and reports of fraud, waste, or abuse;
disciplinary guidelines for enforcement of standards;
internal monitoring and auditing procedures, including
monitoring and auditing of contractors; procedures for
ensuring prompt responses to detected offenses and
development of corrective action initiatives, including
responses to potential offenses; and procedures to
return all identified overpayments to the programs
under this title, title XIX, and title XXI.
``(C) Timeline for implementation.--The Secretary
shall determine a timeline for the establishment of the
core elements under subparagraph (B) and the date on
which a provider of services and suppliers (other than
physicians and skilled nursing facilities) shall be
required to have established such a program for
purposes of this subsection.
``(D) Pilot program.--The Secretary may conduct a
pilot program on the application of this subsection
with respect to a category of providers of services or
suppliers (other than physicians and skilled nursing
facilities) that the Secretary determines to be a
category which is at high risk for waste, fraud, and
abuse before implementing the requirements of this
subsection to all providers of services and suppliers
described in subparagraph (C).
``(E) Treatment of skilled nursing facilities.--For
the requirement for skilled nursing facilities to
establish compliance and ethics programs see section
1819(d)(1)(C).
``(F) Construction.--Nothing in this subsection
exempts a physician from participating in a compliance
program established by a health care provider or other
entity with which the physician is employed, under
contract, or affiliated if such compliance is required
by such provider or entity.''.
(b) Reference to Similar Medicaid Provision.--For a similar
provision with respect to the Medicaid program under title XIX of the
Social Security Act, see section 1753.
SEC. 1636. MAXIMUM PERIOD FOR SUBMISSION OF MEDICARE CLAIMS REDUCED TO
NOT MORE THAN 12 MONTHS.
(a) Purpose.--In general, the 36-month period currently allowed for
claims filing under parts A, B, C, and, D of title XVIII of the Social
Security Act presents opportunities for fraud schemes in which
processing patterns of the Centers for Medicare & Medicaid Services can
be observed and exploited. Narrowing the window for claims processing
will not overburden providers and will reduce fraud and abuse.
(b) Reducing Maximum Period for Submission.--
(1) Part a.--Section 1814(a) of the Social Security Act (42
U.S.C. 1395f(a)) is amended--
(A) in paragraph (1), by striking ``period of 3
calendar years'' and all that follows and inserting
``period of 1 calendar year from which such services
are furnished; and''; 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.--Section 1835(a) of such Act (42 U.S.C.
1395n(a)) is amended--
(A) in paragraph (1), by striking ``period of 3
calendar years'' and all that follows and inserting
``period of 1 calendar year from which such services
are furnished; and''; 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.''.
(3) Parts c and d.--Section 1857(d) of such Act is amended
by adding at the end the following new paragraph:
``(7) Period for submission of claims.--The contract shall
require an MA organization or PDP sponsor to require any
provider of services under contract with, in partnership with,
or affiliated with such organization or sponsor to ensure that,
with respect to items and services furnished by such provider
to an enrollee of such organization, written request, signed by
such enrollee, except in cases in which the Secretary finds it
impracticable for the enrollee to do so, is filed for payment
for such items and services in such form, in such manner, and
by such person or persons as the Secretary may by regulation
prescribe, no later than the close of the 1 calendar year
period after such items and services are furnished. In applying
the previous sentence, the Secretary may specify exceptions to
the 1 calendar year period specified.''.
(c) Effective Date.--The amendments made by subsection (b) shall be
effective for items and services furnished on or after January 1, 2011.
SEC. 1637. PHYSICIANS WHO ORDER DURABLE MEDICAL EQUIPMENT OR HOME
HEALTH 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 other
professional, as determined by the Secretary''.
(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
other professional, as determined by the Secretary,'' 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
other professional, as determined by the Secretary,'' after ``a
physician''.
(c) Discretion to Expand Application.--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 other categories of items or
services under this title, including covered part D drugs as defined in
section 1860D-2(e), if the Secretary determines that such application
would help to reduce the risk of waste, fraud, and abuse with respect
to such other categories under title XVIII of the Social Security Act.
(d) Effective Date.--The amendments made by this section shall
apply to written orders and certifications made on or after July 1,
2010.
SEC. 1638. 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 is further amended by adding at the end the following new
paragraph
``(9) The Secretary may disenroll, for a period of not more than
one year for each act, 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 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. 1639. FACE-TO-FACE ENCOUNTER WITH PATIENT REQUIRED BEFORE
ELIGIBILITY CERTIFICATIONS FOR HOME HEALTH SERVICES OR
DURABLE MEDICAL EQUIPMENT.
(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 or
recertification made by a physician 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''.
(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
or recertification 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
recertification, 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 by adding before the period at the end the following: ``and
shall require that any written order required for payment under this
subsection be written only pursuant to the eligible health care
professional authorized to make such written order documenting that
such professional 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 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 a face-to-face encounter requirement similar to the 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 a decision would
reduce the risk of waste, fraud, or abuse.
(d) Application to Medicaid and CHIP.--The face-to-face encounter
requirements described in the amendments made by subsections (a) and
(b) and any expanded application of similar requirements pursuant to
subsection (c) shall apply with respect to a certification or
recertification for home health services under title XIX or XXI of the
Social Security Act, a written order for durable medical equipment
under such title, and any other applicable item or service identified
pursuant to subsection (c) for which payment is made under such title,
respectively, in the same manner and to the same extent as such
requirements apply in the case of such a certification or
recertification, written order, or other applicable item or service so
identified, respectively, under title XVIII of such Act.
SEC. 1640. EXTENSION OF TESTIMONIAL SUBPOENA AUTHORITY TO PROGRAM
EXCLUSION INVESTIGATIONS.
(a) In General.--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 or the Administrator of the Centers for Medicare & Medicaid
Services for purposes of any investigation under this section.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to investigations beginning on or after January 1, 2010.
SEC. 1641. REQUIRED REPAYMENTS OF MEDICARE AND MEDICAID OVERPAYMENTS.
Section 1128G of the Social Security Act, as inserted by section
1631 and amended by section 1632, is further amended by adding at the
end the following new subsection:
``(c) Reports on and Repayment of Overpayments Identified Through
Internal Audits and Reviews.--
``(1) Reporting and returning overpayments.--If a person
knows of an overpayment, the person must--
``(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, the State,
intermediary, carrier, or contractor to whom the
overpayment was returned in writing of the reason for
the overpayment.
``(2) Timing.--Subject to section 1620(d) of the Affordable
Health Care for America Act, an overpayment must be reported
and returned under paragraph (1)(A) by not later than the date
that is 60 days after the date the person knows of the
overpayment.
Any known overpayment retained later than the applicable date
specified in this paragraph creates an obligation as defined in
section 3729(b)(3) of title 31 of the United States Code.
``(3) Clarification.--Repayment of any overpayments (or
refunding by withholding of future payments) by a provider of
services or supplier does not otherwise limit the provider or
supplier's potential liability for administrative obligations
such as applicable interests, fines, and penalties or civil or
criminal sanctions involving the same claim if it is determined
later that the reason for the overpayment was related to fraud
or other intentional conduct by the provider or supplier or the
employees or agents of such provider or supplier.
``(4) Definitions.--In this subsection:
``(A) Knows.--The term `knows' has the meaning
given the terms `knowing' and `knowingly' in section
3729(b) of title 31 of the United States Code.
``(B) Overpayment.--The term ``overpayment'' means
any funds that a person receives or retains under title
XVIII, XIX, or XXI to which the person, after
applicable reconciliation (pursuant to the applicable
existing process under the respective title), is not
entitled under such title.
``(C) Person.--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)), but excluding a beneficiary.''.
SEC. 1642. EXPANDED APPLICATION OF HARDSHIP WAIVERS FOR OIG EXCLUSIONS
TO BENEFICIARIES OF ANY FEDERAL HEALTH CARE PROGRAM.
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. 1643. ACCESS TO CERTAIN INFORMATION ON RENAL DIALYSIS FACILITIES.
Section 1881(b) of the Social Security Act (42 U.S.C. 1395rr(b)) is
amended by adding at the end the following new paragraph:
``(15) For purposes of evaluating or auditing payments made to
renal dialysis facilities for items and services under this section
under paragraph (1), each such renal dialysis facility, upon the
request of the Secretary, shall provide to the Secretary access to
information relating to any ownership or compensation arrangement
between such facility and the medical director of such facility or
between such facility and any physician.''.
SEC. 1644. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE PAYEES
REQUIRED TO REGISTER UNDER MEDICARE.
(a) Medicare.--Section 1866(j)(1) of the Social Security Act (42
U.S.C. 1395cc(j)(1)) is amended by adding at the end the following new
subparagraph:
``(D) Billing agents and clearinghouses required to
be registered under medicare.--Any agent,
clearinghouse, or other alternate payee that submits
claims on behalf of a health care provider must be
registered with the Secretary in a form and manner
specified by the Secretary.''.
(b) Medicaid.--For a similar provision with respect to the Medicaid
program under title XIX of the Social Security Act, see section 1759.
(c) Effective Date.--The amendment made by subsection (a) shall
apply to claims submitted on or after January 1, 2012.
SEC. 1645. CONFORMING CIVIL MONETARY PENALTIES TO FALSE CLAIMS ACT
AMENDMENTS.
Section 1128A of the Social Security Act, as amended by sections
1611, 1612, 1613, and 1615, is further amended--
(1) in subsection (a)--
(A) in paragraph (1), by striking ``to an officer,
employee, or agent of the United States, or of any
department or agency thereof, or of any State agency
(as defined in subsection (i)(1))'';
(B) in paragraph (4)--
(i) in the matter preceding subparagraph
(A), by striking ``participating in a program
under title XVIII or a State health care
program'' and inserting ``participating in a
Federal health care program (as defined in
section 1128B(f))''; and
(ii) in subparagraph (A), by striking
``title XVIII or a State health care program''
and inserting ``a Federal health care program
(as defined in section 1128B(f))'';
(C) by striking ``or'' at the end of paragraph
(10);
(D) by inserting after paragraph (11) the following
new paragraphs:
``(12) conspires to commit a violation of this section; or
``(13) knowingly makes, uses, or causes to be made or used,
a false record or statement material to an obligation to pay or
transmit money or property to a Federal health care program, or
knowingly conceals or knowingly and improperly avoids or
decreases an obligation to pay or transmit money or property to
a Federal health care program;''; and
(E) in the matter following paragraph (13), as
inserted by subparagraph (D)--
(i) by striking ``or'' before ``in cases
under paragraph (11)''; and
(ii) by inserting ``, in cases under
paragraph (12), $50,000 for any violation
described in this section committed in
furtherance of the conspiracy involved; or in
cases under paragraph (13), $50,000 for each
false record or statement, or concealment,
avoidance, or decrease'' after ``by an excluded
individual''; and
(F) in the second sentence, by striking ``such
false statement, omission, or misrepresentation)'' and
inserting ``such false statement or misrepresentation,
in cases under paragraph (12), an assessment of not
more than 3 times the total amount that would otherwise
apply for any violation described in this section
committed in furtherance of the conspiracy involved, or
in cases under paragraph (13), an assessment of not
more than 3 times the total amount of the obligation to
which the false record or statement was material or
that was avoided or decreased)''.
(2) in subsection (c)(1), by striking ``six years'' and
inserting ``10 years''; and
(3) in subsection (i)--
(A) by amending paragraph (2) to read as follows:
``(2) The term `claim' means any application, request, or
demand, whether under contract, or otherwise, for money or
property for items and services under a Federal health care
program (as defined in section 1128B(f)), whether or not the
United States or a State agency has title to the money or
property, that--
``(A) is presented or caused to be presented to an
officer, employee, or agent of the United States, or of
any department or agency thereof, or of any State
agency (as defined in subsection (i)(1)); or
``(B) is made to a contractor, grantee, or other
recipient if the money or property is to be spent or
used on the Federal health care program's behalf or to
advance a Federal health care program interest, and if
the Federal health care program--
``(i) provides or has provided any portion
of the money or property requested or demanded;
or
``(ii) will reimburse such contractor,
grantee, or other recipient for any portion of
the money or property which is requested or
demanded.'';
(B) by amending paragraph (3) to read as follows:
``(3) The term `item or service' means, without limitation,
any medical, social, management, administrative, or other item
or service used in connection with or directly or indirectly
related to a Federal health care program.'';
(C) in paragraph (6)--
(i) in subparagraph (C), by striking at the
end ``or'';
(ii) in the first subparagraph (D), by
striking at the end the period and inserting
``; or''; and
(iii) by redesignating the second
subparagraph (D) as a subparagraph (E);
(D) by amending paragraph (7) to read as follows:
``(7) The terms `knowing', `knowingly', and `should know'
mean that a person, with respect to information--
``(A) has actual knowledge of the information;
``(B) acts in deliberate ignorance of the truth or
falsity of the information; or
``(C) acts in reckless disregard of the truth or
falsity of the information;
and require no proof of specific intent to defraud.''; and
(E) by adding at the end the following new
paragraphs:
``(8) The term `obligation' means an established duty,
whether or not fixed, arising from an express or implied
contractual, grantor-grantee, or licensor-licensee
relationship, from a fee-based or similar relationship, from
statute or regulation, or from the retention of any
overpayment.
``(9) The term `material' means having a natural tendency
to influence, or be capable of influencing, the payment or
receipt of money or property.''.
SEC. 1646. REQUIRING PROVIDER AND SUPPLIER PAYMENTS UNDER MEDICARE TO
BE MADE THROUGH DIRECT DEPOSIT OR ELECTRONIC FUNDS
TRANSFER (EFT) AT INSURED DEPOSITORY INSTITUTIONS.
(a) Medicare.--Section 1874 of the Social Security Act (42 U.S.C.
1395kk) is amended by adding at the end the following new subsection:
``(e) Limitation on Payment to Providers of Services and
Suppliers.--No payment shall be made under this title for items and
services furnished by a provider of services or supplier unless each
payment to the provider of services or supplier is in the form of
direct deposit or electronic funds transfer to the provider of
services' or supplier's account, as applicable, at a depository
institution (as defined in section 19(b)(1)(A) of the Federal Reserve
Act.''.
(b) Effective Date.--The amendments made by this section shall
apply to each payment made to a provider of services, provider, or
supplier on or after such date (not later than July 1, 2012) as the
Secretary of Health and Human Services shall specify, regardless of
when the items and services for which such payment is made were
furnished.
SEC. 1647. INSPECTOR GENERAL FOR THE HEALTH CHOICES ADMINISTRATION.
(a) Establishment; Appointment.--There is hereby established an
Office of Inspector General for the Health Choices Administration, to
be headed by the Inspector General for the Health Choices
Administration to be appointed by the President, by and with the advice
and consent of the Senate.
(b) Amendments to the Inspector General Act of 1978.--
(1) Application to health choices administration.--Section
12 of the Inspector General Act of 1978 (5 U.S.C. App.) is
amended--
(A) in paragraph (1), by striking ``or the Federal
Cochairpersons of the Commissions established under
section 15301 of title 40, United States Code'' and
inserting ``the Federal Cochairpersons of the
Commissions established under section 15301 of title
40, United States Code; or the Commissioner of the
Health Choices Administration established under section
241 of the Affordable Health Care for America Act'';
and
(B) in paragraph (2), by striking ``or the
Commissions established under section 15301 of title
40, United States Code'' and inserting ``the
Commissions established under section 15301 of title
40, United States Code, or the Health Choices
Administration established under section 241 of the
Affordable Health Care for America Act''.
(2) Special provisions relating to health choices
administration and hhs.--The Inspector General Act of 1978 (5
U.S.C. App.) is further amended by inserting after section 8L
the following new section:
``SEC. 8M SPECIAL PROVISIONS RELATING TO THE HEALTH CHOICES
ADMINISTRATION AND THE DEPARTMENT OF HEALTH AND HUMAN
SERVICES.
``(a) The Inspector General of the Health Choices Administration
shall--
``(1) have the authority to conduct, supervise, and
coordinate audits, evaluations, and investigations of the
programs and operations of the Health Choices Administration
established under section 241 of the Affordable Health Care for
America Act, including matters relating to fraud, abuse, and
misconduct in connection with the admission and continued
participation of any health benefits plan participating in the
Health Insurance Exchange established under section 301 of such
Act;
``(2) have the authority to conduct audits, evaluations,
and investigations relating to any private Exchange-
participating health benefits plan, as defined in section
201(c) of such Act;
``(3) have the authority, in consultation with the Office
of Inspector General for the Department of Health and Human
Services and subject to subsection (b), to conduct audits,
evaluations, and investigations relating to the public health
insurance option established under section 321 of such Act; and
``(4) have access to all relevant records necessary to
carry out this section, including records relating to claims
paid by Exchange-participating health benefits plans.
``(b) Authority granted to the Health Choices Administration and
the Inspector General of the Health Choices Administration by the
Affordable Health Care for America Act does not limit the duties,
authorities, and responsibilities of the Office of Inspector General
for the Department of Health and Human Services, as in existence as of
the date of the enactment of the Affordable Health Care for America Act
, to oversee programs and operations of such department. The Office of
Inspector General for the Department of Health and Human Services
retains primary jurisdiction over fraud and abuse in connection with
payments made under the public health insurance option established
under section 321 of such Act and administered by the Department of
Health and Human Services.''.
(3) Application of rule of construction.--Section 8J of the
Inspector General Act of 1978 (5 U.S.C. App.) is amended by
striking ``or 8H'' and inserting ``, 8H, or 8M''.
(c) Effective Date.--The provisions of and amendments made by this
section shall take effect on the date of the enactment of this Act.
Subtitle D--Access to Information Needed to Prevent Fraud, Waste, and
Abuse
SEC. 1651. ACCESS TO INFORMATION NECESSARY TO IDENTIFY FRAUD, WASTE,
AND ABUSE.
(a) GAO Access.--Subchapter II of chapter 7 of title 31, United
States Code, is amended by adding at the end the following:
``Sec. 721. Access to certain information
``No provision of the Social Security Act shall be construed to
limit, amend, or supersede the authority of the Comptroller General to
obtain any information, to inspect any record, or to interview any
officer or employee under section 716 of this title, including with
respect to any information disclosed to or obtained by the Secretary of
Health and Human Services under part C or D of title XVIII of the
Social Security Act.''.
(b) Access to Medicare Part D Data Program Integrity Purposes.--
(1) Provision of information as condition of payment.--
Section 1860D-15(d)(2)(B) of the Social Security Act (42 U.S.C.
1395w-115(d)(2)(B)) is amended--
(A) by striking ``may be used by officers'' and all
that follows through the period and inserting ``may be
used by--''; and
(B) by adding at the end the following clauses:
``(i) officers, employees, and contractors
of the Department of Health and Human Services
only for the purposes of, and to the extent
necessary in, carrying out this section; and
``(ii) the Inspector General of the
Department of Health and Human Services, the
Administrator of the Centers for Medicare &
Medicaid Services, and the Attorney General
only for the purposes of protecting the
integrity of the programs under this title and
title XIX; conducting the activities described
in section 1893 and subparagraphs (A) through
(E) of section 1128C(a)(1); and for
investigation, audit, evaluation, oversight,
and law enforcement purposes to the extent
consistent with applicable law.''.
(2) General disclosure of information.--Section 1860D-
15(f)(2) of the Social Security Act (42 U.S.C. 1395w-115(f)(2))
is amended--
(A) by striking ``may be used by officers'' and all
that follows through the period and inserting ``may be
used by--''; and
(B) by adding at the end the following
subparagraphs:
``(A) officers, employees, and contractors of the
Department of Health and Human Services only for the
purposes of, and to the extent necessary in, carrying
out this section; and
``(B) the Inspector General of the Department of
Health and Human Services, the Administrator of the
Centers for Medicare & Medicaid Services, and the
Attorney General only for the purposes of protecting
the integrity of the programs under this title and
title XIX; conducting the activities described in
section 1893 and subparagraphs (A) through (E) of
section 1128C(a)(1); and for investigation, audit,
evaluation, oversight, and law enforcement purposes to
the extent consistent with applicable law.''.
SEC. 1652. ELIMINATION OF DUPLICATION BETWEEN THE HEALTHCARE INTEGRITY
AND PROTECTION DATA BANK AND THE NATIONAL PRACTITIONER
DATA BANK.
(a) In General.--To eliminate duplication between the Healthcare
Integrity and Protection Data Bank (HIPDB) established under section
1128E of the Social Security Act and the National Practitioner Data
Bank (NPBD) established under the Health Care Quality Improvement Act
of 1986, section 1128E of the Social Security Act (42 U.S.C. 1320a-7e)
is amended--
(1) in subsection (a), by striking ``Not later than'' and
inserting ``Subject to subsection (h), not later than'';
(2) in the first sentence of subsection (d)(2), by striking
``(other than with respect to requests by Federal agencies)'';
and
(3) by adding at the end the following new subsection:
``(h) Sunset of the Healthcare Integrity and Protection Data Bank;
Transition Process.--Effective upon the enactment of this subsection,
the Secretary shall implement a process to eliminate duplication
between the Healthcare Integrity and Protection Data Bank (in this
subsection referred to as the `HIPDB' established pursuant to
subsection (a) and the National Practitioner Data Bank (in this
subsection referred to as the `NPDB') as implemented under the Health
Care Quality Improvement Act of 1986 and section 1921 of this Act,
including systems testing necessary to ensure that information formerly
collected in the HIPDB will be accessible through the NPDB, and other
activities necessary to eliminate duplication between the two data
banks. Upon the completion of such process, notwithstanding any other
provision of law, the Secretary shall cease the operation of the HIPDB
and shall collect information required to be reported under the
preceding provisions of this section in the NPDB. Except as otherwise
provided in this subsection, the provisions of subsections (a) through
(g) shall continue to apply with respect to the reporting of (or
failure to report), access to, and other treatment of the information
specified in this section.''.
(b) Elimination of the Responsibility of the HHS Office of the
Inspector General.--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 at the end ``and'';
(2) in subparagraph (D), by striking at the end ``, and''
and inserting a period; and
(3) by striking subparagraph (E).
(c) Special Provision for Access to the National Practitioner Data
Bank by the Department of Veterans Affairs.--
(1) In general.--Notwithstanding any other provision of
law, during the one year period that begins on the effective
date specified in subsection (e)(1), the information described
in paragraph (2) shall be available from the National
Practitioner Data Bank (described in section 1921 of the Social
Security Act) to the Secretary of Veterans Affairs without
charge.
(2) Information described.--For purposes of paragraph (1),
the information described in this paragraph 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.
(d) Funding.--Notwithstanding any provisions of this Act, sections
1128E(d)(2) and 1817(k)(3) of the Social Security Act, or any other
provision of law, there shall be available for carrying out the
transition process under section 1128E(h) of the Social Security Act
over the period required to complete such process, and for operation of
the National Practitioner Data Bank until such process is completed,
without fiscal year limitation--
(1) any fees collected pursuant to section 1128E(d)(2) of
such Act; and
(2) such additional amounts as necessary, from
appropriations available to the Secretary and to the Office of
the Inspector General of the Department of Health and Human
Services under clauses (i) and (ii), respectively, of section
1817(k)(3)(A) of such Act, for costs of such activities during
the first 12 months following the date of the enactment of this
Act.
(e) Effective Date.--The amendments made--
(1) by subsection (a)(2) shall take effect on the first day
after the Secretary of Health and Human Services certifies that
the process implemented pursuant to section 1128E(h) of the
Social Security Act (as added by subsection (a)(3)) is
complete; and
(2) by subsection (b) shall take effect on the earlier of
the date specified in paragraph (1) or the first day of the
second succeeding fiscal year after the fiscal year during
which this Act is enacted.
SEC. 1653. COMPLIANCE WITH HIPAA PRIVACY AND SECURITY STANDARDS.
The provisions of sections 262(a) and 264 of the Health Insurance
Portability and Accountability Act of 1996 (and standards promulgated
pursuant to such sections) and the Privacy Act of 1974 shall apply with
respect to the provisions of this subtitle and amendments made by this
subtitle.
TITLE VII--MEDICAID AND CHIP
SEC. 1. TABLE OF CONTENTS [TEMPORARY].
Sec. 1. Table of contents [Temporary].
Subtitle A--Medicaid and Health Reform
Sec. 1701. Eligibility for individuals with income below 150 percent of
the Federal poverty level.
Sec. 1702. Requirements and special rules for certain Medicaid
eligible individuals.
Sec. 1703. CHIP and Medicaid maintenance of eligibility.
Sec. 1704. Reduction in Medicaid DSH.
Sec. 1705. Expanded outstationing.
Subtitle B--Prevention
Sec. 1711. Required coverage of preventive services.
Sec. 1712. Tobacco cessation.
Sec. 1713. Optional coverage of nurse home visitation services.
Sec. 1714. State eligibility option for family planning services.
Subtitle C--Access
Sec. 1721. Payments to primary care practitioners.
Sec. 1722. Medical home pilot program.
Sec. 1723. Translation or interpretation services.
Sec. 1724. Optional coverage for freestanding birth center services.
Sec. 1725. Inclusion of public health clinics under the vaccines for
children program.
Sec. 1726. Requiring coverage of services of podiatrists.
Sec. 1726A. Requiring coverage of services of optometrists.
Sec. 1727. Therapeutic foster care.
Sec. 1728. Assuring adequate payment levels for services.
Sec. 1729. Preserving Medicaid coverage for youths upon release from
public institutions.
Sec. 1730. Quality measures for maternity and adult health services
under Medicaid and CHIP.
Sec. 1730A. Accountable care organization pilot program.
Sec. 1730B. FQHC coverage.
Subtitle D--Coverage
Sec. 1731. Optional Medicaid coverage of low-income HIV-infected
individuals.
Sec. 1732. Extending transitional Medicaid Assistance (TMA).
Sec. 1733. Requirement of 12-month continuous coverage under certain
CHIP programs.
Sec. 1734. Preventing the application under CHIP of coverage waiting
periods for certain children.
Sec. 1735. Adult day health care services.
Sec. 1736. Medicaid coverage for citizens of Freely Associated States.
Sec. 1737. Continuing requirement of Medicaid coverage of nonemergency
transportation to medically necessary
services.
Sec. 1738. State option to disregard certain income in providing
continued Medicaid coverage for certain
individuals with extremely high
prescription costs.
Sec. 1739. Provisions relating to community living assistance services
and supports (CLASS).
Subtitle E--Financing
Sec. 1741. Payments to pharmacists.
Sec. 1742. Prescription drug rebates.
Sec. 1743. Extension of prescription drug discounts to enrollees of
Medicaid managed care organizations.
Sec. 1744. Payments for graduate medical education.
Sec. 1745. Nursing Facility Supplemental Payment Program.
Sec. 1746. Report on Medicaid payments.
Sec. 1747. Reviews of Medicaid.
Sec. 1748. Extension of delay in managed care organization provider tax
elimination.
Sec. 1749. Extension of ARRA increase in FMAP.
Subtitle F--Waste, Fraud, and Abuse
Sec. 1751. Health care acquired conditions.
Sec. 1752. Evaluations and reports required under Medicaid Integrity
Program.
Sec. 1753. Require providers and suppliers to adopt programs to reduce
waste, fraud, and abuse.
Sec. 1754. Overpayments.
Sec. 1755. Managed care organizations.
Sec. 1756. Termination of provider participation under Medicaid and
CHIP if terminated under Medicare or other
State plan or child health plan.
Sec. 1757. Medicaid and CHIP exclusion from participation relating to
certain ownership, control, and management
affiliations.
Sec. 1758. Requirement to report expanded set of data elements under
MMIS to detect fraud and abuse.
Sec. 1759. Billing agents, clearinghouses, or other alternate payees
required to register under Medicaid.
Sec. 1760. Denial of payments for litigation-related misconduct.
Sec. 1761. Mandatory State use of national correct coding initiative.
Subtitle G--Payments to the Territories
Sec. 1771. Payment to territories.
Subtitle H--Miscellaneous
Sec. 1781. Technical corrections.
Sec. 1782. Extension of QI program.
Sec. 1783. Assuring transparency of information.
Sec. 1784. Medicaid and CHIP Payment and Access Commission.
Sec. 1785. Outreach and enrollment of Medicaid and CHIP eligible
individuals.
Sec. 1786. Prohibitions on Federal Medicaid and CHIP payment for
undocumented aliens.
Sec. 1787. Demonstration project for stabilization of emergency medical
conditions by institutions for mental
diseases.
Sec. 1788. Application of Medicaid Improvement Fund.
Sec. 1789. Treatment of certain Medicaid brokers.
Sec. 1790. Rule for changes requiring State legislation.
Subtitle A--Medicaid and Health Reform
SEC. 1701. ELIGIBILITY FOR INDIVIDUALS WITH INCOME BELOW 150 PERCENT OF
THE FEDERAL POVERTY LEVEL.
(a) Eligibility for Non-traditional Individuals With Income Below
150 Percent of the Federal Poverty Level.--
(1) Full medicaid benefits for non-medicare eligible
individuals.--Section 1902(a)(10)(A)(i) of the Social Security
Act (42 U.S.C. 1396b(a)(10)(A)(i)) 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 adding at the end the following new
subclause:
``(VIII) who are under 65 years of
age, who are not described in a
previous subclause of this clause, who
are not entitled to hospital insurance
benefits under part A of title XVIII,
and whose family income (determined
using methodologies and procedures
specified by the Secretary in
consultation with the Health Choices
Commissioner) does not exceed 150
percent of the income official poverty
line (as defined by the Office of
Management and Budget, and revised
annually in accordance with section
673(2) of the Omnibus Budget
Reconciliation Act of 1981) applicable
to a family of the size involved;''.
(2) Medicare cost sharing assistance for medicare-eligible
individuals.--Section 1902(a)(10)(E) of such Act (42 U.S.C.
1396b(a)(10)(E)) is amended--
(A) in clause (iii), by striking ``and'' at the
end;
(B) in clause (iv), by adding ``and'' at the end;
and
(C) by adding at the end the following new clause:
``(v) for making medical assistance available for
medicare cost-sharing described in subparagraphs (B)
and (C) of section 1905(p)(3), for individuals under 65
years of age who would be qualified medicare
beneficiaries described in section 1905(p)(1) but for
the fact that their income exceeds the income level
established by the State under section 1905(p)(2) but
is less than 150 percent of the official poverty line
(referred to in such section) for a family of the size
involved; and''.
(3) Increased fmap for non-traditional full medicaid
eligible individuals.--Section 1905 of such Act (42 U.S.C.
1396d) is amended--
(A) in the first sentence of subsection (b), by
striking ``and'' before ``(4)'' and by inserting before
the period at the end the following: ``, and (5) 100
percent (for periods before 2015 and 91 percent for
periods beginning with 2015) with respect to amounts
described in subsection (y)''; and
(B) by adding at the end the following new
subsection:
``(y) Additional Expenditures Subject to Increased FMAP.--For
purposes of section 1905(b)(5), the amounts described in this
subsection are the following:
``(1) Amounts expended for medical assistance for
individuals described in subclause (VIII) of section
1902(a)(10)(A)(i).''.
(4) Construction.--Nothing in this subsection shall be
construed as not providing for coverage under subparagraph
(A)(i)(VIII) or (E)(v) of section 1902(a)(10) of the Social
Security Act, as added by paragraphs (1) and (2), or an
increased FMAP under the amendments made by paragraph (3), for
an individual who has been provided medical assistance under
title XIX of the Act under a demonstration waiver approved
under section 1115 of such Act or with State funds.
(5) Conforming amendments.--
(A) Section 1903(f)(4) of the Social Security Act
(42 U.S.C. 1396b(f)(4)) is amended--
(i) by inserting
``1902(a)(10)(A)(i)(VIII),'' after
``1902(a)(10)(A)(i)(VII),''; and
(ii) by inserting ``1902(a)(10)(E)(v),''
before ``1905(p)(1)''.
(B) Section 1905(a) of such Act (42 U.S.C.
1396d(a)), as amended by sections 1714(a)(4) and
1731(c), is further amended, in the matter preceding
paragraph (1)--
(i) by striking ``or'' at the end of clause
(xiv);
(ii) by adding ``or'' at the end of clause
(xv); and
(iii) by inserting after clause (xv) the
following:
``(xvi) individuals described in section
1902(a)(10)(A)(i)(VIII),''.
(b) Eligibility for Traditional Medicaid Eligible Individuals With
Income Not Exceeding 150 Percent of the Federal Poverty Level .--
(1) In general.--Section 1902(a)(10)(A)(i) of the Social
Security Act (42 U.S.C. 1396b(a)(10)(A)(i)), as amended by
subsection (a), is amended--
(A) by striking ``or'' at the end of subclause
(VII); and
(B) by adding at the end the following new
subclause:
``(IX) who are over 18, and under
65 years of age, who would be eligible
for medical assistance under the State
plan under subclause (I) or section
1931 (based on the income standards,
methodologies, and procedures in effect
as of June 16, 2009) but for income,
who are in families whose income does
not exceed 150 percent of the income
official poverty line (as defined by
the Office of Management and Budget,
and revised annually in accordance with
section 673(2) of the Omnibus Budget
Reconciliation Act of 1981) applicable
to a family of the size involved; or
``(X) beginning with 2014, who are
over 5, and under 19, years of age, who
would be eligible for medical
assistance under the State plan under
subclause (I) or (VII) (based on the
income standards, methodologies, and
procedures in effect as of June 16,
2009) but for income, who are in
families whose income does not exceed
150 percent of the income official
poverty line (as defined by the Office
of Management and Budget, and revised
annually in accordance with section
673(2) of the Omnibus Budget
Reconciliation Act of 1981) applicable
to a family of the size involved; or
``(XI) beginning with 2014, who are
under 19 years of age, who are not
described in subclause (X), and who
would be eligible for child health
assistance under a State child health
plan insofar as such plan provides
benefits under this title (as described
in section 2101(a)(2)) based on such
plan as in effect as of June 16, 2009;
or''.
(2) Increased fmap for certain traditional medicaid
eligible individuals.--
(A) Increased fmap for adults.--Section 1905(y) of
such Act (42 U.S.C. 1396d(y)), as added by subsection
(a)(2)(B), is amended by inserting ``or (IX)'' after
``(VIII)''.
(B) Enhanced fmap for children.--Section 1905(b)(4)
of such Act is amended by inserting
``1902(a)(10)(A)(i)(X), 1902(a)(10)(A)(i)(XI), or''
after ``on the basis of section''.
(3) Construction.--Nothing in this subsection shall be
construed as not providing for coverage under subclause (IX),
(X), or (XI) of section 1902(a)(10)(A)(i) of the Social
Security Act, as added by paragraph (1), or an increased or
enhanced FMAP under the amendments made by paragraph (2), for
an individual who has been provided medical assistance under
title XIX of the Act under a demonstration waiver approved
under section 1115 of such Act or with State funds.
(4) Conforming amendment.--Section 1903(f)(4) of the Social
Security Act (42 U.S.C. 1396b(f)(4)), as amended by subsection
(a)(4), is amended by inserting ``1902(a)(10)(A)(i)(IX),
1902(a)(10)(A)(i)(X), 1902(a)(10)(A)(i)(XI),'' after
``1902(a)(10)(A)(i)(VIII),''.
(c) Increased Matching Rate for Temporary Coverage of Certain
Newborns.--Section 1905(y) of such Act, as added by subsection
(a)(3)(B), is amended by adding at the end the following:
``(2) Amounts expended for medical assistance for children
described in section 305(d)(1) of the Affordable Health Care
for America Act during the time period specified in such
section.''.
(d) Network Adequacy.--Section 1932(a)(2) of the Social Security
Act (42 U.S.C. 1396u-2(a)(2)) is amended by adding at the end the
following new subparagraph:
``(D) Enrollment of non-traditional medicaid
eligibles.--A State may not require under paragraph (1)
the enrollment in a managed care entity of an
individual described in section 1902(a)(10)(A)(i)(VIII)
unless the State demonstrates, to the satisfaction of
the Secretary, that the entity, through its provider
network and other arrangements, has the capacity to
meet the health, mental health, and substance abuse
needs of such individuals.''.
(e) Effective Date.--The amendments made by this section shall take
effect on the first day of Y1, and shall apply with respect to items
and services furnished on or after such date.
SEC. 1702. REQUIREMENTS AND SPECIAL RULES FOR CERTAIN MEDICAID ELIGIBLE
INDIVIDUALS.
(a) In General.--Title XIX of the Social Security Act is amended by
adding at the end the following new section:
`` requirements and special rules for certain medicaid eligible
individuals
``Sec. 1943. (a) Coordination With NHI Exchange Through Memorandum
of Understanding.--
``(1) In general.--The State shall enter into a Medicaid
memorandum of understanding described in section 305(e)(2) of
the Affordable Health Care for America Act with the Health
Choices Commissioner, acting in consultation with the
Secretary, with respect to coordinating the implementation of
the provisions of division A of such Act with the State plan
under this title in order to ensure the enrollment of Medicaid
eligible individuals in acceptable coverage. Nothing in this
section shall be construed as permitting such memorandum to
modify or vitiate any requirement of a State plan under this
title.
``(2) Enrollment of exchange-referred individuals.--
``(A) Non-traditional individuals.--Pursuant to
such memorandum the State shall accept without further
determination the enrollment under this title of an
individual determined by the Commissioner to be a non-
traditional Medicaid eligible individual. The State
shall not do any redeterminations of eligibility for
such individuals unless the periodicity of such
redeterminations is consistent with the periodicity for
redeterminations by the Commissioner of eligibility for
affordability credits under subtitle C of title II of
division A of the Affordable Health Care for America
Act, as specified under such memorandum.
``(B) Traditional individuals.--Pursuant to such
memorandum, the State shall accept without further
determination the enrollment under this title of an
individual determined by the Commissioner to be a
traditional Medicaid eligible individual. The State may
do redeterminations of eligibility of such individual
consistent with such section and the memorandum.
``(3) Determinations of eligibility for affordability
credits.--If the Commissioner determines that a State Medicaid
agency has the capacity to make determinations of eligibility
for affordability credits under subtitle C of title II of
division A of the Affordable Health Care for America Act, under
such memorandum--
``(A) the State Medicaid agency shall conduct such
determinations for any Exchange-eligible individual who
requests such a determination;
``(B) in the case that a State Medicaid agency
determines that an Exchange-eligible individual is not
eligible for affordability credits, the agency shall
forward the information on the basis of which such
determination was made to the Commissioner; and
``(C) the Commissioner shall reimburse the State
Medicaid agency for the costs of conducting such
determinations.
``(4) Referrals under memorandum.--Pursuant to such
memorandum, if an individual applies to the State for
assistance in obtaining health coverage and the State
determines that the individual is not eligible for medical
assistance under this title and is not authorized under such
memorandum to make an determination with respect to eligibility
for coverage and affordability credits through the Health
Insurance Exchange, the State shall refer the individual to the
Commissioner for a determination of such eligibility and, with
the individual's authorization, provide to the Commissioner
information obtained by the State as part of the application
process.
``(5) Additional terms.--Such memorandum shall include such
additional provisions as are necessary to implement efficiently
the provisions of this section and title II of division A of
the Affordable Health Care for America Act.
``(b) Treatment of Certain Newborns.--
``(1) In general.--In the case of a child who is deemed
under section 305(d) of the Affordable Health Care for America
Act to be a Medicaid eligible individual and enrolled under
this title pursuant to such section, the State shall provide
for a determination, by not later than the end of the period
referred to in paragraph (2) of such section, of the child's
eligibility for medical assistance under this title.
``(2) Extended treatment as traditional medicaid eligible
individual.--In accordance with paragraph (2) of section 305(d)
of the Affordable Health Care for America Act, in the case of a
child described in paragraph (1) of such section who at the end
of the period referred to in such paragraph is not otherwise
covered under acceptable coverage, the child shall be deemed
(until such time as the child obtains such coverage or the
State otherwise makes a determination of the child's
eligibility for medical assistance under its plan under this
title pursuant to paragraph (1)) to be a Medicaid eligible
individual described in section 1902(l)(1)(B).
``(c) Definitions.--In this section:
``(1) Medicaid eligible individual.--The term `Medicaid
eligible individual' means an individual who is eligible for
medical assistance under Medicaid.
``(2) Traditional medicaid eligible individual.--The term
`traditional Medicaid eligible individual' means a Medicaid
eligible individual other than an individual who is--
``(A) a Medicaid eligible individual by reason of
the application of subclause (VIII) of section
1902(a)(10)(A)(i) of the Social Security Act; or
``(B) a childless adult not described in section
1902(a)(10)(A) or (C) of such Act (as in effect as of
the day before the date of the enactment of this Act).
``(3) Non-traditional medicaid eligible individual.--The
term `non-traditional Medicaid eligible individual' means a
Medicaid eligible individual who is not a traditional Medicaid
eligible individual.
``(4) Memorandum.--The term `memorandum' means a Medicaid
memorandum of understanding under section 305(e)(2) of the
Affordable Health Care for America Act.
``(5) Y1.--The term `Y1' has the meaning given such term in
section 100(c) of the Affordable Health Care for America
Act.''.
(b) Conforming Amendments to Error Rate.--
(1) Section 1903(u)(1)(D) of the Social Security Act (42
U.S.C. 1396b(u)(1)(D)) is amended by adding at the end the
following new clause:
``(vi) In determining the amount of erroneous excess payments,
there shall not be included any erroneous payments made that are
attributable to an error in an eligibility determination under subtitle
C of title II of division A of the Affordable Health Care for America
Act.''.
(2) Section 2105(c)(11) of such Act (42 U.S.C.
1397ee(c)(11)) is amended by adding at the end the following
new sentence: ``Clause (vi) of section 1903(u)(1)(D) shall
apply with respect to the application of such requirements
under this title and title XIX.''.
SEC. 1703. CHIP AND MEDICAID MAINTENANCE OF ELIGIBILITY.
(a) CHIP Maintenance of Eligibility.--Section 1902 of the Social
Security Act (42 U.S.C. 1396a) is amended--
(1) in subsection (a), as amended by section
1631(b)(1)(D)--
(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 for maintenance of effort under the State
child health plan under title XXI in accordance with subsection
(gg).''; and
(2) by adding at the end the following new subsection:
``(gg) CHIP Maintenance of Eligibility Requirement.--
``(1) In general.--Subject to paragraph (2), as a condition
of its State plan under this title under subsection (a)(75) and
receipt of any Federal financial assistance under section
1903(a) for calendar quarters beginning after the date of the
enactment of this subsection and before CHIP MOE termination
date specified in paragraph (3), a State shall not have in
effect eligibility standards, methodologies, or procedures
under its State child health plan under title XXI (including
any waiver under such title or demonstration project under
section 1115) that are more restrictive than the eligibility
standards, methodologies, or procedures, respectively, under
such plan (or waiver) as in effect on June 16, 2009.
``(2) Limitation.--Paragraph (1) shall not be construed as
preventing a State from imposing a limitation described in
section 2110(b)(5)(C)(i)(II) for a fiscal year in order to
limit expenditures under its State child health plan under
title XXI to those for which Federal financial participation is
available under section 2105 for the fiscal year.
``(3) CHIP moe termination date.--In paragraph (1), the
`CHIP MOE termination date' for a State is the date that is the
last day of Y1 (as defined in section 100(c) of the Affordable
Health Care for America Act).
``(4) CHIP transition report.--Not later than December 31,
2011, the Secretary shall submit to Congress a report--
``(A) that compares the benefits packages offered
under an average State child health plan under title
XXI in 2011 and to the benefit standards initially
adopted under section 224(b) of the Affordable Health
Care for America Act and for affordability credits
under subtitle C of title II of division C of such Act;
and
``(B) that includes such recommendations as may be
necessary to ensure that--
``(i) such coverage is at least comparable
to the coverage provided to children under such
an average State child health plan; and
``(ii) there are procedures in effect for
the enrollment of CHIP enrollees (including
CHIP-eligible pregnant women) at the end of Y1
under this title, into a qualified health
benefits plan offered through the Health
Insurance Exchange, or into other acceptable
coverage (as defined for purposes of such Act)
without interruption of coverage or a written
plan of treatment.''.
(b) Medicaid Maintenance of Effort; Simplifying and Coordinating
Eligibility Rules Between Exchange and Medicaid.--
(1) In general.--Section 1903 of such Act (42 U.S.C. 1396b)
is amended by adding at the end the following new subsection:
``(aa) Maintenance of Medicaid Effort; Simplifying and Coordinating
Eligibility Rules Between Health Insurance Exchange and Medicaid.--
``(1) Maintenance of effort.--
``(A) In general.--Subject to subparagraph (B), a
State is not eligible for payment under subsection (a)
for a calendar quarter beginning after the date of the
enactment of this subsection if eligibility standards,
methodologies, or procedures under its plan under this
title (including any waiver under this title or
demonstration project under section 1115) that are more
restrictive than the eligibility standards,
methodologies, or procedures, respectively, under such
plan (or waiver) as in effect on June 16, 2009. The
Secretary shall extend such a waiver (including the
availability of Federal financial participation under
such waiver) for such period as may be required for a
State to meet the requirement of the previous sentence.
``(B) Exception for certain demonstration
projects.--In the case of a State demonstration project
under section 1115 in effect on June 16, 2009, that
permits individuals to be eligible solely to receive a
premium or cost-sharing subsidy for individual or group
health insurance coverage, effective for coverage
provided in Y1--
``(i) the Secretary shall permit the State
to amend such waiver to apply more restrictive
eligibility standards, methodologies, or
procedures with respect to such individuals
under such waiver; and
``(ii) the application of such more
restrictive, standards, methodologies, or
procedures under such an amendment shall not be
considered in violation of the requirement of
subparagraph (A).
``(2) Removal of asset test for certain eligibility
categories.--
``(A) In general.--A State is not eligible for
payment under subsection (a) for a calendar quarter
beginning on or after the first day of Y1 (as defined
in section 100(c) of the Affordable Health Care for
America Act), if the State applies any asset or
resource test in determining (or redetermining)
eligibility of any individual on or after such first
day under any of the following:
``(i) Subclause (I), (III), (IV), (VI),
(VIII), (IX), (X), or (XI) of section
1902(a)(10)(A)(i).
``(ii) Subclause (II), (IX), (XIV) or
(XVII) of section 1902(a)(10)(A)(ii).
``(iii) Section 1931(b).
``(B) Overriding contrary provisions; references.--
The provisions of this title that prevent the waiver of
an asset or resource test described in subparagraph (A)
are hereby waived.
``(C) References.--Any reference to a provision
described in a provision in subparagraph (A) shall be
deemed to be a reference to such provision as modified
through the application of subparagraphs (A) and
(B).''.
(2) Conforming amendments.--(A) Section 1902(a)(10)(A) of
such Act (42 U.S.C. 1396a(a)(10)(A)) is amended, in the matter
before clause (i), by inserting ``subject to section
1903(aa)(2),'' after ``(A)''.
(B) Section 1931(b)(1) of such Act (42 U.S.C. 1396u-
1(b)(1)) is amended by inserting ``and section 1903(aa)(2)''
after ``and (3)''.
(c) Standards for Benchmark Packages.--Section 1937(b) of such Act
(42 U.S.C. 1396u-7(b)) is amended--
(1) in each of paragraphs (1) and (2), by inserting
``subject to paragraph (5),'' after ``subsection (a)(1),''; and
(2) by adding at the end the following new paragraph:
``(5) Minimum standards.--Effective January 1, 2013, any
benchmark benefit package (or benchmark equivalent coverage
under paragraph (2)) must meet the minimum benefits and cost-
sharing standards of a basic plan offered through the Health
Insurance Exchange.''.
(d) Repeal of CHIP.--Section 2104(a) of the Social Security Act is
amended by inserting at the end the following:
``No funds shall be appropriated or authorized to be
appropriated under this section for fiscal year 2014 and
subsequent years.''.
SEC. 1704. REDUCTION IN MEDICAID DSH.
(a) Report.--
(1) In general.--Not later than January 1, 2016, the
Secretary of Health and Human Services (in this title referred
to as the ``Secretary'') shall submit to Congress a report
concerning the extent to which, based upon the impact of the
health care reforms carried out under division A in reducing
the number of uninsured individuals, there is a continued role
for Medicaid DSH. In preparing the report, the Secretary shall
consult with community-based health care networks serving low-
income beneficiaries.
(2) Matters to be included.--The report shall include the
following:
(A) Recommendations.--Recommendations regarding--
(i) the appropriate targeting of Medicaid
DSH within States; and
(ii) the distribution of Medicaid DSH among
the States, taking into account the ratio of
the amount of DSH funds allocated to a State to
the number of uninsured individuals in such
State.
(B) Specification of dsh health reform
methodology.--The DSH Health Reform methodology
described in paragraph (2) of subsection (b) for
purposes of implementing the requirements of such
subsection.
(3) Coordination with medicare dsh report.--The Secretary
shall coordinate the report under this subsection with the
report on Medicare DSH under section 1112.
(4) Medicaid dsh.--In this section, the term ``Medicaid
DSH'' means adjustments in payments under section 1923 of the
Social Security Act for inpatient hospital services furnished
by disproportionate share hospitals.
(b) Medicaid DSH Reductions.--
(1) Reductions.--
(A) In general.--For each of fiscal years 2017
through 2019 the Secretary shall effect the following
reductions:
(i) Reduction dsh allotments.--The
Secretary shall reduce DSH allotments to States
in the amount specified under the DSH health
reform methodology under paragraph (2) for the
State for the fiscal year.
(ii) Reductions in payments.--The Secretary
shall reduce payments to States under section
1903(a) of the Social Security Act (42 U.S.C.
1396b(a)) for each calendar quarter in the
fiscal year, in the manner specified in
subparagraph (C), in an amount equal to \1/4\
of the DSH allotment reduction under clause (i)
for the State for the fiscal year.
(B) Aggregate reductions.--The aggregate reductions
in DSH allotments for all States under subparagraph
(A)(i) shall be equal to--
(i) $1,500,000,000 for fiscal year 2017;
(ii) $2,500,000,000 for fiscal year 2018;
and
(iii) $6,000,000,000 for fiscal year 2019.
The Secretary shall distribute such aggregate reduction
among States in accordance with paragraph (2).
(C) Manner of payment reduction.--The amount of the
payment reduction under subparagraph (A)(ii) for a
State for a quarter shall be deemed an overpayment to
the State under title XIX of the Social Security Act to
be disallowed against the State's regular quarterly
draw for all Medicaid spending under section 1903(d)(2)
of such Act (42 U.S.C. 1396b(d)(2)). Such a
disallowance is not subject to a reconsideration under
1116(d) of such Act (42 U.S.C. 1316(d)).
(D) Definitions.--In this section:
(i) State.--The term ``State'' means the 50
States and the District of Columbia.
(ii) DSH allotment.--The term ``DSH
allotment'' means, with respect to a State for
a fiscal year, the allotment made under section
1923(f) of the Social Security Act (42 U.S.C.
1396r-4(f)) to the State for the fiscal year.
(2) DSH health reform methodology.--The Secretary shall
carry out paragraph (1) through use of a DSH Health Reform
methodology issued by the Secretary that imposes the largest
percentage reductions on the States that--
(A) have the lowest percentages of uninsured
individuals (determined on the basis of audited
hospital cost reports) during the most recent year for
which such data are available; or
(B) do not target their DSH payments on--
(i) hospitals with high volumes of Medicaid
inpatients (as defined in section 1923(b)(1)(A)
of the Social Security Act (42 U.S.C. 1396r-
4(b)(1)(A)); and
(ii) hospitals that have high levels of
uncompensated care (excluding bad debt).
(3) DSH allotment publications.--
(A) In general.--Not later than the publication
deadline specified in subparagraph (B), the Secretary
shall publish in the Federal Register a notice
specifying the DSH allotment to each State under
1923(f) of the Social Security Act for the respective
fiscal year specified in such subparagraph, consistent
with the application of the DSH Health Reform
methodology described in paragraph (2).
(B) Publication deadline.--The publication deadline
specified in this subparagraph is--
(i) January 1, 2016, with respect to DSH
allotments described in subparagraph (A) for
fiscal year 2017;
(ii) January 1, 2017, with respect to DSH
allotments described in subparagraph (A) for
fiscal year 2018; and
(iii) January 1, 2018, with respect to DSH
allotments described in subparagraph (A) for
fiscal year 2019.
(c) Conforming Amendments.--
(1) Section 1923(f) of the Social Security Act (42 U.S.C.
1396r-4(f)) is amended--
(A) by redesignating paragraph (7) as paragraph
(8); and
(B) by inserting after paragraph (6) the following
new paragraph:
``(7) Special rule for fiscal years 2017, 2018, and 2019.--
For each of fiscal years 2017, 2018, and 2018, the DSH
allotments under this subsection are subject to reduction under
section 1704(b) of the Affordable Health Care for America
Act.''.
(2) The second sentence of section 1923(b)(4) of such Act
(42 U.S.C. 1396r-4(b)(4)) is amended by inserting before the
period the following: ``or to affect the authority of the
Secretary to issue and implement the DSH Health Reform
methodology under section 1704(b)(2) of the Affordable Health
Care for America Act''.
(d) Disproportionate Share Hospitals (DSH) and Essential Access
Hospital (EAH) Non-discrimination.--
(1) In general.--Section 1923(d) of the Social Security Act
(42 U.S.C. 1396r-4) is amended by adding at the end the
following new paragraph:
``(4) No hospital may be defined or deemed as a
disproportionate share hospital, or as an essential access
hospital (for purposes of subsection (f)(6)(A)(iv)), under a
State plan under this title or subsection (b) of this section
(including any demonstration project under section 1115) unless
the hospital--
``(A) provides services to beneficiaries under this
title without discrimination on the ground of race,
color, national origin, creed, source of payment,
status as a beneficiary under this title, or any other
ground unrelated to such beneficiary's need for the
services or the availability of the needed services in
the hospital; and
``(B) makes arrangements for, and accepts,
reimbursement under this title for services provided to
eligible beneficiaries under this title.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to expenditures made on or after July 1, 2010.
SEC. 1705. EXPANDED OUTSTATIONING.
(a) In General.--Section 1902(a)(55) of the Social Security Act (42
U.S.C. 1396a(a)(55)) is amended by striking ``under subsection
(a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or
(a)(10)(A)(ii)(IX)'' and inserting ``(including receipt and processing
of applications of individuals for affordability credits under subtitle
C of title II of division A of the Affordable Health Care for America
Act pursuant to a Medicaid memorandum of understanding under section
1943(a)(1))''.
(b) Effective Date.--Except as provided in section 1790, the
amendment made by subsection (a) shall apply to services furnished on
or after July 1, 2010, without regard to whether or not final
regulations to carry out such amendment have been promulgated by such
date.
Subtitle B--Prevention
SEC. 1711. REQUIRED COVERAGE OF PREVENTIVE SERVICES.
(a) Coverage.--Section 1905 of the Social Security Act (42 U.S.C.
1396d), as amended by section 1701(a)(3)(B), is amended--
(1) in subsection (a)(4)--
(A) by striking ``and'' before ``(C)''; and
(B) by inserting before the semicolon at the end
the following: ``; and (D) preventive services
described in subsection (z)''; and
(2) by adding at the end the following new subsection:
``(z) Preventive Services.--The preventive services described in
this subsection are services not otherwise described in subsection (a)
or (r) that the Secretary determines are--
``(1)(A) recommended with a grade of A or B by the Task
Force for Clinical Preventive Services; or
``(B) vaccines recommended for use as appropriate by the
Director of the Centers for Disease Control and Prevention; and
``(2) appropriate for individuals entitled to medical
assistance under this title.''.
(b) Elimination of Cost-sharing.--
(1) Subsections (a)(2)(D) and (b)(2)(D) of section 1916 of
such Act (42 U.S.C. 1396o) are each amended by inserting
``preventive services described in section 1905(z),'' after
``emergency services (as defined by the Secretary),''.
(2) Section 1916A(a)(1) of such Act (42 U.S.C. 1396o-1
(a)(1)) is amended by inserting ``, preventive services
described in section 1905(z),'' after ``subsection (c)''.
(c) Conforming Amendment.--Section 1928 of such Act (42 U.S.C.
1396s) is amended--
(1) in subsection (c)(2)(B)(i), by striking ``the advisory
committee referred to in subsection (e)'' and inserting ``the
Director of the Centers for Disease Control and Prevention'';
(2) in subsection (e), by striking ``Advisory Committee''
and all that follows and inserting ``Director of the Centers
for Disease Control and Prevention.''; and
(3) by striking subsection (g).
(d) Effective Date.--Except as provided in section 1790, the
amendments made by this section shall apply to services furnished on or
after July 1, 2010, without regard to whether or not final regulations
to carry out such amendments have been promulgated by such date.
SEC. 1712. TOBACCO CESSATION.
(a) Dropping Tobacco Cessation Exclusion From Covered Outpatient
Drugs.--Section 1927(d)(2) of the Social Security Act (42 U.S.C. 1396r-
8(d)(2)) is amended--
(1) by striking subparagraph (E);
(2) in subparagraph (G), by inserting before the period at
the end the following: ``, except agents approved by the Food
and Drug Administration for purposes of promoting, and when
used to promote, tobacco cessation''; and
(3) by redesignating subparagraphs (F) through (K) as
subparagraphs (E) through (J), respectively.
(b) Effective Date.--The amendments made by this section shall
apply to drugs and services furnished on or after January 1, 2010.
SEC. 1713. OPTIONAL COVERAGE OF NURSE HOME VISITATION SERVICES.
(a) In General.--Section 1905 of the Social Security Act (42 U.S.C.
1396d), as amended by sections 1701(a)(3)(B) and 1711(a), 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) nurse home visitation services (as defined in
subsection (aa)); and''; and
(2) by adding at the end the following new subsection:
``(aa) The term `nurse home visitation services' means home visits
by trained nurses to families with a first-time pregnant woman, or a
child (under 2 years of age), who is eligible for medical assistance
under this title, but only, to the extent determined by the Secretary
based upon evidence, that such services are effective in one or more of
the following:
``(1) Improving maternal or child health and pregnancy
outcomes or increasing birth intervals between pregnancies.
``(2) Reducing the incidence of child abuse, neglect, and
injury, improving family stability (including reduction in the
incidence of intimate partner violence), or reducing maternal
and child involvement in the criminal justice system.
``(3) Increasing economic self-sufficiency, employment
advancement, school-readiness, and educational achievement, or
reducing dependence on public assistance.''.
(b) Effective Date.--The amendments made by this section shall
apply to services furnished on or after January 1, 2010.
(c) Construction.--Nothing in the amendments made by this section
shall be construed as affecting the ability of a State under title XIX
or XXI of the Social Security Act to provide nurse home visitation
services as part of another class of items and services falling within
the definition of medical assistance or child health assistance under
the respective title, or as an administrative expenditure for which
payment is made under section 1903(a) or 2105(a) of such Act,
respectively, on or after the date of the enactment of this Act.
SEC. 1714. 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)) is amended--
(A) in subclause (XVIII), by striking ``or'' at the
end;
(B) in subclause (XIX), by adding ``or'' at the
end; and
(C) by adding at the end the following new
subclause:
``(XX) who are described in
subsection (hh) (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 1703, is amended by adding at the
end the following new subsection:
``(hh)(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 demonstration project 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 such
Act (42 U.S.C. 1396a(a)(10)) is amended in the matter following
subparagraph (G)--
(A) by striking ``and (XIV)'' and inserting
``(XIV)''; and
(B) by inserting ``, and (XV) the medical
assistance made available to an individual described in
subsection (hh) 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'' after
``cervical cancer''.
(4) Conforming amendments.--Section 1905(a) of such Act (42
U.S.C. 1396d(a)), as amended by section 1731(c), is amended in
the matter preceding paragraph (1)--
(A) in clause (xiii), by striking ``or'' at the
end;
(B) in clause (xiv), by adding ``or'' at the end;
and
(C) by inserting after clause (xiv) the following:
``(xv) individuals described in section 1902(hh),''.
(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(hh) (relating to individuals who
meet certain income eligibility standard) during a presumptive
eligibility period. In the case of an individual described in section
1902(hh), 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(hh); 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;
``(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)) is amended 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''.
(B) Section 1903(u)(1)(D)(v) of such Act (42 U.S.C.
1396b(u)(1)(D)(v)) is amended--
(i) by striking ``or for'' and inserting
``for''; and
(ii) by inserting before the period the
following: ``, or for medical assistance
provided to an individual described in
subsection (a) of section 1920C 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 1703(c)(2), is amended by adding at the
end the following:
``(6) 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.
Subtitle C--Access
SEC. 1721. PAYMENTS TO PRIMARY CARE PRACTITIONERS.
(a) In General.--
(1) Fee-for-service payments.--Section 1902 of the Social
Security Act (42 U.S.C. 1396b)as amended by sections 1703(a),
1714(a), 1731(a), and 1746, is amended--
(A) in subsection (a)(13)--
(i) by striking ``and'' at the end of
subparagraph (A);
(ii) by adding ``and'' at the end of
subparagraph (B); and
(iii) by adding at the end the following
new subparagraph:
``(C) payment for primary care services (as defined
in subsection (kk)(1)) furnished by physicians (or for
services furnished by other health care professionals
that would be primary care services under such section
if furnished by a physician) at a rate not less than 80
percent of the payment rate that would be applicable if
the adjustment described in subsection (kk)(2) were to
apply to such services and physicians or professionals
(as the case may be) under part B of title XVIII for
services furnished in 2010, 90 percent of such adjusted
payment rate for services and physicians (or
professionals) furnished in 2011, or 100 percent of
such adjusted payment rate for services and physicians
(or professionals) furnished in 2012 and each
subsequent year;''; and
(B) by adding at the end the following new
subsection:
``(kk) Increased Payment for Primary Care Services.--For purposes
of subsection (a)(13)(C):
``(1) Primary care services defined.--The term `primary
care services' means evaluation and management services,
without regard to the specialty of the physician furnishing the
services, that are procedure codes (for services covered under
title XVIII) for services in the category designated Evaluation
and Management in the Health Care Common Procedure Coding
System (established by the Secretary under section 1848(c)(5)
as of December 31, 2009, and as subsequently modified by the
Secretary).
``(2) Adjustment.--The adjustment described in this
paragraph is the substitution of 1.25 percent for the update
otherwise provided under section 1848(d)(4) for each year
beginning with 2010.''.
(2) Under medicaid managed care plans.--Section 1932(f) of
such Act (42 U.S.C. 1396u-2(f)) is amended--
(A) in the heading, by adding at the end the
following: ``; Adequacy of Payment for Primary Care
Services''; and
(B) by inserting before the period at the end the
following: ``and, in the case of primary care services
described in section 1902(a)(13)(C), consistent with
the minimum payment rates specified in such section
(regardless of the manner in which such payments are
made, including in the form of capitation or partial
capitation)''.
(b) Increase in Payment Using Increased FMAP.--Section 1905(y) of
the Social Security Act, as added by section 1701(a)(3)(B) and as
amended by section 1701(c)(2), is amended by adding at the end the
following:
``(3)(A) The portion of the amounts expended for medical
assistance for services described in section 1902(a)(13)(C)
furnished on or after January 1, 2010, that is attributable to
the amount by which the minimum payment rate required under
such section (or, by application, section 1932(f)) exceeds the
payment rate applicable to such services under the State plan
as of June 16, 2009.
``(B) Subparagraph (A) shall not be construed as preventing
the payment of Federal financial participation based on the
Federal medical assistance percentage for amounts in excess of
those specified under such subparagraph.''.
(c) Effective Date.--The amendments made by this section shall
apply to services furnished on or after January 1, 2010.
SEC. 1722. MEDICAL HOME PILOT PROGRAM.
(a) In General.--The Secretary of Health and Human Services shall
establish under this section a medical home pilot program under which a
State may apply to the Secretary for approval of a medical home pilot
project described in subsection (b) (in this section referred to as a
``pilot project'') for the application of the medical home concept
under title XIX of the Social Security Act. The pilot program shall
operate for a period of up to 5 years.
(b) Pilot Project Described.--
(1) In general.--A pilot project is a project that applies
one or more of the medical home models described in section
1866F(a)(3) of the Social Security Act (as inserted by section
1302(a)) or such other model as the Secretary may approve, to
individuals (including medically fragile children and high-risk
pregnant women) who are eligible for medical assistance under
title XIX of the Social Security Act. The Secretary shall
provide for appropriate coordination of the pilot program under
this section with the medical home pilot program under section
1866F of such Act.
(2) Limitation.--A pilot project shall be for a duration of
not more than 5 years.
(3) Consideration for certain technologies.--In considering
applications for pilots projects under this section, the
Secretary may approve a project which tests the effectiveness
of applications and devices, such as wireless patient
management technologies, that are approved by the Food and Drug
Administration and enable providers and practitioners to
communicate directly with their patients in managing chronic
illness.
(c) Additional Incentives.--In the case of a pilot project, the
Secretary may--
(1) waive the requirements of section 1902(a)(1) of the
Social Security Act (relating to statewideness) and section
1902(a)(10)(B) of such Act (relating to comparability); and
(2) increase to up to 90 percent (for the first 2 years of
the pilot program) or 75 percent (for the next 3 years) the
matching percentage for administrative expenditures (such as
those for community care workers).
(d) Medically Fragile Children.--In the case of a model involving
medically fragile children, the model shall ensure that the patient-
centered medical home services received by each child, in addition to
fulfilling the requirements under 1866F(b)(1) of the Social Security
Act, provide for continuous involvement and education of the parent or
caregiver and for assistance to the child in obtaining necessary
transitional care if a child's enrollment ceases for any reason.
(e) Evaluation; Report.--
(1) Evaluation.--The Secretary, using the criteria
described in section 1866F(e)(1) of the Social Security Act (as
inserted by section 1123), shall conduct an evaluation of the
pilot program under this section.
(2) Report.--Not later than 60 days after the date of
completion of the evaluation under paragraph (1), the Secretary
shall submit to Congress and make available to the public a
report on the findings of the evaluation under such paragraph.
(f) Funding.--The additional Federal financial participation
resulting from the implementation of the pilot program under this
section may not exceed in the aggregate $1,235,000,000 over the 5-year
period of the program.
SEC. 1723. TRANSLATION OR INTERPRETATION SERVICES.
(a) In General.--Section 1903(a)(2)(E) of the Social Security Act
(42 U.S.C. 1396b(a)(2)), as added by section 201(b)(2)(A) of the
Children's Health Insurance Program Reauthorization Act of 2009 (Public
Law 111-3), is amended by inserting ``and other individuals'' after
``children of families''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to payment for translation or interpretation services furnished
on or after January 1, 2010.
SEC. 1724. OPTIONAL COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES.
(a) In General.--Section 1905 of the Social Security Act (42 U.S.C.
1396d), as amended by section 1713(a), is amended--
(1) in subsection (a)--
(A) by redesignating paragraph (29) as paragraph
(30);
(B) in paragraph (28), by striking at the end
``and''; and
(C) by inserting after paragraph (28) the following
new paragraph:
``(29) 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)), including by a licensed birth attendant
(as defined in subparagraph (C)) at such center.
``(B) The term `freestanding birth center' means a health
facility--
``(i) that is not a hospital; and
``(ii) where childbirth is planned to occur away from the
pregnant woman's residence.
``(C) The term `licensed birth attendant' means an individual who
is licensed 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 licensed birth attendant.''.
(b) Effective Date.--The amendments made by this section shall
apply to items and services furnished on or after the date of the
enactment of this Act.
SEC. 1725. INCLUSION OF PUBLIC HEALTH CLINICS UNDER THE VACCINES FOR
CHILDREN PROGRAM.
Section 1928(b)(2)(A)(iii)(I) of the Social Security Act (42 U.S.C.
1396s(b)(2)(A)(iii)(I)) is amended--
(1) by striking ``or a rural health clinic'' and inserting
``, a rural health clinic''; and
(2) by inserting ``or a public health clinic,'' after
```1905(l)(1)),''.
SEC. 1726. REQUIRING COVERAGE OF SERVICES OF PODIATRISTS.
(a) In General.--Section 1905(a)(5)(A) of the Social Security Act
(42 U.S.C. 1396d(a)(5)(A)) is amended by striking ``section
1861(r)(1)'' and inserting ``paragraphs (1) and (3) of section
1861(r)''.
(b) Effective Date.--Except as provided in section 1790, the
amendment made by subsection (a) shall apply to services furnished on
or after January 1, 2010.
SEC. 1726A. REQUIRING COVERAGE OF SERVICES OF OPTOMETRISTS.
(a) In General.--Section 1905(a)(5) of the Social Security Act (42
U.S.C. 1396d(a)(5)) is amended--
(1) by striking ``and'' before ``(B)''; and
(2) by inserting before the semicolon at the end the
following: ``, and (C) medical and other health services (as
defined in section 1861(s)) as authorized by State law,
furnished by an optometrist (described in section 1861(r)(4))
to the extent such services may be performed under State law''.
(b) Effective Date.--Except as provided in section 1790, the
amendments made by subsection (a) shall take effect 90 days after the
date of the enactment of this Act and shall apply to services furnished
or other actions required on or after such date.
SEC. 1727. THERAPEUTIC FOSTER CARE.
(a) Rule of Construction.--Nothing in this title shall prevent or
limit a State from covering therapeutic foster care for eligible
children in out-of-home placements under section 1905(a) of the Social
Security Act (42 U.S.C. 1396d(a)).
(b) Therapeutic Foster Care Defined.--For purposes of this section,
the term ``therapeutic foster care'' means a foster care program that
provides--
(1) to the child--
(A) structured daily activities that develop,
improve, monitor, and reinforce age-appropriate social,
communications, and behavioral skills;
(B) crisis intervention and crisis support
services;
(C) medication monitoring;
(D) counseling; and
(E) case management services; and
(2) specialized training for the foster parent and
consultation with the foster parent on the management of
children with mental illnesses and related health and
developmental conditions.
SEC. 1728. ASSURING ADEQUATE PAYMENT LEVELS FOR SERVICES.
(a) In General.--Title XIX of the Social Security Act is amended by
inserting after section 1925 the following new section:
``assuring adequate payment levels for services
``Sec. 1926. (a) In General.--A State plan under this title shall
not be considered to meet the requirement of section 1902(a)(30)(A) for
a year (beginning with 2011) unless, by not later than April 1 before
the beginning of such year, the State submits to the Secretary an
amendment to the plan that specifies the payment rates to be used for
such services under the plan in such year and includes in such
submission such additional data as will assist the Secretary in
evaluating the State's compliance with such requirement, including data
relating to how rates established for payments to medicaid managed care
organizations under sections 1903(m) and 1932 take into account such
payment rates.
``(b) Secretarial Review.--The Secretary, by not later than 90 days
after the date of submission of a plan amendment under subsection (a),
shall--
``(1) review each such amendment for compliance with the
requirement of section 1902(a)(30)(A); and
``(2) approve or disapprove each such amendment.
If the Secretary disapproves such an amendment, the State shall
immediately submit a revised amendment that meets such requirement.''.
(b) Effective Date.--The amendment made by subsection (a) shall
take effect on the date of the enactment of this Act.
SEC. 1729. PRESERVING MEDICAID COVERAGE FOR YOUTHS UPON RELEASE FROM
PUBLIC INSTITUTIONS.
Section 1902(a) of the Social Security Act (42 U.S.C. 1396a), as
amended by section 1631(b) and 1703(a), is amended--
(1) by striking ``and'' at the end of paragraph (74);
(2) by striking the period at the end of paragraph (75) and
inserting ``; and''; and
(3) by inserting after paragraph (75) the following new
paragraph:
``(76) provide that in the case of any youth who is 18
years of age or younger, was enrolled for medical assistance
under the State plan immediately before becoming an inmate of a
public institution, is 18 years of age or younger upon release
from such institution, and is eligible for such medical
assistance under the State plan at the time of release from
such institution--
``(A) during the period such youth is incarcerated
in a public institution, the State shall not terminate
eligibility for medical assistance under the State plan
for such youth;
``(B) during the period such youth is incarcerated
in a public institution, the State shall establish a
process that ensures--
``(i) that the State does not claim federal
financial participation for services that are
provided to such youth and that are excluded
under subsection 1905(a)(28)(A); and
``(ii) that the youth receives medical
assistance for which federal participation is
available under this title;
``(C) on or before the date such youth is released
from such institution, the State shall ensure that such
youth is enrolled for medical assistance under this
title, unless and until there is a determination that
the individual is no longer eligible to be so enrolled;
and
``(D) the State shall ensure that enrollment under
subparagraph (C) will be completed before such date so
that the youth can access medical assistance under this
title immediately upon leaving the institution.''
SEC. 1730. QUALITY MEASURES FOR MATERNITY AND ADULT HEALTH SERVICES
UNDER MEDICAID AND CHIP.
Title XI of the Social Security Act (42 U.S.C. 1301 et seq.) is
amended by inserting after section 1139A the following new section:
``SEC. 1139B. QUALITY MEASURES FOR MATERNITY AND ADULT HEALTH SERVICES
UNDER MEDICAID AND CHIP.
``(a) Maternity Care Quality Measures Under Medicaid and CHIP.--
``(1) Development of measures.--No later than January 1,
2011, the Secretary shall develop and publish for comment a
proposed set of measures that accurately describe the quality
of maternity care provided under State plans under titles XIX
and XXI. The Secretary shall publish a final recommended set of
such measures no later than July 1, 2011.
``(2) Standardized reporting format.--No later than January
1, 2012, the Secretary shall develop and publish a standardized
reporting format for maternity care quality measures for use by
State programs under titles XIX and XXI to collect data from
managed care entities and providers and practitioners that
participate in such programs and to report maternity care
quality measures to the Secretary.
``(b) Other Adult Health Quality Measures Under Medicaid.--
``(1) Development of measures.--The Secretary shall develop
quality measures that are not otherwise developed under section
1192 for services received under State plans under title XIX by
individuals who are 21 years of age or older but have not
attained age 65. The Secretary shall publish such quality
measures through notice and comment rulemaking.
``(2) Standardized reporting format.--The Secretary shall
develop and publish a standardized reporting format for quality
measures developed under paragraph (1) and section 1192 for
services furnished under State plans under title XIX to
individuals who are 21 years of age or older but have not
attained age 65 for use under such plans and State plans under
title XXI. The format shall enable State agencies administering
such plans to collect data from managed care entities and
providers and practitioners that participate in such plans and
to report quality measures to the Secretary.
``(c) Development Process.--With respect to the development of
quality measures under subsections (a) and (b)--
``(1) Use of qualified entities.--The Secretary may enter
into agreements with public, nonprofit, or academic
institutions with technical expertise in the area of health
quality measurement to assist in such development. The
Secretary may carry out these agreements by contract, grant, or
otherwise.
``(2) Multi-stakeholder pre-rulemaking input.--The
Secretary shall obtain the input of stakeholders with respect
to such quality measures using a process similar to that
described in section 1808(d).
``(3) Coordination.--The Secretary shall coordinate the
development of such measures under such subsections and with
the development of child health quality measures under section
1139A.
``(d) Annual Report to Congress.--No later than January 1, 2013,
and annually thereafter, the Secretary shall report to the Committee on
Energy and Commerce of the House of Representatives the Committee on
Finance of the Senate regarding--
``(1) the availability of reliable data relating to the
quality of maternity care furnished under State plans under
titles XIX and XXI;
``(2) the availability of reliable data relating to the
quality of services furnished under State plans under title XIX
to adults who are 21 years of age or older but have not
attained age 65; and
``(3) recommendations for improving the quality of such
care and services furnished under such State plans.
``(e) Rule of Construction.--Notwithstanding any other provision in
this section, no quality measure developed, published, or used as a
basis of measurement or reporting under this section may be used to
establish an irrebuttable presumption regarding either the medical
necessity of care or the maximum permissible coverage for any
individual who receives medical assistance under title XIX or child
health assistance under title XXI.
``(f) Appropriation.--For purposes of carrying out this section, in
addition to funds otherwise available, out of any funds in the Treasury
not otherwise appropriated, there are appropriated $40,000,000 for the
5-fiscal-year period beginning with fiscal year 2010. Funds
appropriated under this subsection shall remain available until
expended.''.
SEC. 1730A. ACCOUNTABLE CARE ORGANIZATION PILOT PROGRAM.
(a) In General.--The Secretary of Health and Human Services shall
establish under this section an accountable care program under which a
State may apply to the Secretary for approval of an accountable care
organization pilot program described in subsection (b) (in this section
referred to as a ``pilot program'') for the application of the
accountable care organization concept under title XIX of the Social
Security Act.
(b) Pilot Program Described.--
(1) In general.--The pilot program described in this
subsection is a program that applies one or more of the
accountable care organization models described in section 1866E
of the Social Security Act, as added by section 1301 of this
Act.
(2) Limitation.--The pilot program shall operate for a
period of not more than 5 years.
(c) Additional Incentives.--In the case of the pilot program under
this section, the Secretary may--
(1) waive the requirements of--
(A) section 1902(a)(1) of the Social Security Act
(relating to statewideness);
(B) section 1902(a)(10)(B) of such Act (relating to
comparability); and
(2) increase the matching percentage for administrative
expenditures up to--
(A) 90 percent (for the first 2 years of the pilot
program); and
(B) 75 percent (for the next 3 years).
(d) Evaluation; Report.--
(1) Evaluation.--The Secretary shall conduct an evaluation
of the pilot program under this section. In conducting such
evaluation, the Secretary shall use the criteria used under
subsection (g)(1) of section 1866E of the Social Security Act
(as inserted by section 1301 of this Act) to evaluate pilot
programs under such section.
(2) Report.--Not later than 60 days after the date of
completion of the evaluation under paragraph (1), the Secretary
shall submit to Congress and make available to the public a
report on the findings of the evaluation under such paragraph.
SEC. 1730B. FQHC COVERAGE.
Section 1905(l)(2)(B) of the Social Security Act (42 U.S.C.
1396d(l)(2)(B)) is amended--
(1) by striking ``or'' at the end of clause (iii);
(2) by striking the semicolon at the end of clause (iv) and
inserting ``, and''; and
(3) by inserting after clause (iv) the following new
clause:
``(v) is receiving a grant under section 399Z-1 of the
Public Health Service Act;''.
Subtitle D--Coverage
SEC. 1731. OPTIONAL MEDICAID COVERAGE OF LOW-INCOME HIV-INFECTED
INDIVIDUALS.
(a) In General.-- Section 1902 of the Social Security Act (42
U.S.C. 1396a), as amended by section 1714(a)(1), is amended--
(1) in subsection (a)(10)(A)(ii)--
(A) by striking ``or'' at the end of subclause
(XIX);
(B) by adding ``or'' at the end of subclause (XX);
and
(C) by adding at the end the following:
``(XXI) who are described in
subsection (ii) (relating to HIV-
infected individuals);''; and
(2) by adding at the end, as amended by sections 1703 and
1714(a), the following:
``(ii) Individuals described in this subsection are individuals not
described in subsection (a)(10)(A)(i)--
``(1) who have HIV infection;
``(2) whose income (as determined under the State plan
under this title with respect to disabled individuals) does not
exceed the maximum amount of income a disabled individual
described in subsection (a)(10)(A)(i) may have and obtain
medical assistance under the plan; and
``(3) whose resources (as determined under the State plan
under this title with respect to disabled individuals) do not
exceed the maximum amount of resources a disabled individual
described in subsection (a)(10)(A)(i) may have and obtain
medical assistance under the plan.''.
(b) Enhanced Match.--The first sentence of section 1905(b) of such
Act (42 U.S.C. 1396d(b)) is amended by striking ``section
1902(a)(10)(A)(ii)(XVIII)'' and inserting ``subclause (XVIII) or (XXI)
of section 1902(a)(10)(A)(ii)''.
(c) Conforming Amendments.--Section 1905(a) of such Act (42 U.S.C.
1396d(a)) is amended, in the matter preceding paragraph (1)--
(1) by striking ``or'' at the end of clause (xii);
(2) by adding ``or'' at the end of clause (xiii); and
(3) by inserting after clause (xiii) the following:
``(xiv) individuals described in section 1902(ii),''.
(d) Exemption From Funding Limitation for Territories.--Section
1108(g) of the Social Security Act (42 U.S.C. 1308(g)) is amended by
adding at the end the following:
``(5) Disregarding medical assistance for optional low-
income hiv-infected individuals.--The limitations under
subsection (f) and the previous provisions of this subsection
shall not apply to amounts expended for medical assistance for
individuals described in section 1902(ii) who are only eligible
for such assistance on the basis of section
1902(a)(10)(A)(ii)(XXI).''.
(e) Effective Date; Sunset.--The amendments made by this section
shall apply to expenditures for calendar quarters beginning on or after
the date of the enactment of this Act, and before January 1, 2013,
without regard to whether or not final regulations to carry out such
amendments have been promulgated by such date.
SEC. 1732. EXTENDING TRANSITIONAL MEDICAID ASSISTANCE (TMA).
Sections 1902(e)(1)(B) and 1925(f) of the Social Security Act (42
U.S.C. 1396a(e)(1)(B), 1396r-6(f)), as amended by section 5004(a)(1) of
the American Recovery and Reinvestment Act of 2009 (Public Law 111-5),
are each amended by striking ``December 31, 2010'' and inserting
``December 31, 2012''.
SEC. 1733. REQUIREMENT OF 12-MONTH CONTINUOUS COVERAGE UNDER CERTAIN
CHIP PROGRAMS.
(a) In General.--Section 2102(b) of the Social Security Act (42
U.S.C. 1397bb(b)) is amended by adding at the end the following new
paragraph:
``(6) Requirement for 12-month continuous eligibility.--In
the case of a State child health plan that provides child
health assistance under this title through a means other than
described in section 2101(a)(2), the plan shall provide for
implementation under this title of the 12-month continuous
eligibility option described in section 1902(e)(12) for
targeted low-income children whose family income is below 200
percent of the poverty line.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to determinations (and redeterminations) of eligibility made on
or after January 1, 2010.
SEC. 1734. PREVENTING THE APPLICATION UNDER CHIP OF COVERAGE WAITING
PERIODS FOR CERTAIN CHILDREN.
(a) In General.--Section 2102(b)(1) of the Social Security Act (42
U.S.C. 1397bb(b)(1)) is amended--
(1) in subparagraph (B)--
(A) in clause (iii), by striking ``and'' at the
end;
(B) in clause (iv), by striking the period at the
end and inserting ``; and''; and
(C) by adding at the end the following new clause:
``(v) may not apply a waiting period
(including a waiting period to carry out
paragraph (3)(C)) in the case of a child
described in subparagraph (C).''; and
(2) by adding at the end the following new subparagraph:
``(C) Description of children not subject to
waiting period.--For purposes of this paragraph, a
child described in this subparagraph is a child who, on
the date an application is submitted for such child for
child health assistance under this title, meets any of
the following requirements:
``(i) Infants and toddlers.--The child is
under two years of age.
``(ii) Loss of group health plan
coverage.--The child previously had private
health insurance coverage through a group
health plan or health insurance coverage
offered through an employer and lost such
coverage due to--
``(I) termination of an
individual's employment;
``(II) a reduction in hours that an
individual works for an employer;
``(III) elimination of an
individual's retiree health benefits;
or
``(IV) termination of an
individual's group health plan or
health insurance coverage offered
through an employer.
``(iii) Unaffordable private coverage.--
``(I) In general.--The family of
the child demonstrates that the cost of
health insurance coverage (including
the cost of premiums, co-payments,
deductibles, and other cost sharing)
for such family exceeds 10 percent of
the income of such family.
``(II) Determination of family
income.--For purposes of subclause (I),
family income shall be determined in
the same manner specified by the State
for purposes of determining a child's
eligibility for child health assistance
under this title.''.
(b) Effective Date.--The amendments made by this section shall take
effect as of the date that is 90 days after the date of the enactment
of this Act.
SEC. 1735. ADULT DAY HEALTH CARE SERVICES.
(a) In General.--The Secretary of Health and Human Services shall
not--
(1) withhold, suspend, disallow, or otherwise deny Federal
financial participation under section 1903(a) of the Social
Security Act (42 U.S.C. 1396b(a)) for the provision of adult
day health care services, day activity and health services, or
adult medical day care services, as defined under a State
Medicaid plan approved during or before 1994, during such
period if such services are provided consistent with such
definition and the requirements of such plan; or
(2) withdraw Federal approval of any such State plan or
part thereof regarding the provision of such services (by
regulation or otherwise).
(b) Effective Date.--Subsection (a) shall apply with respect to
services provided on or after October 1, 2008.
SEC. 1736. MEDICAID COVERAGE FOR CITIZENS OF FREELY ASSOCIATED STATES.
(a) In General.--Section 402(b)(2) of the Personal Responsibility
and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1612(b)(2))
is amended by adding at the end the following:
``(G) Medicaid exception for citizens of freely
associated states.--With respect to eligibility for
benefits for the designated Federal program defined in
paragraph (3)(C) (relating to the Medicaid program),
section 401(a) and paragraph (1) shall not apply to any
individual who lawfully resides in 1 of the 50 States
or the District of Columbia in accordance with the
Compacts of Free Association between the Government of
the United States and the Governments of the Federated
States of Micronesia, the Republic of the Marshall
Islands, and the Republic of Palau.''.
(b) Exception to 5-year Limited Eligibility.--Section 403(d) of
such Act (8 U.S.C. 1613(d)) is amended--
(1) in paragraph (1), by striking ``or'' at the end;
(2) in paragraph (2), by striking the period at the end and
inserting ``; or''; and
(3) by adding at the end the following:
``(3) an individual described in section 402(b)(2)(G), but
only with respect to the designated Federal program defined in
section 402(b)(3)(C).''.
(c) Definition of Qualified Alien.--Section 431(b) of such Act (8
U.S.C. 1641(b)) is amended--
(1) in paragraph (6), by striking ``; or'' at the end and
inserting a comma;
(2) in paragraph (7), by striking the period at the end and
inserting ``, or''; and
(3) by adding at the end the following:
``(8) an individual who lawfully resides in the United
States in accordance with a Compact of Free Association
referred to in section 402(b)(2)(G), but only with respect to
the designated Federal program defined in section 402(b)(3)(C)
(relating to the Medicaid program).''.
SEC. 1737. CONTINUING REQUIREMENT OF MEDICAID COVERAGE OF NONEMERGENCY
TRANSPORTATION TO MEDICALLY NECESSARY SERVICES.
(a) Requirement.--Section 1902(a)(10) of the Social Security Act
(42 U.S.C. 1396a(a)(10)) is amended--
(1) in subparagraph (A), in the matter preceding clause
(i), by striking ``and (21)'' and inserting ``, (21), and
(30)''; and
(2) in subparagraph (C)(iv), by striking ``and (17)'' and
inserting ``, (17), and (30)''.
(b) Description of Services.--Section 1905(a) of such Act (42
U.S.C. 1395d(a)), as amended by sections 1713(a)(1) and 1724(a)(1), is
amended--
(1) in paragraph (29), by striking ``and'' at the end;
(2) by redesignating paragraph (30) as paragraph (31) and
by striking the comma at the end and inserting a semicolon; and
(3) by inserting after paragraph (29) the following new
paragraph:
``(30) nonemergency transportation to medically necessary
services, consistent with the requirement of section 431.53 of
title 42, Code of Federal Regulations, as in effect as of June
1, 2008; and''.
(c) Effective Date.--The amendments made by this section shall take
effect on the date of the enactment of this Act and shall apply to
transportation on or after such date.
SEC. 1738. STATE OPTION TO DISREGARD CERTAIN INCOME IN PROVIDING
CONTINUED MEDICAID COVERAGE FOR CERTAIN INDIVIDUALS WITH
EXTREMELY HIGH PRESCRIPTION COSTS.
Section 1902(e) of the Social Security Act (42 U.S.C. 1396b(e)), as
amended by section 203(a) of the Children's Health Insurance Program
Reauthorization Act of 2009 (Public Law 111-3), is amended by adding at
the end the following new paragraph:
``(14)(A) At the option of the State, in the case of an individual
with extremely high prescription drug costs described in subparagraph
(B) who has been determined (without the application of this paragraph)
to be eligible for medical assistance under this title, the State may,
in redetermining the individual's eligibility for medical assistance
under this title, disregard any family income of the individual to the
extent such income is less than an amount that is specified by the
State and does not exceed the amount specified in subparagraph (C), or,
if greater, income equal to the cost of the orphan drugs described in
subparagraph (B)(iii).
``(B) An individual with extremely high prescription drug costs
described in this subparagraph for a 12-month period is an individual--
``(i) who is covered under health insurance or a health
benefits plan that has a maximum lifetime limit of not less
than $1,000,000 which includes all prescription drug coverage;
``(ii) who has exhausted all available prescription drug
coverage under the plan as of the beginning of such period;
``(iii) who incurs (or is reasonably expected to incur) on
an annual basis during the period costs for orphan drugs in
excess of the amount specified in subparagraph (C) for the
period; and
``(iv) whose annual family income (determined without
regard to this paragraph) as of the beginning of the period
does not exceed 75 percent of the amount incurred for such
drugs (as described in clause (iii)).
``(C) The amount specified in this subparagraph for a 12-month
period beginning in--
``(i) 2009 or 2010, is $200,000; or
``(ii) a subsequent year, is the amount specified in clause
(i) (or this subparagraph) for the previous year increased by
the annual rate of increase in the medical care component of
the consumer price index (U.S. city average) for the 12-month
period ending in August of the previous year.
Any amount computed under clause (ii) that is not a multiple of $1,000
shall be rounded to the nearest multiple of $1,000.
``(D) In applying this paragraph, amounts incurred for prescription
drugs for cosmetic purposes shall not be taken into account.
``(E) With respect to an individual described in subparagraph (A),
notwithstanding section 1916, the State plan--
``(i) shall provide for the application of cost-sharing
that is at least nominal as determined under section 1916; and
``(ii) may provide, consistent with section 1916A, for such
additional cost-sharing as does not exceed a maximum level of
cost-sharing that is specified by the Secretary and is adjusted
by the Secretary on an annual basis.
``(F) A State electing the option under this paragraph shall
provide for a determination on an individual's application for
continued medical assistance under this title within 30 days of the
date the application if filed with the State.
``(G) In this paragraph:
``(i) The term `orphan drugs' means prescription drugs
designated under section 526 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 360bb) as a drug for a rare disease or
condition.
``(ii) The term `health benefits plan' includes coverage
under a plan offered under a State high risk pool.''.
SEC. 1739. PROVISIONS RELATING TO COMMUNITY LIVING ASSISTANCE SERVICES
AND SUPPORTS (CLASS).
(a) Coordination With CLASS Provisions.--Section 1902(a) of the
Social Security Act (42 U.S.C. 1396a(a)), as amended by sections
1631(b), 1703(a), 1729, 1753, 1757(a), 1759(a), 1783(a), and 1907(b),
is amended--
(1) in paragraph (80), by striking ``and'' at the end;
(2) in paragraph (81), by striking the period and inserting
``; and''; and
(3) by inserting after paragraph (81) the following:
``(82) 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.''.
(b) Assurance of Adequate Infrastructure for the Provision of
Personal Care Attendant Workers.--Section 1902(a) of such Act (42
U.S.C. 1396a(a)), as amended by subsection (a), 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:
``(83) provide that, not later than 2 years after the date
of enactment of this paragraph, 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) 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
(2) in paragraph (3)--
(A) by striking ``2010'' and inserting ``2015'';
and
(B) by adding at the end the following: ``In
addition to the amount appropriated under the previous
sentence, there are authorized to be appropriated to
carry out this subsection, $7,000,000 for each of
fiscal years 2011, 2012, and 2013.''.
(d) Effective Date.--The amendments made by this section take
effect on January 1, 2011.
Subtitle E--Financing
SEC. 1741. PAYMENTS TO PHARMACISTS.
(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) 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 130 percent of the weighted
average (determined on the basis of manufacturer utilization)
of monthly average manufacturer prices. Nothing in the previous
sentence shall be construed as preventing the Secretary from
performing such calculation using a smoothing process in order
to reduce significant variations from month to month as a
result of rebates, discounts, and other pricing practices, such
as in the manner such a process is used by the Secretary in
determining the average sales price of a drug or biological
under section 1847A.''
(2) Definition of amp.--Section 1927(k)(1)(B) of such Act
(42 U.S.C. 1396r-8(k)(1)(B)) is amended--
(B) in the heading, by striking ``extended to
wholesalers'' and inserting ``and other payments''; and
(C) by striking ``regard to'' and all that follows
through the period and inserting the following:
``regard to--
``(i) customary prompt pay discounts
extended to wholesalers;
``(ii) bona fide service fees paid by
manufacturers;
``(iii) reimbursement by manufacturers for
recalled, damaged, expired, or otherwise
unsalable returned goods, including
reimbursement for the cost of the goods and any
reimbursement of costs associated with return
goods handling and processing, reverse
logistics, and drug destruction;
``(iv) sales directly to, or rebates,
discounts, or other price concessions provided
to, pharmacy benefit managers, managed care
organizations, health maintenance
organizations, insurers, mail order pharmacies
that are not open to all members of the public,
or long term care providers, provided that
these rebates, discounts, or price concessions
are not passed through to retail pharmacies;
``(v) sales directly to, or rebates,
discounts, or other price concessions provided
to, hospitals, clinics, and physicians, unless
the drug is an inhalation, infusion, or
injectable drug, or unless the Secretary
determines, as allowed for in Agency
administrative procedures, that it is necessary
to include such sales, rebates, discounts, and
price concessions in order to obtain an
accurate AMP for the drug. Such a determination
shall not be subject to judicial review; or
``(vi) rebates, discounts, and other price
concessions required to be provided under
agreements under subsections (f) and (g) of
section 1860D-2(f).''.
(3) Manufacturer reporting requirements.--Section
1927(b)(3)(A) of such Act (42 U.S.C. 1396r-8(b)(3)(A)) is
amended--
(A) in clause (ii), by striking ``and'' at the end;
(B) by striking the period at the end of clause
(iii) and inserting ``; and''; and
(C) by inserting after clause (iii) the following
new clause:
``(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.''.
(4) Authority to promulgate regulation.--The Secretary of
Health and Human Services may promulgate regulations to clarify
the requirements for upper payment limits and for the
determination of the average manufacturer price in an expedited
manner. Such regulations may become effective on an interim
final basis, pending opportunity for public comment.
(5) Pharmacy reimbursements through december 31, 2010.--The
specific upper limit under section 447.332 of title 42, Code of
Federal Regulations (as in effect on December 31, 2006)
applicable to payments made by a State for multiple source
drugs under a State Medicaid plan shall continue to apply
through December 31, 2010, for purposes of the availability of
Federal financial participation for such payments.
(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 clause (i), in the matter preceding
subclause (I), by inserting ``month of a'' after
``each''; and
(B) in the last sentence, by striking ``and
shall,'' and all that follows up to the period; and
(2) in subparagraph (D)(v), by inserting ``weighted''
before ``average manufacturer prices''.
SEC. 1742. PRESCRIPTION DRUG REBATES.
(a) 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.--In the case
of a drug that is a line extension of a single source
drug or an innovator multiple source drug that is an
oral solid dosage form, the rebate obligation with
respect to such drug under this section shall be the
amount computed under this section for such new drug
or, if greater, the product of--
``(i) the average manufacturer price of the
line extension of a single source drug or an
innovator multiple source drug that is an oral
solid dosage form;
``(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 line extension
product paid for under the State plan in the
rebate period (as reported by the State).
In this subparagraph, the term `line extension' means,
with respect to a drug, a new formulation of the drug,
such as an extended release formulation.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to drugs dispensed after December 31, 2009.
(b) Increase Minimum Rebate Percentage for Single Source Drugs.--
(1) In general.--Section 1927(c)(1)(B)(i) of the Social
Security Act (42 U.S.C. 1396r-8(c)(1)(B)(i)) is amended--
(A) in subclause (IV), by striking ``and'' at the
end;
(B) 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
(C) by adding at the end the following new
subclause:
``(VI) after December 31, 2009, is
23.1 percent.''.
(2) Recapture of total savings due to increase.--Section
1927(b)(1) of such Act 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 section
1742(b)(1) of the Affordable Health
Care for America Act, taking into
account the additional drugs included
under the amendments made by section
1743 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 1116(d).''.
SEC. 1743. EXTENSION OF PRESCRIPTION DRUG DISCOUNTS TO ENROLLEES OF
MEDICAID MANAGED CARE ORGANIZATIONS.
(a) In General.--Section 1903(m)(2)(A) of the Social Security Act
(42 U.S.C. 1396b(m)(2)(A)) is amended--
(1) in clause (xi), by striking ``and'' at the end;
(2) in clause (xii), by striking the period at the end and
inserting ``; and''; and
(3) by adding at the end the following:
``(xiii) such contract provides that the entity shall
report to the State such information, on such timely and
periodic basis as specified by the Secretary, as the State may
require in order to include, in the information submitted by
the State to a manufacturer under section 1927(b)(2)(A) and to
the Secretary under section 1927(b)(2)(C), information on
covered outpatient drugs dispensed to individuals eligible for
medical assistance who are enrolled with the entity and for
which the entity is responsible for coverage of such drugs
under this subsection.''.
(b) Conforming Amendments.--Section 1927 of such Act (42 U.S.C.
1396r-8) is amended----
(1) in the first sentence of subsection (b)(1)(A), by
inserting before the period at the end the following: ``,
including such drugs dispensed to individuals enrolled with a
medicaid managed care organization if the organization is
responsible for coverage of such drugs'';
(2) in subsection (b)(2), by adding at the end the
following new subparagraph:
``(C) Reporting on mmco drugs.--On a quarterly
basis, each State shall report to the Secretary the
total amount of rebates in dollars received from
pharmacy manufacturers for drugs provided to
individuals enrolled with Medicaid managed care
organizations that contract under section 1903(m) and
such other information as the Secretary may require to
carry out paragraph (1)(C) with respect to such
rebates.''; and
(3) in subsection (j)--
(A) in the heading by striking ``Exemption'' and
inserting ``Special Rules''; and
(B) in paragraph (1), by striking ``are not subject
to the requirements of this section'' and inserting
``are subject to the requirements of this section
unless such drugs are subject to discounts under
section 340B of the Public Health Service Act''.
(c) Effective Date.--The amendments made by this section take
effect on January 1, 2010, and shall apply to drugs dispensed on or
after such date, without regard to whether or not final regulations to
carry out such amendments have been promulgated by such date.
SEC. 1744. PAYMENTS FOR GRADUATE MEDICAL EDUCATION.
(a) In General.--Section 1905 of the Social Security Act (42 U.S.C.
1396d), as amended by sections 1701(a)(3)(B), 1711(a), and 1713(a), is
amended by adding at the end the following new subsection:
``(bb) Payment for Graduate Medical Education.--
``(1) In general.--The term `medical assistance' includes
payment for costs of graduate medical education consistent with
this subsection, whether provided in or outside of a hospital.
``(2) Submission of information.--For purposes of paragraph
(1) and section 1902(a)(13)(A)(v), payment for such costs is
not consistent with this subsection unless--
``(A) the State submits to the Secretary, in a
timely manner and on an annual basis specified by the
Secretary, information on total payments for graduate
medical education and how such payments are being used
for graduate medical education, including--
``(i) the institutions and programs
eligible for receiving the funding;
``(ii) the manner in which such payments
are calculated;
``(iii) the types and fields of education
being supported;
``(iv) the workforce or other goals to
which the funding is being applied;
``(v) State progress in meeting such goals;
and
``(vi) such other information as the
Secretary determines will assist in carrying
out paragraphs (3) and (4); and
``(B) such expenditures are made consistent with
such goals and requirements as are established under
paragraph (4).
``(3) Review of information.--The Secretary shall make the
information submitted under paragraph (2) available to the
Advisory Committee on Health Workforce Evaluation and
Assessment (established under section 2261 of the Public Health
Service Act). The Secretary and the Advisory Committee shall
independently review the information submitted under paragraph
(2), taking into account State and local workforce needs.
``(4) Specification of goals and requirements.--The
Secretary shall specify by rule, initially published by not
later than December 31, 2011--
``(A) program goals for the use of funds described
in paragraph (1), taking into account recommendations
of the such Advisory Committee and the goals for
approved medical residency training programs described
in section 1886(h)(1)(B); and
``(B) requirements for use of such funds consistent
with such goals.
Such rule may be effective on an interim basis pending revision
after an opportunity for public comment.''.
(b) Conforming Amendment.--Section 1902(a)(13)(A) of such Act (42
U.S.C. 1396a(a)(13)(A)), as amended by section 1721(a)(1)(A), is
amended--
(1) by striking ``and'' at the end of clause (iii);
(2) by striking the semicolon in clause (iv) and inserting
``, and''; and
(3) by adding at the end the following new clause:
``(v) in the case of hospitals and at the
option of a State, such rates may include, to
the extent consistent with section 1905(bb),
payment for graduate medical education; and''.
(c) Effective Date.--The amendments made by this section shall take
effect on the date of the enactment of this Act. Nothing in this
section shall be construed as affecting payments made before such date
under a State plan under title XIX of the Social Security Act for
graduate medical education.
SEC. 1745. NURSING FACILITY SUPPLEMENTAL PAYMENT PROGRAM.
(a) Total Amount Available for Payments.--
(1) In general.--Out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the Secretary
of Health and Human Services (in this section referred to as
the ``Secretary'') to carry out this section $6,000,000,000, of
which the following amounts shall be available for obligation
in the following years:
(A) $1,500,000,000 shall be available beginning in
2010.
(B) $1,500,000,000 shall be available beginning in
2011.
(C) $1,500,000,000 shall be available beginning in
2012.
(D) $1,500,000,000 shall be available beginning in
2013.
(2) Availability.--Funds appropriated under paragraph (1)
shall remain available until all eligible dually-certified
facilities (as defined in subsection (b)(3)) have been
reimbursed for underpayments under this section during cost
reporting periods ending during calendar years 2010 through
2013.
(3) Limitation of authority.--The Secretary may not may
payments under this section that exceed the funds appropriated
under paragraph (1).
(4) Disposition of remaining funds into mif.--Any funds
appropriated under paragraph (1) which remain available after
the application of paragraph (2) shall be deposited into the
Medicaid Improvement Fund under section 1941 of the Social
Security Act.
(b) Use of Funds.--
(1) Authority to make payments.--From the amounts available
for obligation in a year under subsection (a), the Secretary,
acting through the Administrator of the Centers for Medicare &
Medicaid Services, shall pay the amount determined under
paragraph (2) directly to an eligible dually-certified facility
for the purpose of providing funding to reimburse such facility
for furnishing quality care to Medicaid-eligible individuals.
(2) Determination of payment amounts.--
(A) In general.--Subject to subparagraphs (B) and
(C), the payment amount determined under this paragraph
for a year for an eligible dually-certified facility
shall be an amount determined by the Secretary as
reported on the facility's latest available Medicare
cost report.
(B) Limitation on payment amount.--In no case shall
the payment amount for an eligible dually-certified
facility for a year under subparagraph (A) be more than
the payment deficit described in paragraph (3)(D) for
such facility as reported on the facility's latest
available Medicare cost report.
(C) Pro-rata reduction.--If the amount available
for obligation under subsection (a) for a year (as
reduced by allowable administrative costs under this
section) is insufficient to ensure that each eligible
dually-certified facility receives the amount of
payment calculated under subparagraph (A), the
Secretary shall reduce that amount of payment with
respect to each such facility in a pro-rata manner to
ensure that the entire amount available for such
payments for the year be paid.
(D) No required match.--The Secretary may not
require that a State provide matching funds for any
payment made under this subsection.
(3) Eligible dually-certified facility defined.--For
purposes of this section, the term ``eligible dually-certified
facility'' means, for a cost reporting period ending during a
year (beginning no earlier than 2010) that is covered by the
latest available Medicare cost report, a nursing facility that
meets all of the following requirements:
(A) The facility is participating as a nursing
facility under title XIX of the Social Security Act and
as a skilled nursing facility under title XVIII of such
Act during the entire year.
(B) The base Medicaid payment rate (excluding any
supplemental payments) to the facility is not less than
the base Medicaid payment rate (excluding any
supplemental payments) to such facility as of June 16,
2009.
(C) As reported on the facility's latest Medicare
cost report--
(i) the Medicaid share of patient days for
such facility is not less than 60 percent of
the combined Medicare and Medicaid share of
resident days for such facility; and
(ii) the combined Medicare and Medicaid
share of resident days for such facility, as
reported on the facility's latest available
Medicare cost report, is not less than 75
percent of the total resident days for such
facility.
(D) The facility has received Medicaid
reimbursement (including any supplemental payments) for
the provision of covered services to Medicaid eligible
individuals, as reported on the facility's latest
available Medicare cost report, that is significantly
less (as determined by the Secretary) than the
allowable costs (as determined by the Secretary)
incurred by the facility in providing such services.
(E) The facility is not in the highest quartile of
costs costs per day, as determined by the Secretary and
as adjusted for case mix, wages, and type of facility.
(F) The facility provides quality care, as
determined by the Secretary, to--
(i) Medicaid eligible individuals; and
(ii) individuals who are entitled to items
and services under part A of title XVIII of the
Social Security Act.
(G) In the most recent standard survey available,
the facility was not cited for any immediate jeopardy
deficiencies as defined by the Secretary.
(H) In the most recent standard survey available,
the facility maintains an appropriate staffing level to
attain or maintain the highest practicable well-being
of each resident as defined by the Secretary
(I) The facility complies with all the
requirements, as determined by the Secretary, contained
in sections 1411 through 1416 and the amendments made
by such sections.
(J) The facility was not listed as a Centers for
Medicare & Medicaid Services Special Focus Facility
(SFF) nor as a SFF on a State-based list.
(4) Frequency of payment.--Payment of an amount under this
subsection to an eligible dually-certified facility shall be
made for a year in a lump sum or in such periodic payments in
such frequency as the Secretary determines appropriate.
(5) Direct payments.--Such payment--
(A) shall be made directly by the Secretary to an
eligible dually-certified facility or a contractor
designated by such facility; and
(B) shall not be made through a State.
(c) Administration.--
(1) Annual applications; deadlines.--The Secretary shall
establish a process, including deadlines, under which
facilities may apply on an annual basis to qualify as eligible
dually-certified facilities for payment under subsection (b).
(2) Contracting authority.--The Secretary may enter into
one or more contracts with entities for the purpose of
implementation of this section.
(3) Limitation.--The Secretary may not spend more than 0.75
percent of the amount made available under subsection (a) in
any year on the costs of administering the program of payments
under this section for the year.
(4) Implementation.--Notwithstanding any other provision of
law, the Secretary may implement, by program instruction or
otherwise, the provisions of this section.
(5) Limitations on review.--There shall be no
administrative or judicial review of--
(A) the determination of the eligibility of a
facility for payments under subsection (b); or
(B) the determination of the amount of any payment
made to a facility under such subsection.
(d) Annual Reports.--The Secretary shall submit an annual report to
the committees with jurisdiction in the Congress on payments made under
subsection (b). Each such report shall include information on--
(1) the facilities receiving such payments;
(2) the amount of such payments to such facilities; and
(3) the basis for selecting such facilities and the amount
of such payments.
(e) Reference to Report.--For report by the Medicaid and CHIP
Payment and Access Commission on the adequacy of payments to nursing
facilities under the Medicaid program, see section 1900(b)(2)(B) of the
Social Security Act, as amended by section 1784.
(f) Definitions.--For purposes of this section:
(1) Dually-certified facility.--The term ``dually-certified
facility'' means a facility that is participating as a nursing
facility under title XIX of the Social Security Act and as a
skilled nursing facility under title XVIII of such Act.
(2) Medicaid eligible individual.--The term ``Medicaid
eligible individual'' means an individual who is eligible for
medical assistance, with respect to nursing facility services
(as defined in section 1905(f) of the Social Security Act),
under title XIX of the such Act.
(3) State.--The term ``State'' means the 50 States and the
District of Columbia.
SEC. 1746. REPORT ON MEDICAID PAYMENTS.
Section 1902 of the Social Security Act (42 U.S.C. 1396), as
amended by sections 1703(a), 1714(a), and 1731(a), is amended by adding
at the end the following new subsection:
``(jj) Report on Medicaid Payments.--Each year, on or before a date
determined by the Secretary, a State participating in the Medicaid
program under this title shall submit to the Administrator of the
Centers for Medicare & Medicaid Services--
``(1) information on the determination of rates of payment
to providers for covered services under the State plan,
including--
``(A) the final rates;
``(B) the methodologies used to determine such
rates; and
``(C) justifications for the rates; and
``(2) an explanation of the process used by the State to
allow providers, beneficiaries and their representatives, and
other concerned State residents a reasonable opportunity to
review and comment on such rates, methodologies, and
justifications before the State made such rates final.''.
SEC. 1747. REVIEWS OF MEDICAID.
(a) GAO Study on FMAP.--.
(1) Study.--The Comptroller General of the United States
shall conduct a study regarding federal payments made to the
State Medicaid programs under title XIX of the Social Security
Act for the purposes of making recommendations to Congress.
(2) Report.--Not later than February 15, 2011, the
Comptroller General shall submit to the appropriate committees
of Congress a report on the study conducted under paragraph (1)
and the effect on the federal government, States, providers,
and beneficiaries of--
(A) removing the 50 percent floor, or 83 percent
ceiling, or both, in the Federal medical assistance
percentage under section 1905(b)(1) of the Social
Security Act; and
(B) revising the current formula for such Federal
medical assistance percentage to better reflect State
fiscal capacity and State effort to pay for health and
long-term care services and to better adjust for
national or regional economic downturns.
(b) GAO Study on Medicaid Administrative Costs..--
(1) Study.--The Comptroller General of the United States
shall conduct a study of the administration of the Medicaid
program by the Department of Health and Human Services, State
Medicaid agencies, and local government agencies. The report
shall address the following issues:
(A) The extent to which federal funds for each
administrative function, such as survey and
certification and claims processing, are being used
effectively and efficiently.
(B) The administrative functions on which federal
Medicaid funds are expended and the amounts of such
expenditures (whether spent directly or by contract).
(2) Report.--Not later than February 15, 2011, the
Comptroller General shall submit to the appropriate committees
of Congress a report on the study conducted under paragraph
(1).
SEC. 1748. EXTENSION OF DELAY IN MANAGED CARE ORGANIZATION PROVIDER TAX
ELIMINATION.
Effective as if included in the enactment of section 6051 of the
Deficit Reduction Act of 2005 (Public Law 109-171), subsection
(b)(2)(A) of such section is amended by striking ``October 1, 2009''
and inserting ``October 1, 2010''.
SEC. 1749. EXTENSION OF ARRA INCREASE IN FMAP.
Section 5001 of the American Recovery and Reinvestment Act of 2009
(Public Law 111-5) is amended--
(1) in subsection (a)(3), by striking ``first calendar
quarter'' and inserting ``first 3 calendar quarters'';
(2) in subsection (b)(2), by inserting before the period at
the end the following: ``and such paragraph shall not apply to
calendar quarters beginning on or after October 1, 2010'';
(3) in subsection (c)(4)(C)(ii), by striking ``December
2009'' and ``January 2010'' and inserting ``June 2010'' and
``July 2010'', respectively;
(4) in subsection (d), by inserting ``ending before October
1, 2010'' after ``entire fiscal years'' and after ``with
respect to fiscal years'';
(5) in subsection (g)(1), by striking ``September 30,
2011'' and inserting ``December 31, 2011''; and
(6) in subsection (h)(3), by striking ``December 31, 2010''
and inserting ``June 30, 2011''.
Subtitle F--Waste, Fraud, and Abuse
SEC. 1751. HEALTH CARE ACQUIRED CONDITIONS.
(a) Medicaid Non-payment for Certain Health Care-acquired
Conditions.--Section 1903(i) of the Social Security Act (42 U.S.C.
1396b(i)) is amended--
(1) by striking ``or'' at the end of paragraph (23);
(2) by striking the period at the end of paragraph (24) and
inserting ``; or''; and
(3) by inserting after paragraph (24) the following new
paragraph:
``(25) with respect to amounts expended for services
related to the presence of a condition that could be identified
by a secondary diagnostic code described in section
1886(d)(4)(D)(iv) and for any health care acquired condition
determined as a non-covered service under title XVIII.''.
(b) Application to CHIP.--Section 2107(e)(1)(G) of such Act (42
U.S.C. 1397gg(e)(1)(G)) is amended by striking ``and (17)'' and
inserting ``(17), and (25)''.
(c) Permission to Include Additional Health Care-acquired
Conditions.--Nothing in this section shall prevent a State from
including additional health care-acquired conditions for non-payment in
its Medicaid program under title XIX of the Social Security Act.
(d) Effective Date.--The amendments made by this section shall
apply to discharges occurring on or after January 1, 2010.
SEC. 1752. EVALUATIONS AND REPORTS REQUIRED UNDER MEDICAID INTEGRITY
PROGRAM.
Section 1936(c)(2)) of the Social Security Act (42 U.S.C. 1396u-
7(c)(2)) is amended--
(1) by redesignating subparagraph (D) as subparagraph (E);
and
(2) by inserting after subparagraph (C) the following new
subparagraph:
``(D) For the contract year beginning in 2011 and
each subsequent contract year, the entity provides
assurances to the satisfaction of the Secretary that
the entity will conduct periodic evaluations of the
effectiveness of the activities carried out by such
entity under the Program and will submit to the
Secretary an annual report on such activities.''.
SEC. 1753. REQUIRE PROVIDERS AND SUPPLIERS TO ADOPT PROGRAMS TO REDUCE
WASTE, FRAUD, AND ABUSE.
Section 1902(a) of such Act (42 U.S.C. 42 U.S.C. 1396a(a)), as
amended by sections 1631(b)(1), 1703, and 1729, is further amended--
(1) in paragraph (75), by striking at the end ``and'';
(2) in paragraph (76), by striking at the end the period
and inserting ``; and''; and
(3) by inserting after paragraph (76) the following new
paragraph:
``(77) provide that any provider or supplier (other than a
physician or nursing facility) providing services under such
plan shall, subject to paragraph (5) of section 1874(d),
establish a compliance program described in paragraph (1) of
such section in accordance with such section.''.
SEC. 1754. OVERPAYMENTS.
(a) In General.--Section 1903(d)(2)(C) of the Social Security Act
(42 U.S.C. 1396b(d)(2)(C)) is amended--
(1) in the first sentence, by inserting ``(or of 1 year in
the case of overpayments due to fraud)'' after ``60 days''; and
(2) in the second sentence, by striking ``the 60 days'' and
inserting ``such period''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply in the case of overpayments discovered on or after the date of
the enactment of this Act.
SEC. 1755. MANAGED CARE ORGANIZATIONS.
(a) Minimum Medical Loss Ratio.--
(1) Medicaid.--Section 1903(m)(2)(A) of the Social Security
Act (42 U.S.C. 1396b(m)(2)(A)), as amended by section
1743(a)(3), is amended--
(A) by striking ``and'' at the end of clause (xii);
(B) by striking the period at the end of clause
(xiii) and inserting ``; and''; and
(C) by adding at the end the following new clause:
``(xiv) such contract has a medical loss ratio, as
determined in accordance with a methodology specified by the
Secretary that is a percentage (not less than 85 percent) as
specified by the Secretary.''.
(2) CHIP.--Section 2107(e)(1) of such Act (42 U.S.C.
1397gg(e)(1)) is amended--
(A) by redesignating subparagraphs (H) through (L)
as subparagraphs (I) through (M); and
(B) by inserting after subparagraph (G) the
following new subparagraph:
``(H) Section 1903(m)(2)(A)(xiv) (relating to
application of minimum loss ratios), with respect to
comparable contracts under this title.''.
(3) Effective date.--The amendments made by this subsection
shall apply to contracts entered into or renewed on or after
July 1, 2010.
(b) Patient Encounter Data.--
(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. 1756. TERMINATION OF PROVIDER PARTICIPATION UNDER MEDICAID AND
CHIP IF TERMINATED UNDER MEDICARE OR OTHER STATE PLAN OR
CHILD HEALTH PLAN.
(a) State Plan Requirement.--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 are
permitted with respect to exclusion under sections 1128(b)(3)(C) and
1128(d)(3)(B)) participation of such individual or entity is terminated
under title XVIII, any other State plan under this title, or any child
health plan under title XXI,''.
(b) Application to CHIP.--Section 2107(e)(1)(A) of such Act (42
U.S.C. 1397gg(e)(1)(A)) is amended by inserting before the period at
the end the following: ``and section 1902(a)(39) (relating to exclusion
and termination of participation)''.
(c) Effective Date.--Except as provided in section 1790, the
amendments made by this section shall apply to services furnished on or
after January 1, 2011, without regard to whether or not final
regulations to carry out such amendments have been promulgated by such
date.
SEC. 1757. MEDICAID AND CHIP EXCLUSION FROM PARTICIPATION RELATING TO
CERTAIN OWNERSHIP, CONTROL, AND MANAGEMENT AFFILIATIONS.
(a) State Plan Requirement.--Section 1902(a) of the Social Security
Act (42 U.S.C. 1396a(a)), as amended by sections 1631(b)(1), 1703(a),
1729, and 1753, is further amended--
(1) in paragraph (76), by striking at the end ``and'';
(2) in paragraph (77), by striking at the end the period
and inserting ``; and''; and
(3) by inserting after paragraph (77) the following new
paragraph:
``(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 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.''.
(b) Child Health Plan Requirement.--Section 2107(e)(1)(A) of such
Act (42 U.S.C. 1397gg(e)(1)(A)), as amended by section 1756(b), is
amended by striking ``section 1902(a)(39)'' and inserting ``sections
1902(a)(39) and 1902(a)(78)''.
(c) Effective Date.--Except as provided in section 1790, the
amendments made by this section shall apply to services furnished on or
after January 1, 2011, without regard to whether or not final
regulations to carry out such amendments have been promulgated by such
date.
SEC. 1758. REQUIREMENT TO REPORT EXPANDED SET OF DATA ELEMENTS UNDER
MMIS TO DETECT FRAUD AND ABUSE.
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 July 1, 2010, data elements from the automated data system that
the Secretary determines to be necessary for detection of waste, fraud,
and abuse''.
SEC. 1759. 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 sections 1631(b), 1703(a),
1729, 1753, and 1757(a), is further amended--
(1) in paragraph (77); by striking at the end ``and'';
(2) in paragraph (78), by striking the period at the end
and inserting ``and''; and
(3) by inserting after paragraph (78) the following new
paragraph:
``(79) provide that any agent, clearinghouse, or other
alternate payee 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 under section
1866(j)(1)(D).''.
(b) Denial of Payment.--Section 1903(i) of such Act (42 U.S.C.
1396b(i)), as amended by section 1751, is amended--
(1) by striking ``or'' at the end of paragraph (24);
(2) by striking the period at the end of paragraph (25) and
inserting ``; or''; and
(3) by inserting after paragraph (25) the following new
paragraph:
``(26) with respect to any amount paid to a billing agent,
clearinghouse, or other alternate payee that is not registered
with the State and the Secretary as required under section
1902(a)(79).''.
(c) Effective Date.--Except as provided in section 1790, the
amendments made by this section shall apply to claims submitted on or
after January 1, 2012, without regard to whether or not final
regulations to carry out such amendments have been promulgated by such
date.
SEC. 1760. DENIAL OF PAYMENTS FOR LITIGATION-RELATED MISCONDUCT.
(a) In General.--Section 1903(i) of the Social Security Act (42
U.S.C. 1396b(i)), as amended by sections 1751(a) and 1759(b), is
amended--
(1) by striking ``or'' at the end of paragraph (25);
(2) by striking the period at the end of paragraph (26) and
inserting ``; or''; and
(3) by inserting after paragraph (26) the following new
paragraph:
``(27) with respect to any amount expended--
``(A) on litigation in which a court imposes
sanctions on the State, its employees, or its counsel
for litigation-related misconduct; or
``(B) to reimburse (or otherwise compensate) a
managed care entity for payment of legal expenses
associated with any action in which a court imposes
sanctions on the managed care entity for litigation-
related misconduct.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to amounts expended on or after January 1, 2010.
SEC. 1761. 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'' at the end;
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) Not later than September 1, 2010, the Secretary shall do the
following:
``(A) 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.
``(B) 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.
``(C) 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.
``(D) Submit a report to Congress that includes the notice
to States under subparagraph (C) and an analysis supporting the
identification of the methodologies made under subparagraphs
(A) and (B).''.
Subtitle G--Payments to the Territories
SEC. 1771. PAYMENT TO TERRITORIES.
(a) Increase in Cap.--Section 1108 of the Social Security Act (42
U.S.C. 1308) is amended--
(1) in subsection (f), by striking ``subsection (g)'' and
inserting ``subsections (g) and (h)'';
(2) in subsection (g)(1), by striking ``With respect to''
and inserting ``Subject to subsection (h), with respect to'';
and
(3) by adding at the end the following new subsection:
``(h) Additional Increase for Fiscal Years 2011 Through 2019.--
Subject to section 347(b)(1) of the Affordable Health Care for America
Act, with respect to fiscal years 2011 through 2019, the amounts
otherwise determined under subsections (f) and (g) for Puerto Rico, the
Virgin Islands, Guam, the Northern Mariana Islands and American Samoa
shall be increased by the following amounts:
``(1) For Puerto Rico, for fiscal year 2011, $727,600,000;
for fiscal year 2012, $775,000,000; for fiscal year 2013,
$850,000,000; for fiscal year 2014, $925,000,000; for fiscal
year 2015, $1,000,000,000; for fiscal year 2016,
$1,075,000,000; for fiscal year 2017, $1,150,000,000; for
fiscal year 2018, $1,225,000,000; and for fiscal year 2019,
$1,396,400,000.
``(2) For the Virgin Islands, for fiscal year 2011,
$34,000,000; for fiscal year 2012, $37,000,000; for fiscal year
2013, $40,000,000; for fiscal year 2014, $43,000,000; for
fiscal year 2015, $46,000,000; for fiscal year 2016,
$49,000,000; for fiscal year 2017, $52,000,000; for fiscal year
2018, $55,000,000; and for fiscal year 2019, $58,000,000.
``(3) For Guam, for fiscal year 2011, $34,000,000; for
fiscal year 2012, $37,000,000; for fiscal year 2013,
$40,000,000; for fiscal year 2014, $43,000,000; for fiscal year
2015, $46,000,000; for fiscal year 2016, $49,000,000; for
fiscal year 2017, $52,000,000; for fiscal year 2018,
$55,000,000; and for fiscal year 2019, $58,000,000.
``(4) For the Northern Mariana Islands, for fiscal year
2011, $13,500,000; fiscal year 2012, $14,500,000; for fiscal
year 2013, $15,500,000; for fiscal year 2014, $16,500,000; for
fiscal year 2015, $17,500,000; for fiscal year 2016,
$18,500,000; for fiscal year 2017, $19,500,000; for fiscal year
2018, $21,000,000; and for fiscal year 2019, $22,000,000.
``(5) For American Samoa, fiscal year 2011, $22,000,000;
fiscal year 2012, $23,687,500; for fiscal year 2013,
$24,687,500; for fiscal year 2014, $25,687,500; for fiscal year
2015, $26,687,500; for fiscal year 2016, $27,687,500; for
fiscal year 2017, $28,687,500; for fiscal year 2018,
$29,687,500; and for fiscal year 2019, $30,687,500.''.
(b) Report on Achieving Medicaid Parity Payments Beginning With
Fiscal Year 2020.--
(1) In general.--Not later than October 1, 2013, the
Secretary of Health and Human Services shall submit to Congress
a report that details a plan for the transition of each
territory to full parity in Medicaid with the 50 States and the
District of Columbia in fiscal year 2020 by modifying their
existing Medicaid programs and outlining actions the Secretary
and the governments of each territory must take by fiscal year
2020 to ensure parity in financing. Such report shall include
what the Federal medical assistance percentages would be for
each territory if the formula applicable to the 50 States were
applied. Such report shall also include any recommendations
that the Secretary may have as to whether the mandatory ceiling
amounts for each territory provided for in section 1108 of the
Social Security Act (42 U.S.C. 1308) should be increased any
time before fiscal year 2020 due to any factors that the
Secretary deems relevant.
(2) Per capita data.--As part of such report the Secretary
shall include information about per capita income data that
could be used to calculate Federal medical assistance
percentages under section 1905(b) of the Social Security Act,
under section 1108(a)(8)(B) of such Act, for each territory on
how such data differ from the per capita income data used to
promulgate Federal medical assistance percentages for the 50
States. The report under this subsection shall include
recommendations on how the Federal medical assistance
percentages can be calculated for the territories beginning in
fiscal year 2020 to ensure parity with the 50 States.
(3) Subsequent reports.--The Secretary shall submit
subsequent reports to Congress in 2015, 2017, and 2019
detailing the progress that the Secretary and the governments
of each territory have made in fulfilling the actions outlined
in the plan submitted under paragraph (1).
(c) Application of FMAP for Additional Funds.--Section 1905(b) of
such Act (42 U.S.C. 1396d(b)) is amended by adding at the end the
following sentence: ``Notwithstanding the first sentence of this
subsection and any other provision of law, for fiscal years 2011
through 2019, the Federal medical assistance percentage for Puerto
Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and
American Samoa shall be the highest Federal medical assistance
percentage applicable to any of the 50 States or the District of
Columbia for the fiscal year involved, taking into account the
application of subsections (a) and (b)(1) of section 5001 of division B
of the American Recovery and Reinvestment Act of 2009 (Public Law 111-
5) to such States and the District for calendar quarters during such
fiscal years for which such subsections apply.''.
(d) Waivers.--
(1) In general.--Section 1902(j) of the Social Security Act
(42 U.S.C. 1396a(j)) is amended--
(A) by striking ``American Samoa and the Northern
Mariana Islands'' and inserting ``Puerto Rico, the
Virgin Islands, Guam, the Northern Mariana Islands, and
American Samoa''; and
(B) by striking ``American Samoa or the Northern
Mariana Islands'' and inserting ``Puerto Rico, the
Virgin Islands, Guam, the Northern Mariana Islands, or
American Samoa''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply beginning with fiscal year 2011.
(e) Technical Assistance.--The Secretary shall provide nonmonetary
technical assistance to the governments of Puerto Rico, the Virgin
Islands, Guam, the Northern Mariana Islands, and American Samoa in
upgrading their existing computer systems in order to anticipate
meeting reporting requirements necessary to implement the plan
contained in the report under subsection (b)(1).
Subtitle H--Miscellaneous
SEC. 1781. TECHNICAL CORRECTIONS.
(a) Technical Correction to Section 1144 of the Social Security
Act.--The first sentence of section 1144(c)(3) of the Social Security
Act (42 U.S.C. 1320b--14(c)(3)) is amended--
(1) by striking ``transmittal''; and
(2) by inserting before the period the following: ``as
specified in section 1935(a)(4)''.
(b) Clarifying Amendment to Section 1935 of the Social Security
Act.--Section 1935(a)(4) of the Social Security Act (42 U.S.C. 1396u--
5(a)(4)), as amended by section 113(b) of Public Law 110-275, is
amended--
(1) by striking the second sentence;
(2) by redesignating the first sentence as a subparagraph
(A) with appropriate indentation and with the following
heading: ``In general.--'';
(3) by adding at the end the following subparagraphs:
``(B) Furnishing medical assistance with reasonable
promptness.--For the purpose of a State's obligation
under section 1902(a)(8) to furnish medical assistance
with reasonable promptness, the date of the electronic
transmission of low-income subsidy program data, as
described in section 1144(c), from the Commissioner of
Social Security to the State Medicaid Agency, shall
constitute the date of filing of such application for
benefits under the Medicare Savings Program.
``(C) Determining availability of medical
assistance.--For the purpose of determining when
medical assistance will be made available, the State
shall consider the date of the individual's application
for the low income subsidy program to constitute the
date of filing for benefits under the Medicare Savings
Program.''.
(c) Effective Date Relating to Medicaid Agency Consideration of
Low-income Subsidy Application and Data Transmittal.--The amendments
made by subsections (a) and (b) shall be effective as if included in
the enactment of section 113(b) of Public Law 110-275.
(d) Technical Correction to Section 605 of CHIPRA.--Section 605 of
the Children's Health Insurance Program Reauthorization Act of 2009
(Public Law 111-3) is amended by striking ``legal residents'' and
inserting ``lawfully residing in the United States''.
(e) Technical Correction to Section 1905 of the Social Security
Act.--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''.
(f) Clarifying Amendment to Section 1115 of the Social Security
Act.--Section 1115(a) of the Social Security Act (42 U.S.C. 1315(a)) is
amended by adding at the end the following: ``If an experimental,
pilot, or demonstration project that relates to title XIX is approved
pursuant to any part of this subsection, such project shall be treated
as part of the State plan, all medical assistance provided on behalf of
any individuals affected by such project shall be medical assistance
provided under the State plan, and all provisions of this Act not
explicitly waived in approving such project shall remain fully
applicable to all individuals receiving benefits under the State
plan.''.
SEC. 1782. EXTENSION OF QI PROGRAM.
(a) In General.--Section 1902(a)(10)(E)(iv) of the Social Security
Act (42 U.S.C. 1396b(a)(10)(E)(iv)) is amended--
(1) by striking ``sections 1933 and'' and by inserting
``section''; and
(2) by striking ``December 2010'' and inserting ``December
2012''.
(b) Elimination of Funding Limitation.--
(1) In general.--Section 1933 of such Act (42 U.S.C. 1396u-
3) is amended--
(A) in subsection (a), by striking ``who are
selected to receive such assistance under subsection
(b)'';
(B) by striking subsections (b), (c), (e), and (g);
(C) in subsection (d), by striking ``furnished in a
State'' and all that follows and inserting ``the
Federal medical assistance percentage shall be equal to
100 percent.''; and
(D) by redesignating subsections (d) and (f) as
subsections (b) and (c), respectively.
(2) Conforming amendment.--Section 1905(b) of such Act (42
U.S.C. 1396d(b)) is amended by striking ``1933(d)'' and
inserting ``1933(b)''.
(3) Effective date.--The amendments made by paragraph (1)
shall take effect on January 1, 2011.
SEC. 1783. ASSURING TRANSPARENCY OF INFORMATION.
(a) In General.--Section 1902(a) of the Social Security Act (42
U.S.C. 1396a(a)), as amended by sections 1631(b), 1703(a), 1729, 1753,
1757(a), 1759(a), and 1907(b), is amended--
(1) by striking ``and'' at the end of paragraph (79);
(2) by striking the period at the end of paragraph (80) and
inserting ``; and''; and
(3) by inserting after paragraph (80) the following new
paragraph:
``(81) provide that the State will establish and maintain
laws, in accordance with the requirements of section 1921A, to
require disclosure of information on hospital charges and
quality and to make such information available to the public
and the Secretary.''; and
(4) by inserting after section 1921 the following new
section:
``hospital price transparency
``Sec. 1921A. (a) In General.--The requirements referred to in
section 1902(a)(81) are that the laws of a State must--
``(1) require reporting to the State (or its agent) by each
hospital located therein, of information on,--
``(A) the charges for the most common inpatient and
outpatient hospital services;
``(B) the Medicare and Medicaid reimbursement
amount for such services; and
``(C) if the hospitals allows for or provides
reduced charges for individuals based on financial
need, the factors considered in making determinations
for reductions in charges, including any formula for
such determination and the contact information for the
specific department of a hospital that responds to such
inquiries;
``(2) provide for notice to individuals seeking or
requiring such services of the availability of information on
charges described in paragraph (1);
``(3) provide for timely access to such information,
including at least through an Internet website, by individuals
seeking or requiring such services; and
``(4) provide for timely access to information regarding
the quality of care at each hospital made publicly available in
accordance with section 501 of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (Public Law 108-
173), section 1139A, or section 1139B.
The Secretary shall consult with stakeholders (including those entities
in section 1808(d)(6) and the National Governors Association) through a
formal process to obtain guidance prior to issuing implementing
policies under this section.
``(b) Hospital Defined.--For purposes of this section, the term
`hospital' means an institution that meets the requirements of
paragraphs (1) and (7) of section 1861(e) and includes those to which
section 1820(c) applies.''.
(b) Effective Date; Administration.--
(1) In general.--Except as provided in paragraphs (2)(B)
and section 1790, the amendments made by subsection (a) shall
take effect on October 1, 2010.
(2) Existing programs.--
(A) In general.--The Secretary of Health and Human
Services shall establish a process by which a State
with an existing program may certify to the Secretary
that its program satisfies the requirements of section
1921A of the Social Security Act, as inserted by
subsection (a).
(B) 2-year period to become in compliance.--States
that, as of the date of the enactment of this Act,
administer hospital price transparency policies that do
not meet such requirements shall have 2 years from such
date to make necessary modifications to come into
compliance and shall not be regarded as failing to
comply with such requirements during such 2-year
period.
SEC. 1784. MEDICAID AND CHIP PAYMENT AND ACCESS COMMISSION.
(a) Report on Nursing Facility Payment Policies.--Section 1900(b)
of the Social Security Act (42 U.S.C. 1396(b)) is amended by adding at
the end the following new paragraph:
``(10) Reports on special topics on payment policies.--
``(A) Nursing facility payment policies.--Not later
than January 1, 2012, the Commission shall submit to
Congress a report on nursing facility payment policies
under Medicaid that includes--
``(i) information on the difference between
the amount paid by each State to nursing
facilities in such State under the Medicaid
program under this title and the cost to such
facilities of providing efficient quality care
to Medicaid eligible individuals;
``(ii) an evaluation of patient outcomes
and quality as a result of the supplemental
payments under section 1745(b) of the
Affordable Health Care for America Act; and
``(iii) whether adjustments should be made
under the Medicaid program to the rates that
States pay skilled nursing facilities to ensure
that such rates are sufficient to provide
efficient quality care to Medicaid eligible
individuals.''.
(b) Pediatric Subspecialist Payment Policies.--Section 1900(b)(10)
of the Social Security Act, as added by subsection (a) is amended by
adding at the end the following new subparagraph:
``(B) Pediatric subspecialist payment policies.--
Not later than January 1, 2011, the Commission shall
submit to Congress a report on payment policies for
pediatric subspecialist services under Medicaid that
includes--
``(i) a comprehensive review of each
State's Medicaid payment rates for inpatient
and outpatient pediatric speciality services;
``(ii) a comparison, on a State-by-State
basis, of the rates under clause (i) to
Medicare payments for similar services;
``(iii) information on any limitations in
patient access to pediatric speciality care,
such as delays in receiving care or wait times
for receiving care;
``(iv) an analysis of the extent to which
low Medicaid payment rates in any State
contributes to limits in access to pediatric
subspecialty services in such State; and
``(v) recommendations to ameliorate any
problems found with such payment rates or with
access to such services.''.
(c) Additional Amendments.--
(1) Commission status.--Section 1900(a) of the Social
Security Act is amended by inserting ``as an agency of
Congress'' after ``established''.
(2) Expansion of scope.--Section 1900(b)(1)(A) of the
Social Security Act is amended by striking ``children's
access'' and inserting ``access by low-income children and
other eligible individuals''.
(3) Change in report deadlines.--Subparagraphs (C) and (D)
of section 1900(b)(1) of such Act are amended by striking
``2010'' and inserting ``2011'' each place it appears.
(4) Report in health reform.--Section 1900(b)(2) of such
Act is amended--
(A) in subparagraph (A)(i), by striking
``skilled'';
(B) by striking subparagraph (B);
(C) by redesignating subparagraph (C) as
subparagraph (B); and
(D) by adding at the end the following new
subparagraph:
``(C) Implementation of health reform.--The
implementation of the provisions of the Affordable
Health Care for America Act that relate to Medicaid or
CHIP by the Secretary, the Health Choices Commissioner,
and the States, including the effect of such
implementation on the access to needed health care
items and services by low-income individuals and
families.''.
(5) Clarification of membership.--Section 1900(c)(2)(B) of
such Act is amended by striking ``consumers'' and inserting
``individuals''.
(6) Authorization of appropriations.--
(A) Current authorization.--Section 1900(f)(2) of
such Act is amended--
(i) in the heading, by inserting ``of
appropriations prior to 2010'' after
``Authorization''; and
(ii) by striking ``There are'' and
inserting ``Prior to January 1, 2010, there
are''
(B) Future authorization.--Section 1900(f) of such
Act is further amended by adding at the end the
following new paragraph: after the period the
following:
``(3) Authorization of appropriations for 2010.--Beginning
on January 1, 2010, there is authorized to be appropriated
$11,800,000 to carry out the provisions of this section. Such
funds shall remain available until expended.''.
SEC. 1785. OUTREACH AND ENROLLMENT OF MEDICAID AND CHIP ELIGIBLE
INDIVIDUALS.
(a) In General.--Not later than 12 months after date of enactment
of this Act, the Secretary of Health and Human Services shall issue
guidance regarding standards and best practices for conducting outreach
to inform eligible individuals about healthcare coverage under Medicaid
under title XIX of the Social Security Act or for child health
assistance under CHIP under title XXI of such Act, providing assistance
to such individuals for enrollment in applicable programs, and
establishing methods or procedures for eliminating application and
enrollment barriers. Such guidance shall include provisions to ensure
that outreach, enrollment assistance, and administrative simplification
efforts are targeted specifically to vulnerable populations such as
children, unaccompanied homeless youth, victims of abuse or trauma,
individuals with mental health or substance related disorders, and
individuals with HIV/AIDS. Guidance issued pursuant to this section
relating to methods to increase outreach and enrollment provided for
under titles XIX and XXI of the Social Security Act shall specifically
target such vulnerable and underserved populations and shall include,
but not be limited to, guidance on outstationing of eligibility
workers, express lane eligibility, residence requirements,
documentation of income and assets, presumptive eligibility, continuous
eligibility, and automatic renewal.
(b) Implementation.--In implementing the requirements under
subsection (a), the Secretary may use such authorities as are available
under law and may work with such entities as the Secretary deems
appropriate to facilitate effective implementation of such programs.
Not later than 2 years after the enactment of this Act and annually
thereafter, the Secretary shall review and report to Congress on
progress in implementing targeted outreach, application and enrollment
assistance, and administrative simplification methods for such
vulnerable and underserved populations as are specified in subsection
(a).
SEC. 1786. PROHIBITIONS ON FEDERAL MEDICAID AND CHIP PAYMENT FOR
UNDOCUMENTED ALIENS.
Nothing in this title shall change current prohibitions against
Federal Medicaid and CHIP payments under titles XIX and XXI of the
Social Security Act on behalf of individuals who are not lawfully
present in the United States.
SEC. 1787. DEMONSTRATION PROJECT FOR STABILIZATION OF EMERGENCY MEDICAL
CONDITIONS BY INSTITUTIONS FOR MENTAL DISEASES.
(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
reimbursement under the State Medicaid plan under title XIX of the
Social Security Act to an institution for mental diseases 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 an individual who--
(1) has attained age 21, but has not attained age 65;
(2) is eligible for medical assistance under such plan; and
(3) requires such medical assistance to stabilize an
emergency medical condition.
(b) In-stay Review.--The Secretary shall establish a mechanism for
in-stay review to determine whether or not the patient has 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
these benefits under the project 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) Application.--Upon approval of an application submitted
by a State described in paragraph (2), the State shall be an
eligible State for purposes of conducting a demonstration
project under this section.
(2) State described.--States shall be selected by the
Secretary in a manner so as to provide geographic diversity on
the basis of the application to conduct a demonstration project
under this section submitted by such States.
(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
2010.
(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) 3-year availability.--Funds appropriated under
paragraph (1) shall remain available for obligation through
December 31, 2012.
(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, 2012.
(4) Funds allocated to states.--The Secretary shall
allocate funds to eligible States based on their applications
and the availability of funds.
(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).
(f) Reports.--
(1) Annual progress reports.--The Secretary shall submit
annual reports to Congress on the progress of the demonstration
project conducted under this section.
(2) Final report and recommendation.--An evaluation shall
be conducted of the demonstration project's impact on the
functioning of the health and mental health service system and
on individuals enrolled in the Medicaid program. This
evaluation shall include collection of baseline data for one-
year prior to the initiation of the demonstration project as
well as collection of data from matched comparison states not
participating in the demonstration. The evaluation measures
shall include the following:
(A) A determination, by State, as to whether the
demonstration project resulted in increased access to
inpatient mental health services under the Medicaid
program and whether average length of stays were longer
(or shorter) for individuals admitted under the
demonstration project compared with individuals
otherwise admitted in comparison sites.
(B) An analysis, by State, regarding whether the
demonstration project produced a significant reduction
in emergency room visits for individuals eligible for
assistance under the Medicaid program or in the
duration of emergency room lengths of stay.
(C) An assessment of discharge planning by
participating hospitals that ensures access to further
(non-emergency) inpatient or residential care as well
as continuity of care for those discharged to
outpatient care.
(D) 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) under the plan as contrasted with
the comparison areas.
(E) Data on 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.
(F) A recommendation regarding whether the
demonstration project should be continued after
December 31, 2012, and expanded on a national basis.
(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 title 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 to 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.).
SEC. 1788. APPLICATION OF MEDICAID IMPROVEMENT FUND.
Section 1941(b)(1) of the Social Security Act (42 U.S.C. 1396w-
1(b)(1)) is amended by striking ``from the Fund'' and all that follows
and inserting ``from the Fund, only such amounts as may be appropriated
or otherwise made available by law.''.
SEC. 1789. TREATMENT OF CERTAIN MEDICAID BROKERS.
Section 1903(b)(4) of the Social Security Act (42 U.S.C.
1396b(b)(4)) is amended--
(1) in the matter before subparagraph (A), by inserting
after ``respect to the broker'' the following: ``(or, in the
case of subparagraph (A) and subparagraph (B)(i), if the
Inspector General of Department of Health and Human Services
finds that the broker has established and maintains procedures
to ensure the independence of its enrollment activities from
the interests of any managed care entity or provider)''; and
(2) in subparagraph (B)--
(A) by inserting ``(i)'' after ``either''; and
(B) by inserting ``(ii)'' after ``health care
provider or''.
SEC. 1790. RULE FOR CHANGES REQUIRING STATE LEGISLATION.
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 an additional
requirement imposed by an amendment made by this title, the State plan
shall not be regarded as failing to comply with the requirements of
such title XIX 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.
TITLE VIII--REVENUE-RELATED PROVISIONS
SEC. 1801. DISCLOSURES TO FACILITATE IDENTIFICATION OF INDIVIDUALS
LIKELY TO BE INELIGIBLE FOR THE LOW-INCOME ASSISTANCE
UNDER THE MEDICARE PRESCRIPTION DRUG PROGRAM TO ASSIST
SOCIAL SECURITY ADMINISTRATION'S OUTREACH TO ELIGIBLE
INDIVIDUALS.
(a) In General.--Paragraph (19) of section 6103(l) of the Internal
Revenue Code of 1986 is amended to read as follows:
``(19) Disclosures to facilitate identification of
individuals likely to be ineligible for low-income subsidies
under medicare prescription drug program to assist social
security administration's outreach to eligible individuals.--
``(A) In general.--Upon written request from the
Commissioner of Social Security, the following return
information (including such information disclosed to
the Social Security Administration under paragraph (1)
or (5)) shall be disclosed to officers and employees of
the Social Security Administration, with respect to any
taxpayer identified by the Commissioner of Social
Security--
``(i) return information for the applicable
year from returns with respect to wages (as
defined in section 3121(a) or 3401(a)) and
payments of retirement income (as described in
paragraph (1) of this subsection),
``(ii) unearned income information and
income information of the taxpayer from
partnerships, trusts, estates, and subchapter S
corporations for the applicable year,
``(iii) if the individual filed an income
tax return for the applicable year, the filing
status, number of dependents, income from
farming, and income from self-employment, on
such return,
``(iv) if the individual is a married
individual filing a separate return for the
applicable year, the social security number (if
reasonably available) of the spouse on such
return,
``(v) if the individual files a joint
return for the applicable year, the social
security number, unearned income information,
and income information from partnerships,
trusts, estates, and subchapter S corporations
of the individual's spouse on such return, and
``(vi) such other return information
relating to the individual (or the individual's
spouse in the case of a joint return) as is
prescribed by the Secretary by regulation as
might indicate that the individual is likely to
be ineligible for a low-income prescription
drug subsidy under section 1860D-14 of the
Social Security Act.
``(B) Applicable year.--For the purposes of this
paragraph, the term `applicable year' means the most
recent taxable year for which information is available
in the Internal Revenue Service's taxpayer information
records.
``(C) Restriction on individuals for whom
disclosure may be requested.--The Commissioner of
Social Security shall request information under this
paragraph only with respect to--
``(i) individuals the Social Security
Administration has identified, using all other
reasonably available information, as likely to
be eligible for a low-income prescription drug
subsidy under section 1860D-14 of the Social
Security Act and who have not applied for such
subsidy, and
``(ii) any individual the Social Security
Administration has identified as a spouse of an
individual described in clause (i).
``(D) Restriction on use of disclosed
information.--Return information disclosed under this
paragraph may be used only by officers and employees of
the Social Security Administration solely for purposes
of identifying individuals likely to be ineligible for
a low-income prescription drug subsidy under section
1860D-14 of the Social Security Act for use in outreach
efforts under section 1144 of the Social Security
Act.''.
(b) Safeguards.--Paragraph (4) of section 6103(p) of such Code is
amended--
(1) by striking ``(19),'' each place it appears, and
(2) by striking ``or (17)'' each place it appears and
inserting ``(17), or (19)''.
(c) Conforming Amendment.--Paragraph (3) of section 6103(a) of such
Code is amended by striking ``(19),''.
(d) Effective Date.--The amendments made by this section shall
apply to disclosures made after the date which is 12 months after the
date of the enactment of this Act.
SEC. 1802. COMPARATIVE EFFECTIVENESS RESEARCH TRUST FUND; FINANCING FOR
TRUST FUND.
(a) Establishment of Trust Fund.--
(1) In general.--Subchapter A of chapter 98 of the Internal
Revenue Code of 1986 (relating to trust fund code) is amended
by adding at the end the following new section:
``SEC. 9511. HEALTH CARE COMPARATIVE EFFECTIVENESS 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 `Health Care
Comparative Effectiveness Research Trust Fund' (hereinafter in this
section referred to as the `CERTF'), 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) In general.--There are hereby appropriated to the
Trust Fund the following:
``(A) For fiscal year 2010, $90,000,000.
``(B) For fiscal year 2011, $100,000,000.
``(C) For fiscal year 2012, $110,000,000.
``(D) For each fiscal year beginning with 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) subject to subsection (c)(2),
amounts determined by the Secretary of Health
and Human Services to be equivalent to the fair
share per capita amount computed under
subsection (c)(1) for the fiscal year
multiplied by the average number of individuals
entitled to benefits under part A, or enrolled
under part B, of title XVIII of the Social
Security Act during such fiscal year.
``(2) Administrative provisions.--
``(A) Transfers from other trust funds.--The
amounts appropriated by subparagraphs (A), (B), (C),
and (D)(ii) of paragraph (1) shall be transferred from
the Federal Hospital Insurance Trust Fund and from the
Federal Supplementary Medical Insurance Trust Fund
(established under section 1841 of such Act), and from
the Medicare Prescription Drug Account within such
Trust Fund, in proportion (as estimated by the
Secretary) to the total expenditures during such fiscal
year that are made under title XVIII of such Act from
the respective trust fund or account.
``(B) Appropriations not subject to fiscal year
limitation.--The amounts appropriated by paragraph (1)
shall not be subject to any fiscal year limitation.
``(C) Periodic transfers, estimates, and
adjustments.--Except as provided in subparagraph (A),
the provisions of section 9601 shall apply to the
amounts appropriated by paragraph (1).
``(c) Fair Share Per Capita Amount.--
``(1) Computation.--
``(A) In general.--Subject to subparagraph (B), the
fair share per capita amount under this paragraph for a
fiscal year (beginning with fiscal year 2013) is an
amount computed by the Secretary of Health and Human
Services for such fiscal year that, when applied under
this section and subchapter B of chapter 34 of the
Internal Revenue Code of 1986, will result in revenues
to the CERTF of $375,000,000 for the fiscal year.
``(B) Alternative computation.--
``(i) In general.--If the Secretary is
unable to compute the fair share per capita
amount under subparagraph (A) for a fiscal
year, the fair share per capita amount under
this paragraph for the fiscal year shall be the
default amount determined under clause (ii) for
the fiscal year.
``(ii) Default amount.--The default amount
under this clause for--
``(I) fiscal year 2013 is equal to
$2; or
``(II) a subsequent year is equal
to the default amount under this clause
for the preceding fiscal year increased
by the annual percentage increase in
the medical care component of the
consumer price index (United States
city average) for the 12-month period
ending with April of the preceding
fiscal year.
Any amount determined under subclause (II)
shall be rounded to the nearest penny.
``(2) Limitation on medicare funding.--In no case shall the
amount transferred under subsection (b)(4)(B) for any fiscal
year exceed $90,000,000.
``(d) Expenditures From Fund.--
``(1) In general.--Subject to paragraph (2), amounts in the
CERTF are available, without the need for further
appropriations and without fiscal year limitation, to the
Secretary of Health and Human Services to carry out section
1181 of the Social Security Act.
``(2) Allocation for commission.--The following amounts in
the CERTF shall be available, without the need for further
appropriations and without fiscal year limitation, to the
Commission to carry out the activities of the Comparative
Effectiveness Research Commission established under section
1181(b) of the Social Security Act:
``(A) For fiscal year 2010, $7,000,000.
``(B) For fiscal year 2011, $9,000,000.
``(C) For each fiscal year beginning with 2012, 2.6
percent of the total amount appropriated to the CERTF
under subsection (b) for the fiscal year.
``(e) Net Revenues.--For purposes of this section, the term `net
revenues' means the amount estimated by the Secretary 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.''.
(2) Clerical amendment.--The table of sections for such
subchapter A is amended by adding at the end thereof the
following new item:
``Sec. 9511. Health Care Comparative Effectiveness Research Trust
Fund.''.
(b) Financing for Fund From Fees on Insured and Self-Insured Health
Plans.--
(1) 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 a fee equal to the fair
share per capita amount determined under section 9511(c)(1) 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 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)--
``(i) such arrangement shall be treated as
a specified health insurance policy, and
``(ii) 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.
``SEC. 4376. SELF-INSURED HEALTH PLANS.
``(a) Imposition of Fee.--In the case of any applicable self-
insured health plan for each plan year, there is hereby imposed a fee
equal to the fair share per capita amount determined under section
9511(c)(1) 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 one or more employers for the benefit of
their employees or former employees,
``(B) by one 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).
``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--
``(i) members of the Armed Forces of the
United States, or
``(ii) 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.''.
(2) Clerical amendments.--
(A) 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''.
(B) 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''.
(3) Effective date.--The amendments made by this subsection
shall apply with respect to policies and plans for portions of
policy or plan years beginning on or after October 1, 2012.
TITLE IX--MISCELLANEOUS PROVISIONS
SEC. 1901. REPEAL OF TRIGGER PROVISION.
Subtitle A of title VIII of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (Public Law 108-173) is
repealed and the provisions of law amended by such subtitle are
restored as if such subtitle had never been enacted.
SEC. 1902. REPEAL OF COMPARATIVE COST ADJUSTMENT (CCA) PROGRAM.
Section 1860C-1 of the Social Security Act (42 U.S.C. 1395w-29), as
added by section 241(a) of the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 (Public Law 108-173), is repealed.
SEC. 1903. 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''.
SEC. 1904. GRANTS TO STATES FOR QUALITY HOME VISITATION PROGRAMS FOR
FAMILIES WITH YOUNG CHILDREN AND FAMILIES EXPECTING
CHILDREN.
Part B of title IV of the Social Security Act (42 U.S.C. 621-629i)
is amended by adding at the end the following:
``Subpart 3--Support for Quality Home Visitation Programs
``SEC. 440. HOME VISITATION PROGRAMS FOR FAMILIES WITH YOUNG CHILDREN
AND FAMILIES EXPECTING CHILDREN.
``(a) Purpose.--The purpose of this section is to improve the well-
being, health, and development of children by enabling the
establishment and expansion of high quality programs providing
voluntary home visitation for families with young children and families
expecting children.
``(b) Grant Application.--A State that desires to receive a grant
under this section shall submit to the Secretary for approval, at such
time and in such manner as the Secretary may require, an application
for the grant that includes the following:
``(1) Description of home visitation programs.--A
description of the high quality programs of home visitation for
families with young children and families expecting children
that will be supported by a grant made to the State under this
section, the outcomes the programs are intended to achieve, and
the evidence supporting the effectiveness of the programs.
``(2) Results of needs assessment.--The results of a
statewide needs assessment that describes--
``(A) the number, quality, and capacity of home
visitation programs for families with young children
and families expecting children in the State;
``(B) the number and types of families who are
receiving services under the programs;
``(C) the sources and amount of funding provided to
the programs;
``(D) the gaps in home visitation in the State,
including identification of communities that are in
high need of the services; and
``(E) training and technical assistance activities
designed to achieve or support the goals of the
programs.
``(3) Assurances.--Assurances from the State that--
``(A) in supporting home visitation programs using
funds provided under this section, the State shall
identify and prioritize serving communities that are in
high need of such services, especially communities with
a high proportion of low-income families or a high
incidence of child maltreatment;
``(B) the State will reserve 5 percent of the grant
funds for training and technical assistance to the home
visitation programs using such funds;
``(C) in supporting home visitation programs using
funds provided under this section, the State will
promote coordination and collaboration with other home
visitation programs (including programs funded under
title XIX) and with other child and family services,
health services, income supports, and other related
assistance;
``(D) home visitation programs supported using such
funds will, when appropriate, provide referrals to
other programs serving children and families; and
``(E) the State will comply with subsection (i),
and cooperate with any evaluation conducted under
subsection (j).
``(4) Other information.--Such other information as the
Secretary may require.
``(c) Allotments.--
``(1) Indian tribes.--From the amount reserved under
subsection (l)(2) for a fiscal year, the Secretary shall allot
to each Indian tribe that meets the requirement of subsection
(d), if applicable, for the fiscal year the amount that bears
the same ratio to the amount so reserved as the number of
children in the Indian tribe whose families have income that
does not exceed 200 percent of the poverty line bears to the
total number of children in such Indian tribes whose families
have income that does not exceed 200 percent of the poverty
line.
``(2) States and territories.--From the amount appropriated
under subsection (m) for a fiscal year that remains after
making the reservations required by subsection (l), the
Secretary shall allot to each State that is not an Indian tribe
and that meets the requirement of subsection (d), if
applicable, for the fiscal year the amount that bears the same
ratio to the remainder of the amount so appropriated as the
number of children in the State whose families have income that
does not exceed 200 percent of the poverty line bears to the
total number of children in such States whose families have
income that does not exceed 200 percent of the poverty line.
``(3) Reallotments.--The amount of any allotment to a State
under a paragraph of this subsection for any fiscal year that
the State certifies to the Secretary will not be expended by
the State pursuant to this section shall be available for
reallotment using the allotment methodology specified in that
paragraph. Any amount so reallotted to a State is deemed part
of the allotment of the State under this subsection.
``(d) Maintenance of Effort.--Beginning with fiscal year 2011, a
State meets the requirement of this subsection for a fiscal year if the
Secretary finds that the aggregate expenditures by the State from State
and local sources for programs of home visitation for families with
young children and families expecting children for the then preceding
fiscal year was not less than 100 percent of such aggregate
expenditures for the then 2nd preceding fiscal year.
``(e) Payment of Grant.--
``(1) In general.--The Secretary shall make a grant to each
State that meets the requirements of subsections (b) and (d),
if applicable, for a fiscal year for which funds are
appropriated under subsection (m), in an amount equal to the
reimbursable percentage of the eligible expenditures of the
State for the fiscal year, but not more than the amount
allotted to the State under subsection (c) for the fiscal year.
``(2) Reimbursable percentage defined.--In paragraph (1),
the term `reimbursable percentage' means, with respect to a
fiscal year--
``(A) 85 percent, in the case of fiscal year 2010;
``(B) 80 percent, in the case of fiscal year 2011;
or
``(C) 75 percent, in the case of fiscal year 2012
and any succeeding fiscal year.
``(f) Eligible Expenditures.--
``(1) In general.--In this section, the term `eligible
expenditures'--
``(A) means expenditures to provide voluntary home
visitation for as many families with young children
(under the age of school entry) and families expecting
children as practicable, through the implementation or
expansion of high quality home visitation programs
that--
``(i) adhere to clear evidence-based models
of home visitation that have demonstrated
positive effects on important program-
determined child and parenting outcomes, such
as reducing abuse and neglect and improving
child health and development;
``(ii) employ well-trained and competent
staff, maintain high quality supervision,
provide for ongoing training and professional
development, and show strong organizational
capacity to implement such a program;
``(iii) establish appropriate linkages and
referrals to other community resources and
supports;
``(iv) monitor fidelity of program
implementation to ensure that services are
delivered according to the specified model; and
``(v) provide parents with--
``(I) knowledge of age-appropriate
child development in cognitive,
language, social, emotional, and motor
domains (including knowledge of second
language acquisition, in the case of
English language learners);
``(II) knowledge of realistic
expectations of age-appropriate child
behaviors;
``(III) knowledge of health and
wellness issues for children and
parents;
``(IV) modeling, consulting, and
coaching on parenting practices;
``(V) skills to interact with their
child to enhance age-appropriate
development;
``(VI) skills to recognize and seek
help for issues related to health,
developmental delays, and social,
emotional, and behavioral skills; and
``(VII) activities designed to help
parents become full partners in the
education of their children;
``(B) includes expenditures for training, technical
assistance, and evaluations related to the programs;
and
``(C) does not include any expenditure with respect
to which a State has submitted a claim for payment
under any other provision of Federal law.
``(2) Priority funding for programs with strongest
evidence.--
``(A) In general.--The expenditures, described in
paragraph (1), of a State for a fiscal year that are
attributable to the cost of programs that do not adhere
to a model of home visitation with the strongest
evidence of effectiveness shall not be considered
eligible expenditures for the fiscal year to the extent
that the total of the expenditures exceeds the
applicable percentage for the fiscal year of the
allotment of the State under subsection (c) for the
fiscal year.
``(B) Applicable percentage defined.--In
subparagraph (A), the term `applicable percentage'
means, with respect to a fiscal year--
``(i) 60 percent for fiscal year 2010;
``(ii) 55 percent for fiscal year 2011;
``(iii) 50 percent for fiscal year 2012;
``(iv) 45 percent for fiscal year 2013; or
``(v) 40 percent for fiscal year 2014.
``(g) No Use of Other Federal Funds for State Match.--A State to
which a grant is made under this section may not expend any Federal
funds to meet the State share of the cost of an eligible expenditure
for which the State receives a payment under this section.
``(h) Waiver Authority.--
``(1) In general.--The Secretary may waive or modify the
application of any provision of this section, other than
subsection (b) or (f), to an Indian tribe if the failure to do
so would impose an undue burden on the Indian tribe.
``(2) Special rule.--An Indian tribe is deemed to meet the
requirement of subsection (d) for purposes of subsections (c)
and (e) if--
``(A) the Secretary waives the requirement; or
``(B) the Secretary modifies the requirement, and
the Indian tribe meets the modified requirement.
``(i) State Reports.--Each State to which a grant is made under
this section shall submit to the Secretary an annual report on the
progress made by the State in addressing the purposes of this section.
Each such report shall include a description of--
``(1) the services delivered by the programs that received
funds from the grant;
``(2) the characteristics of each such program, including
information on the service model used by the program and the
performance of the program;
``(3) the characteristics of the providers of services
through the program, including staff qualifications, work
experience, and demographic characteristics;
``(4) the characteristics of the recipients of services
provided through the program, including the number of the
recipients, the demographic characteristics of the recipients,
and family retention;
``(5) the annual cost of implementing the program,
including the cost per family served under the program;
``(6) the outcomes experienced by recipients of services
through the program;
``(7) the training and technical assistance provided to aid
implementation of the program, and how the training and
technical assistance contributed to the outcomes achieved
through the program;
``(8) the indicators and methods used to monitor whether
the program is being implemented as designed; and
``(9) other information as determined necessary by the
Secretary.
``(j) Evaluation.--
``(1) In general.--The Secretary shall, by grant or
contract, provide for the conduct of an independent evaluation
of the effectiveness of home visitation programs receiving
funds provided under this section, which shall examine the
following:
``(A) The effect of home visitation programs on
child and parent outcomes, including child
maltreatment, child health and development, school
readiness, and links to community services.
``(B) The effectiveness of home visitation programs
on different populations, including the extent to which
the ability of programs to improve outcomes varies
across programs and populations.
``(2) Reports to the congress.--
``(A) Interim report.--Within 3 years after the
date of the enactment of this section, the Secretary
shall submit to the Congress an interim report on the
evaluation conducted pursuant to paragraph (1).
``(B) Final report.--Within 5 years after the date
of the enactment of this section, the Secretary shall
submit to the Congress a final report on the evaluation
conducted pursuant to paragraph (1).
``(k) Annual Reports to the Congress.--The Secretary shall submit
annually to the Congress a report on the activities carried out using
funds made available under this section, which shall include a
description of the following:
``(1) The high need communities targeted by States for
programs carried out under this section.
``(2) The service delivery models used in the programs
receiving funds provided under this section.
``(3) The characteristics of the programs, including--
``(A) the qualifications and demographic
characteristics of program staff; and
``(B) recipient characteristics including the
number of families served, the demographic
characteristics of the families served, and family
retention and duration of services.
``(4) The outcomes reported by the programs.
``(5) The research-based instruction, materials, and
activities being used in the activities funded under the grant.
``(6) The training and technical activities, including on-
going professional development, provided to the programs.
``(7) The annual costs of implementing the programs,
including the cost per family served under the programs.
``(8) The indicators and methods used by States to monitor
whether the programs are being been implemented as designed.
``(l) Reservations of Funds.--From the amounts appropriated for a
fiscal year under subsection (m), the Secretary shall reserve--
``(1) an amount equal to 5 percent of the amounts to pay
the cost of the evaluation provided for in subsection (j), and
the provision to States of training and technical assistance,
including the dissemination of best practices in early
childhood home visitation; and
``(2) after making the reservation required by paragraph
(1), an amount equal to 3 percent of the amount so
appropriated, to pay for grants to Indian tribes under this
section.
``(m) Appropriations.--Out of any money in the Treasury of the
United States not otherwise appropriated, there is appropriated to the
Secretary to carry out this section--
``(1) $50,000,000 for fiscal year 2010;
``(2) $100,000,000 for fiscal year 2011;
``(3) $150,000,000 for fiscal year 2012;
``(4) $200,000,000 for fiscal year 2013; and
``(5) $250,000,000 for fiscal year 2014.
``(n) Indian Tribes Treated as States.--In this section, paragraphs
(4), (5), and (6) of section 431(a) shall apply.''.
SEC. 1905. IMPROVED COORDINATION AND PROTECTION FOR DUAL ELIGIBLES.
Title XI of the Social Security Act is amended by inserting after
section 1150 the following new section:
``improved coordination and protection for dual eligibles
``Sec. 1150A. (a) In General.--The Secretary shall provide,
through an identifiable office or program within the Centers for
Medicare & Medicaid Services, for a focused effort to provide for
improved coordination between Medicare and Medicaid and protection in
the case of dual eligibles (as defined in subsection (g)). The office
or program shall--
``(1) review Medicare and Medicaid policies related to
enrollment, benefits, service delivery, payment, and grievance
and appeals processes under parts A and B of title XVIII, under
the Medicare Advantage program under part C of such title, and
under title XIX;
``(2) identify areas of such policies where better
coordination and protection could improve care and costs; and
``(3) issue guidance to States regarding improving such
coordination and protection.
``(b) Elements.--The improved coordination and protection under
this section shall include efforts--
``(1) to simplify access of dual eligibles to benefits and
services under Medicare and Medicaid;
``(2) to improve care continuity for dual eligibles and
ensure safe and effective care transitions;
``(3) to harmonize regulatory conflicts between Medicare
and Medicaid rules with regard to dual eligibles; and
``(4) to improve total cost and quality performance under
Medicare and Medicaid for dual eligibles.
``(c) Responsibilities.--In carrying out this section, the
Secretary shall provide for the following:
``(1) An examination of Medicare and Medicaid payment
systems to develop strategies to foster more integrated and
higher quality care.
``(2) Development of methods to facilitate access to post-
acute and community-based services and to identify actions that
could lead to better coordination of community-based care.
``(3) A study of enrollment of dual eligibles in the
Medicare Savings Program (as defined in section 1144(c)(7)),
under Medicaid, and in the low-income subsidy program under
section 1860D-14 to identify methods to more efficiently and
effectively reach and enroll dual eligibles.
``(4) An assessment of communication strategies for dual
eligibles to determine whether additional informational
materials or outreach is needed, including an assessment of the
Medicare website, 1-800-MEDICARE, and the Medicare handbook.
``(5) Research and evaluation of areas where service
utilization, quality, and access to cost sharing protection
could be improved and an assessment of factors related to
enrollee satisfaction with services and care delivery.
``(6) Collection (and making available to the public) of
data and a database that describe the eligibility, benefit and
cost-sharing assistance available to dual eligibles by State.
``(7) Support for coordination of State and Federal
contracting and oversight for dual coordination programs
supportive of the goals described in subsection (b).
``(8) Support for State Medicaid agencies through the
provision of technical assistance for Medicare and Medicaid
coordination initiatives designed to improve acute and long-
term care for dual eligibles.
``(9) Monitoring total combined Medicare and Medicaid
program costs in serving dual eligibles and making
recommendations for optimizing total quality and cost
performance across both programs.
``(10) Coordination of activities relating to Medicare
Advantage plans under 1859(b)(6)(B)(ii) and Medicaid.
``(d) Reporting.--The Office or program shall work with relevant
State agencies and any appropriate quality measurement entities to
improve and coordinate reporting requirements for Medicare and
Medicaid. In addition, the Office or program shall seek to minimize
duplication in reporting requirements, where appropriate, and to
identify opportunities to combine assessment requirements, where
appropriate. The Office or program shall seek to identify quality
metrics and assessment requirements that facilitate comparisons of the
quality of care received by beneficiaries enrolled in or entitled to
benefits under fee-for-service Medicare, the Medicare Advantage
program, fee-for-service Medicaid, and Medicaid managed care, and
combinations thereof (including integrated Medicare-Medicaid programs
for dual eligibles).
``(e) Endorsement.--The Secretary shall seek endorsement by the
entity with a contract under section 1890(a) of quality measures and
benchmarks developed under this section.
``(f) Consultation With Stakeholders.--The Office or program shall
consult with relevant stakeholders, including dual eligible
beneficiaries representatives for dual eligible beneficiaries, health
plans, providers, and relevant State agencies, in the development of
policies related to integrated Medicare-Medicaid programs for dual
eligibles.
``(g) Periodic Reports.--Not later than 1 year after the date of
the enactment of this section and every 3 years thereafter the
Secretary shall submit to Congress a report on progress in activities
conducted under this section.
``(h) Definitions.--In this section:
``(1) Dual eligible.--The term `dual eligible' means an
individual who is dually eligible for benefits under title
XVIII, and medical assistance under title XIX, including such
individuals who are eligible for benefits under the Medicare
Savings Program (as defined in section 1144(c)(7)).
``(2) Medicare; medicaid.--The terms `Medicare' and
`Medicaid' mean the programs under titles XVIII and XIX,
respectively.''.
SEC. 1906. ASSESSMENT OF MEDICARE COST-INTENSIVE DISEASES AND
CONDITIONS.
(a) Initial Assessment.--
(1) In general.--The Secretary of Health and Human Services
shall conduct an assessment of the diseases and conditions that
are the most cost-intensive for the Medicare program and, to
the extent possible, assess the diseases and conditions that
could become cost-intensive for Medicare in the future. In
conducting the assessment, the Secretary shall include the
input of relevant research agencies, including the National
Institutes of Health, the Agency for Healthcare Research and
Quality, the Food and Drug Administration, and the Centers for
Medicare & Medicaid Services.
(2) Report.--Not later than January 1, 2011, the Secretary
shall transmit a report to the Committees on Energy and
Commerce, Ways and Means, and Appropriations of the House of
Representatives and the Committees on Health, Education, Labor
and Pensions, Finance, and Appropriations of the Senate on the
assessment conducted under paragraph (1). Such report shall--
(A) include the assessment of current and future
trends of cost-intensive diseases and conditions
described in such paragraph;
(B) address whether current research priorities are
appropriately addressing current and future cost-
intensive conditions so identified; and
(C) include recommendations concerning research in
the Department of Health and Human Services that should
be funded to improve the prevention, treatment, or cure
of such cost-intensive diseases and conditions.
(b) Updates of Assessment.--Not later than January 1, 2013, and
biennially thereafter, the Secretary shall--
(1) review and update the assessment and recommendations
described in subsection (a)(1); and
(2) submit a report described in subsection (a)(2) to the
Committees specified in subsection (a)(2) on such updated
assessment and recommendations.
SEC. 1907. 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 improve the coordination, quality, and efficiency of health
care services provided 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, clinical and analytical experts with
expertise in medicine and health care management, and States.
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 enrolled under
part B and entitled to benefits under part A of
title XVIII;
``(ii) an individual who is eligible for
medical assistance under title XIX; 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 give
preference to testing models for which, as determined
by the Administrator of the Centers for Medicare &
Medicaid Services and using such input from outside the
Centers as the Administrator determines appropriate,
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 Administrator 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) Application to other demonstrations.--The
Secretary shall operate the demonstration programs
under sections 1222 and 1236 of the Affordable Health
Care for America Act through the CMI in accordance with
the rules applicable under this section, including
those relating to evaluations, terminations, and
expansions.
``(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.--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 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 such title;
``(ii) reduce spending under such titles
without reducing the quality of care; or
``(iii) do both.
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 through the use of
patient-level outcomes measures; and
``(ii) the changes in spending under the
applicable titles by reason of the model.
The Secretary shall make the results of each evaluation
under this paragraph available to the public in a
timely fashion.
``(B) 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 developed under section 1192(c)(1).
``(5) Testing period.--In no case shall a model be tested
under this subsection for more than a 7-year period.
``(c) Expansion of Models (Phase II).--The Secretary may expand the
duration and the scope of a model that is being tested under subsection
(b) (including implementation on a nationwide basis), to the extent
determined appropriate by the Secretary, if--
``(1) the Secretary determines that such expansion is
expected--
``(A) to improve the quality of patient care
without increasing spending under the applicable
titles;
``(B) to reduce spending under applicable titles
without reducing the quality of care; or
``(C) to do both;
``(2) the Chief Actuary of the Centers for Medicare &
Medicaid Services certifies that such expansion would reduce
(or not result in any increase in) net program spending under
applicable titles; and
``(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.
``(d) Implementation.--
``(1) Waiver authority.--The Secretary may waive such
requirements of titles XI and XVIII and of sections 1902 and
1903(m) 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 elements, parameters, scope, and duration
of such models for testing or dissemination;
``(C) the termination or modification of the design
and implementation of a model under subsection
(b)(3)(B); and
``(D) 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 paragraphs (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.
``(4) Funding for testing items and services and
administrative costs.--
``(A) Additional benefits.--There shall be
available until expended, equally divided from the
Federal Supplementary Hospital Insurance Trust Fund and
Federal Supplementary Medical Insurance Trust Fund for
payments for additional benefits for items and services
under models tested under subsection (b) not otherwise
covered under this title and applicable to benefits
under this title, and for researching, designing,
implementing, and evaluating such models, $350,000,000
for fiscal year 2010, $440,000,000 for fiscal year
2011, $550,000,000 for fiscal year 2012, and, for a
subsequent fiscal year, the amount determined under
this subparagraph for the preceding fiscal year
increased by the annual percentage rate of increase in
total expenditures under this title for the subsequent
fiscal year as estimated in the latest available Annual
Report of the Board of Trustees as described in section
1841(b)(2).
``(B) Medicaid.--For administrative costs of the
Centers for Medicare & Medicaid Services for
administering this section with respect to title XIX,
from any amounts in the Treasury not otherwise
appropriated there are appropriated to the Secretary
for the Centers for Medicare & Medicaid Services
Program Management Account $25,000,000 for each fiscal
year beginning with fiscal year 2010. Amounts
appropriated under this subparagraph for a fiscal year
shall be available until expended.
``(e) 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 payment 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 believes 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 sections 1631(b),
1703(a), 1729, 1753, 1757(a), and 1759(a), is amended--
(1) in paragraph (78), by striking ``and'' at the end;
(2) in paragraph (79), by striking the period at the end
and inserting ``; and''; and
(3) by inserting after paragraph (79) the following new
paragraph:
``(80) 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.''.
SEC. 1908. 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. 1909. DISREGARD UNDER THE SUPPLEMENTAL SECURITY INCOME PROGRAM OF
COMPENSATION FOR PARTICIPATION IN CLINICAL TRIALS FOR
RARE DISEASES OR CONDITIONS.
(a) Income Disregard.--Section 1612(b) of the Social Security Act
(42 U.S.C. 1382a(b)) is amended--
(1) by striking ``and'' at the end of paragraph (24);
(2) by striking the period at the end of paragraph (25) and
inserting ``; and''; and
(3) by adding at the end the following:
``(26) The first $2,000 per year received by such
individual (or such spouse) for participation in a clinical
trial to test a treatment for a rare disease or condition
(within the meaning of section 5(b)(2) of the Orphan Drug Act
(Public Law 97-414)), that--
``(A) has been reviewed and approved by an
institutional review board that--
``(i) is established to protect the rights
and welfare of human subjects participating in
research; and
``(ii) meet the standards for such bodies
set forth in part 46 of title 45, Code of
Federal Regulations; and
``(B) meets the standards for protection of human
subjects for clinical research (as set forth in such
part).''.
(b) Resource Disregard.--Section 1613(a) of such Act (42 U.S.C.
1382b(a)) is amended--
(1) by striking ``and'' at the end of paragraph (15);
(2) by striking the period at the end of paragraph (16) and
inserting ``; and''; and
(3) by inserting after paragraph (16) the following:
``(17) the first $2,000 per year received by such
individual (or such spouse) for participation in a clinical
trial, as described in section 1612(b)(26).''.
(c) Effective Date.--The amendments made by this section shall
apply to benefits payable for calendar months beginning after the
earlier of--
(1) the date the Commissioner of Social Security
promulgates regulations to carry out the amendments; or
(2) the 180-day period that begins with the date of the
enactment of this Act.
DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT
SEC. 2001. TABLE OF CONTENTS; REFERENCES.
(a) Table of Contents.--The table of contents of this division is
as follows:
Sec. 2001. Table of contents; references.
Sec. 2002. Public Health Investment Fund.
Sec. 2003. Deficit neutrality.
TITLE I--COMMUNITY HEALTH CENTERS
Sec. 2101. Increased funding.
TITLE II--WORKFORCE
Subtitle A--Primary Care Workforce
Part 1--National Health Service Corps
Sec. 2201. National Health Service Corps.
Sec. 2202. Authorizations of appropriations.
Part 2--Promotion of Primary Care and Dentistry
Sec. 2211. Frontline health providers.
``subpart xi--health professional needs areas
``Sec. 340H. In general.
``Sec. 340I. Loan repayments.
``Sec. 340J. Report.
``Sec. 340K. Allocation.
Sec. 2212. Primary care student loan funds.
Sec. 2213. Training in family medicine, general internal medicine,
general pediatrics, geriatrics, and
physician assistants.
Sec. 2214. Training of medical residents in community-based settings.
Sec. 2215. Training for general, pediatric, and public health dentists
and dental hygienists.
Sec. 2216. Authorization of appropriations.
Sec. 2217. Study on effectiveness of scholarships and loan repayments.
Subtitle B--Nursing Workforce
Sec. 2221. Amendments to Public Health Service Act.
Subtitle C--Public Health Workforce
Sec. 2231. Public Health Workforce Corps.
``subpart xii--public health workforce
``Sec. 340L. Public Health Workforce Corps.
``Sec. 340M. Public Health Workforce Scholarship Program.
``Sec. 340N. Public Health Workforce Loan Repayment Program.
Sec. 2232. Enhancing the public health workforce.
Sec. 2233. Public health training centers.
Sec. 2234. Preventive medicine and public health training grant
program.
Sec. 2235. Authorization of appropriations.
Subtitle D--Adapting Workforce to Evolving Health System Needs
Part 1--Health Professions Training for Diversity
Sec. 2241. Scholarships for disadvantaged students, loan repayments and
fellowships regarding faculty positions,
and educational assistance in the health
professions regarding individuals from
disadvantaged backgrounds.
Sec. 2242. Nursing workforce diversity grants.
Sec. 2243. Coordination of diversity and cultural competency programs.
Part 2--Interdisciplinary Training Programs
Sec. 2251. Cultural and linguistic competency training for health
professionals.
Sec. 2252. Innovations in interdisciplinary care training.
Part 3--Advisory Committee on Health Workforce Evaluation and
Assessment
Sec. 2261. Health workforce evaluation and assessment.
Part 4--Health Workforce Assessment
Sec. 2271. Health workforce assessment.
Part 5--Authorization of Appropriations
Sec. 2281. Authorization of appropriations.
TITLE III--PREVENTION AND WELLNESS
Sec. 2301. Prevention and wellness.
``TITLE XXXI--PREVENTION AND WELLNESS
``Subtitle A--Prevention and Wellness Trust
``Sec. 3111. Prevention and Wellness Trust.
``Subtitle B--National Prevention and Wellness Strategy
``Sec. 3121. National Prevention and Wellness Strategy.
``Subtitle C--Prevention Task Forces
``Sec. 3131. Task Force on Clinical Preventive Services.
``Sec. 3132. Task Force on Community Preventive Services.
``Subtitle D--Prevention and Wellness Research
``Sec. 3141. Prevention and wellness research activity
coordination.
``Sec. 3142. Community prevention and wellness research grants.
``Sec. 3143. Research on subsidies and rewards to encourage
wellness and healthy behaviors.
``Subtitle E--Delivery of Community Prevention and Wellness Services
``Sec. 3151. Community prevention and wellness services grants.
``Subtitle F--Core Public Health Infrastructure
``Sec. 3161. Core public health infrastructure for State,
local, and tribal health departments.
``Sec. 3162. Core public health infrastructure and activities
for CDC.
``Subtitle G--General Provisions
``Sec. 3171. Definitions.
TITLE IV--QUALITY AND SURVEILLANCE
Sec. 2401. Implementation of best practices in the delivery of health
care.
Sec. 2402. Assistant Secretary for Health Information.
Sec. 2403. Authorization of appropriations.
TITLE V--OTHER PROVISIONS
Subtitle A--Drug Discount for Rural and Other Hospitals; 340B Program
Integrity
Sec. 2501. Expanded participation in 340B program.
Sec. 2502. Improvements to 340B program integrity.
Sec. 2503. Effective date.
Subtitle B--Programs
Part 1--Grants for Clinics and Centers
Sec. 2511. School-based health clinics.
Sec. 2512. Nurse-Managed health centers.
Sec. 2513. Federally qualified behavioral health centers.
Part 2--Other Grant Programs
Sec. 2521. Comprehensive programs to provide education to nurses and
create a pipeline to nursing.
Sec. 2522. Mental and behavioral health training.
Sec. 2523. Reauthorization of telehealth and telemedicine grant
programs.
Sec. 2524. No child left unimmunized against influenza: demonstration
program using elementary and secondary
schools as influenza vaccination centers.
Sec. 2525. Extension of Wisewoman Program.
Sec. 2526. Healthy teen initiative to prevent teen pregnancy.
Sec. 2527. National training initiatives on autism spectrum disorders.
Sec. 2528. Implementation of medication management services in
treatment of chronic diseases.
Sec. 2529. Postpartum depression.
Sec. 2530. Grants to promote positive health behaviors and outcomes.
Sec. 2531. Medical liability alternatives.
Sec. 2532. Infant mortality pilot programs.
Sec. 2533. Secondary school health sciences training program.
Sec. 2534. Community-based collaborative care networks.
Sec. 2535. Community-based overweight and obesity prevention program.
Sec. 2536. Reducing student-to-school nurse ratios.
Sec. 2537. Medical-legal partnerships.
Part 3--Emergency Care-Related Programs
Sec. 2551. Trauma care centers.
Sec. 2552. Emergency care coordination.
Sec. 2553. Pilot programs to improve emergency medical care.
Sec. 2554. Assisting veterans with military emergency medical training
to become State-licensed or certified
emergency medical technicians (EMTs).
Sec. 2555. Dental emergency responders: public health and medical
response.
Sec. 2556. Dental emergency responders: homeland security.
Part 4--Pain Care and Management Programs
Sec. 2561. Institute of Medicine Conference on Pain.
Sec. 2562. Pain research at National Institutes of Health.
Sec. 2563. Public awareness campaign on pain management.
Subtitle C--Food and Drug Administration
Part 1--In General
Sec. 2571. National medical device registry.
Sec. 2572. Nutrition labeling of standard menu items at chain
restaurants and of articles of food sold
from vending machines.
Sec. 2573. Protecting consumer access to generic drugs.
Part 2--Biosimilars
Sec. 2575. Licensure pathway for biosimilar biological products.
Sec. 2576. Fees relating to biosimilar biological products.
Sec. 2577. Amendments to certain patent provisions.
Subtitle D--Community Living Assistance Services and Supports
Sec. 2581. Establishment of national voluntary insurance program for
purchasing community living assistance
services and support (CLASS program).
``TITLE XXXII--COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS
``Sec. 3201. Purpose.
``Sec. 3202. Definitions.
``Sec. 3203. CLASS Independence Benefit Plan.
``Sec. 3204. Enrollment and disenrollment requirements.
``Sec. 3205. Benefits.
``Sec. 3206. CLASS Independence Fund.
``Sec. 3207. CLASS Independence Advisory Council.
``Sec. 3208. Regulations; annual report.
``Sec. 3209. Inspector General's report.
Subtitle E--Miscellaneous
Sec. 2585. States failing to adhere to certain employment obligations.
Sec. 2586. Health centers under Public Health Service Act; liability
protections for volunteer practitioners.
Sec. 2587. Report to Congress on the current state of parasitic
diseases that have been overlooked among
the poorest Americans.
Sec. 2588. Office of Women's Health.
Sec. 2589. Long-Term Care and Family Caregiver Support.
Sec. 2590. Web site on health care labor market and related educational
and training opportunities.
Sec. 2591. Online health workforce training programs.
Sec. 2592. Access for individuals with disabilities.
(b) References.--Except as otherwise specified, whenever in this
division an amendment is expressed in terms of an amendment to a
section or other provision, the reference shall be considered to be
made to a section or other provision of the Public Health Service Act
(42 U.S.C. 201 et seq.).
SEC. 2002. PUBLIC HEALTH INVESTMENT FUND.
(a) Establishment of Funds.--
(1) In general.--Subject to section 2003, there is hereby
established in the Treasury a separate account to be known as
the ``Public Health Investment Fund'' (referred to in this
section and section 2003 as the ``Fund'').
(2) Funding.--
(A) There shall be deposited into the Fund--
(i) for fiscal year 2011, $4,600,000,000;
(ii) for fiscal year 2012, $5,600,000,000;
(iii) for fiscal year 2013, $6,900,000,000;
(iv) for fiscal year 2014, $7,800,000,000;
and
(v) for fiscal year 2015, $9,000,000,000.
(B) Amounts deposited into the Fund shall be
derived from general revenues of the Treasury only for
the fiscal years set forth in this section, and amounts
appropriated from the Fund shall remain available until
expended.
(b) Authorization of Appropriations From the Fund.--
(1) New funding.--
(A) In general.--Subject to section 2003, amounts
in the Fund are authorized to be appropriated for
carrying out activities under designated public health
provisions.
(B) Designated provisions.--For purposes of this
paragraph, the term ``designated public health
provisions'' means the provisions for which amounts are
authorized to be appropriated under section 330(s),
338(c), 338H-1, 799C, 872, or 3111 of the Public Health
Service Act, as added by this division.
(2) Baseline funding.--
(A) In general.--Amounts in the Fund are authorized
to be appropriated (as described in paragraph (1)) for
a fiscal year only if (excluding any amounts in or
appropriated from the Fund)--
(i) the amounts specified in subparagraph
(B) for the fiscal year involved are equal to
or greater than the amounts specified in
subparagraph (B) for fiscal year 2008; and
(ii) the amounts appropriated, out of the
general fund of the Treasury, to the Prevention
and Wellness Trust under section 3111(a)(1) of
the Public Health Service Act, as added by this
division, for the fiscal year involved are
equal to or greater than the funds--
(I) appropriated under the heading
``Prevention and Wellness Fund'' in
title VIII of division A of the
American Recovery and Reinvestment Act
of 2009 (Public Law 111-5); and
(II) allocated by the second
proviso under such heading for
evidence-based clinical and community-
based prevention and wellness
strategies.
(B) Amounts specified.--The amounts specified in
this subparagraph, with respect to a fiscal year, are
the amounts appropriated for the following:
(i) Community health centers (including
funds appropriated under the authority of
section 330 of the Public Health Service Act
(42 U.S.C. 254b)).
(ii) The National Health Service Corps
Program (including funds appropriated under the
authority of section 338 of such Act (42 U.S.C.
254k)).
(iii) The National Health Service Corps
Scholarship and Loan Repayment Programs
(including funds appropriated under the
authority of section 338H of such Act (42
U.S.C. 254q)).
(iv) Primary care education programs
(including funds appropriated under the
authority of sections 736, 740, 741, and 747 of
such Act (42 U.S.C. 293, 293d, and 293k)).
(v) Sections 761 and 770 of such Act (42
U.S.C. 294n and 295e).
(vi) Nursing workforce development
(including funds appropriated under the
authority of title VIII of such Act (42 U.S.C.
296 et seq.)).
(vii) The National Center for Health
Statistics (including funds appropriated under
the authority of sections 304, 306, 307, and
308 of such Act (42 U.S.C. 242b, 242k, 242l,
and 242m)).
(viii) The Agency for Healthcare Research
and Quality (including funds appropriated under
the authority of title IX of such Act (42
U.S.C. 299 et seq.)).
SEC. 2003. DEFICIT NEUTRALITY.
(a) Availability.--Funds appropriated or made available pursuant to
sections 330(s), 338(c), 338H-1, 799C, 872, or 3111 of the Public
Health Service Act, as added by this division, are only available for
the purposes set forth in this Act. Appropriations shall not be
available and are precluded from obligation for any other purpose.
(b) Estimation of Budgetary Impact.--For the purposes of estimating
the spending effects of this Act, the authorization of appropriations
from the Fund, to the extent amounts in the Fund are derived from the
general revenues of the Treasury, shall be treated as new direct
spending and attributed to this Act.
(c) Budgetary Treatment.--For the purposes of section 257 of the
Balanced Budget and Emergency Deficit Control Act of 1985, the Fund, to
the extent amounts in the Fund are derived from the general revenues of
the Treasury, and not in excess of amounts subsequently appropriated
from the Fund, shall be deemed to be included on the list of
appropriations referenced under section 250(c)(17) of that Act.
TITLE I--COMMUNITY HEALTH CENTERS
SEC. 2101. INCREASED FUNDING.
Section 330 of the Public Health Service Act (42 U.S.C. 254b) is
amended--
(1) in subsection (r)(1)--
(A) in subparagraph (D), by striking ``and'' at the
end;
(B) in subparagraph (E), by striking the period at
the end and inserting ``; and''; and
(C) by inserting at the end the following:
``(F) such sums as may be necessary for each of
fiscal years 2013 through 2015.''; and
(2) by inserting after subsection (r) the following:
``(s) Additional Funding.--For the purpose of carrying out this
section, in addition to any other amounts authorized to be appropriated
for such purpose, there are authorized to be appropriated, out of any
monies in the Public Health Investment Fund, the following:
``(1) For fiscal year 2011, $1,000,000,000.
``(2) For fiscal year 2012, $1,500,000,000.
``(3) For fiscal year 2013, $2,500,000,000.
``(4) For fiscal year 2014, $3,000,000,000.
``(5) For fiscal year 2015, $4,000,000,000.''.
TITLE II--WORKFORCE
Subtitle A--Primary Care Workforce
PART 1--NATIONAL HEALTH SERVICE CORPS
SEC. 2201. NATIONAL HEALTH SERVICE CORPS.
(a) Fulfillment of Obligated Service Requirement Through Half-Time
Service.--
(1) Waivers.--Subsection (i) of section 331 (42 U.S.C.
254d) 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) Definitions.--Subsection (j) of section 331 (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.''.
(b) Reappointment to National Advisory Council.--Section 337(b)(1)
(42 U.S.C. 254j(b)(1)) is amended by striking ``Members may not be
reappointed to the Council.''.
(c) Loan Repayment Amount.--Section 338B(g)(2)(A) (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,''.
(d) Treatment of Teaching as Obligated Service.--Subsection (a) of
section 338C (42 U.S.C. 254m) is amended by adding at the end the
following: ``The Secretary may treat teaching as clinical practice for
up to 20 percent of such period of obligated service.''.
SEC. 2202. AUTHORIZATIONS OF APPROPRIATIONS.
(a) National Health Service Corps Program.--Section 338 (42 U.S.C.
254k) is amended--
(1) in subsection (a), by striking ``2012'' and inserting
``2015''; and
(2) by adding at the end the following:
``(c) For the purpose of carrying out this subpart, in addition to
any other amounts authorized to be appropriated for such purpose, there
are authorized to be appropriated, out of any monies in the Public
Health Investment Fund, the following:
``(1) $63,000,000 for fiscal year 2011.
``(2) $66,000,000 for fiscal year 2012.
``(3) $70,000,000 for fiscal year 2013.
``(4) $73,000,000 for fiscal year 2014.
``(5) $77,000,000 for fiscal year 2015.''.
(b) Scholarship and Loan Repayment Programs.--Subpart III of part D
of title III of the Public Health Service Act (42 U.S.C. 254l et seq.)
is amended--
(1) in section 338H(a)--
(A) in paragraph (4), by striking ``and'' at the
end;
(B) in paragraph (5), by striking the period at the
end and inserting ``; and''; and
(C) by adding at the end the following:
``(6) for each of fiscal years 2013 through 2015, such sums
as may be necessary.''; and
(2) by inserting after section 338H the following:
``SEC. 338H-1. ADDITIONAL FUNDING.
``For the purpose of carrying out this subpart, in addition to any
other amounts authorized to be appropriated for such purpose, there are
authorized to be appropriated, out of any monies in the Public Health
Investment Fund, the following:
``(1) $254,000,000 for fiscal year 2011.
``(2) $266,000,000 for fiscal year 2012.
``(3) $278,000,000 for fiscal year 2013.
``(4) $292,000,000 for fiscal year 2014.
``(5) $306,000,000 for fiscal year 2015.''.
PART 2--PROMOTION OF PRIMARY CARE AND DENTISTRY
SEC. 2211. FRONTLINE HEALTH PROVIDERS.
Part D of title III (42 U.S.C. 254b et seq.) is amended by adding
at the end the following:
``Subpart XI--Health Professional Needs Areas
``SEC. 340H. IN GENERAL.
``(a) Program.--The Secretary, acting through the Administrator of
the Health Resources and Services Administration, shall establish a
program, to be known as the Frontline Health Providers Loan Repayment
Program, to address unmet health care needs in health professional
needs areas through loan repayments under section 340I.
``(b) Designation of Health Professional Needs Areas.--
``(1) In general.--In this subpart, the term `health
professional needs area' means an area, population, or facility
that is designated by the Secretary in accordance with
paragraph (2).
``(2) Designation.--To be designated by the Secretary as a
health professional needs area under this subpart:
``(A) In the case of an area, the area must be a
rational area for the delivery of health services.
``(B) The area, population, or facility must have,
in one or more health disciplines, specialties, or
subspecialties for the population served, as determined
by the Secretary--
``(i) insufficient capacity of health
professionals; or
``(ii) high needs for health services,
including services to address health
disparities.
``(C) With respect to the delivery of primary
health services, the area, population, or facility must
not include a health professional shortage area (as
designated under section 332), except that the area,
population, or facility may include such a health
professional shortage area in which there is an unmet
need for such services.
``(c) Eligibility.--To be eligible to participate in the Program,
an individual shall--
``(1) hold a degree in a course of study or program
(approved by the Secretary) from a school defined in section
799B(1)(A) (other than a school of public health);
``(2) hold a degree in a course of study or program
(approved by the Secretary) from a school or program defined in
subparagraph (C), (D), or (E)(4) of section 799B(1), as
designated by the Secretary;
``(3) be enrolled as a full-time student--
``(A) in a school or program defined in
subparagraph (C), (D), or (E)(4) of section 799B(1), as
designated by the Secretary, or a school described in
paragraph (1); and
``(B) in the final year of a course of study or
program, offered by such school or program and approved
by the Secretary, leading to a degree in a discipline
referred to in subparagraph (A) (other than a graduate
degree in public health), (C), (D), or (E)(4) of
section 799B(1);
``(4) be a practitioner described in section 1842(b)(18)(C)
or 1848(k)(3)(B)(iii) or (iv) of the Social Security Act; or
``(5) be a practitioner in the field of respiratory
therapy, medical technology, or radiologic technology.
``(d) Definitions.--In this subpart:
``(1) The term `health disparities' has the meaning given
to the term in section 3171.
``(2) The term `primary health services' has the meaning
given to such term in section 331(a)(3)(D).
``SEC. 340I. LOAN REPAYMENTS.
``(a) Loan Repayments.--The Secretary, acting through the
Administrator of the Health Resources and Services Administration,
shall enter into contracts with individuals under which--
``(1) the individual agrees--
``(A) to serve as a full-time primary health
services provider or as a full-time or part-time
provider of other health services for a period of time
equal to 2 years or such longer period as the
individual may agree to;
``(B) to serve in a health professional needs area
in a health discipline, specialty, or a subspecialty
for which the area, population, or facility is
designated as a health professional needs area under
section 340H; and
``(C) in the case of an individual described in
section 340H(c)(3) who is in the final year of study
and who has accepted employment as a primary health
services provider or provider of other health services
in accordance with subparagraphs (A) and (B), to
complete the education or training and maintain an
acceptable level of academic standing (as determined by
the educational institution offering the course of
study or training); and
``(2) the Secretary agrees to pay, for each year of such
service, an amount on the principal and interest of the
undergraduate or graduate educational loans (or both) of the
individual that is not more than 50 percent of the average
award made under the National Health Service Corps Loan
Repayment Program under subpart III in that year.
``(b) Practice Setting.--A contract entered into under this section
shall allow the individual receiving the loan repayment to satisfy the
service requirement described in subsection (a)(1) through employment
in a solo or group practice, a clinic, an accredited public or private
nonprofit hospital, or any other health care entity, as deemed
appropriate by the Secretary.
``(c) Application of Certain Provisions.--The provisions of subpart
III of part D shall, except as inconsistent with this section, apply to
the loan repayment program under this subpart in the same manner and to
the same extent as such provisions apply to the National Health Service
Corps Loan Repayment Program established under section 338B.
``(d) Insufficient Number of Applicants.--If there are an
insufficient number of applicants for loan repayments under this
section to obligate all appropriated funds, the Secretary shall
transfer the unobligated funds to the National Health Service Corps for
the purpose of recruiting applicants and entering into contracts with
individuals so as to ensure a sufficient number of participants in the
National Health Service Corps for the following year.
``SEC. 340J. REPORT.
``The Secretary shall submit to the Congress an annual report on
the program carried out under this subpart.
``SEC. 340K. ALLOCATION.
``Of the amount of funds obligated under this subpart each fiscal
year for loan repayments--
``(1) 90 percent shall be for physicians and other health
professionals providing primary health services; and
``(2) 10 percent shall be for health professionals not
described in paragraph (1).''.
SEC. 2212. PRIMARY CARE STUDENT LOAN FUNDS.
(a) In General.--Section 735 (42 U.S.C. 292y) is amended--
(1) by redesignating subsection (f) as subsection (g); and
(2) by inserting after subsection (e) the following:
``(f) Determination of Financial Need.--The Secretary--
``(1) may require, or authorize a school or other entity to
require, the submission of financial information to determine
the financial resources available to any individual seeking
assistance under this subpart; and
``(2) shall take into account the extent to which such
individual is financially independent in determining whether to
require or authorize the submission of such information
regarding such individual's family members.''.
(b) Revised Guidelines.--The Secretary of Health and Human Services
shall--
(1) strike the second sentence of section 57.206(b)(1) of
title 42, Code of Federal Regulations; and
(2) make such other revisions to guidelines and regulations
in effect as of the date of the enactment of this Act as may be
necessary for consistency with the amendments made by paragraph
(1).
SEC. 2213. TRAINING IN FAMILY MEDICINE, GENERAL INTERNAL MEDICINE,
GENERAL PEDIATRICS, GERIATRICS, AND PHYSICIAN ASSISTANTS.
Section 747 (42 U.S.C. 293k) is amended--
(1) by amending the section heading to read as follows:
``primary care training and enhancement'';
(2) by redesignating subsection (e) as subsection (g); and
(3) by striking subsections (a) through (d) and inserting
the following:
``(a) Program.--The Secretary shall establish a primary care
training and capacity building program consisting of awarding grants
and contracts under subsections (b) and (c).
``(b) Support and Development of Primary Care Training Programs.--
``(1) In general.--The Secretary shall make grants to, or
enter into contracts with, eligible entities--
``(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,
general pediatrics, or geriatrics for medical students,
interns, residents, or practicing physicians;
``(B) to provide financial assistance in the form
of traineeships and fellowships to medical students,
interns, residents, or practicing physicians, who are
participants in any such program, and who plan to
specialize or work in family medicine, general internal
medicine, general pediatrics, or geriatrics;
``(C) to plan, develop, operate, or participate in
an accredited program for the training of physicians
who plan to teach in family medicine, general internal
medicine, general pediatrics, or geriatrics training
programs including in community-based settings;
``(D) to provide financial assistance in the form
of traineeships and fellowships to practicing
physicians who are participants in any such programs
and who plan to teach in a family medicine, general
internal medicine, general pediatrics, or geriatrics
training program; and
``(E) to plan, develop, operate, or participate in
an accredited program for physician assistant
education, and for the training of individuals who plan
to teach in programs to provide such training.
``(2) Eligibility.--To be eligible for a grant or contract
under paragraph (1), an entity shall be--
``(A) an accredited school of medicine or
osteopathic medicine, public or nonprofit private
hospital, or physician assistant training program;
``(B) a public or private nonprofit entity; or
``(C) a consortium of 2 or more entities described
in subparagraphs (A) and (B).
``(c) Capacity Building in Primary Care.--
``(1) In general.--The Secretary shall make grants to or
enter into contracts with eligible entities to establish,
maintain, or improve--
``(A) academic administrative units (including
departments, divisions, or other appropriate units) in
the specialties of family medicine, general internal
medicine, general pediatrics, or geriatrics; or
``(B) programs that improve clinical teaching in
such specialties.
``(2) Eligibility.--To be eligible for a grant or contract
under paragraph (1), an entity shall be an accredited school of
medicine or osteopathic medicine.
``(d) Preference.--In awarding grants or contracts under this
section, the Secretary shall give preference to entities that have a
demonstrated record of at least one of the following:
``(1) Training a high or significantly improved percentage
of health professionals who provide primary care.
``(2) Training individuals who are from disadvantaged
backgrounds (including racial and ethnic minorities
underrepresented among primary care professionals).
``(3) A high rate of placing graduates in practice settings
having the principal focus of serving in underserved areas or
populations experiencing health disparities (including serving
patients eligible for medical assistance under title XIX of the
Social Security Act or for child health assistance under title
XXI of such Act or those with special health care needs).
``(4) Supporting teaching programs that address the health
care needs of vulnerable populations.
``(e) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.
``(f) Definition.--In this section, the term `health disparities'
has the meaning given the term in section 3171.''.
SEC. 2214. TRAINING OF MEDICAL RESIDENTS IN COMMUNITY-BASED SETTINGS.
Title VII (42 U.S.C. 292 et seq.) is amended--
(1) by redesignating section 748 as 749A; and
(2) by inserting after section 747 the following:
``SEC. 748. TRAINING OF MEDICAL RESIDENTS IN COMMUNITY-BASED SETTINGS.
``(a) Program.--The Secretary shall establish a program for the
training of medical residents in community-based settings consisting of
awarding grants and contracts under this section.
``(b) Development and Operation of Community-Based Programs.--The
Secretary shall make grants to, or enter into contracts with, eligible
entities--
``(1) to plan and develop a new primary care residency
training program, which may include--
``(A) planning and developing curricula;
``(B) recruiting and training residents and
faculty; and
``(C) other activities designated to result in
accreditation of such a program; or
``(2) to operate or participate in an established primary
care residency training program, which may include--
``(A) planning and developing curricula;
``(B) recruitment and training of residents; and
``(C) retention of faculty.
``(c) Eligible Entity.--To be eligible to receive a grant or
contract under subsection (b), an entity shall--
``(1) be designated as a recipient of payment for the
direct costs of medical education under section 1886(k) of the
Social Security Act;
``(2) be designated as an approved teaching health center
under section 1502(d) of the Affordable Health Care for America
Act and continuing to participate in the demonstration project
under such section;
``(3) be an applicant for designation described in
paragraph (1) or (2) and have demonstrated to the Secretary
appropriate involvement of an accredited teaching hospital to
carry out the inpatient responsibilities associated with a
primary care residency training program; or
``(4) be eligible to be designated as described in
paragraph (1) or (2), not be an applicant as described in
paragraph (3), and have demonstrated appropriate involvement of
an accredited teaching hospital to carry out the inpatient
responsibilities associated with a primary care residency
training program.
``(d) Preferences.--In awarding grants and contracts under
paragraph (1) or (2) of subsection (b), the Secretary shall give
preference to entities that--
``(1) support teaching programs that address the health
care needs of vulnerable populations; or
``(2) are a Federally qualified health center (as defined
in section 1861(aa)(4) of the Social Security Act) or a rural
health clinic (as defined in section 1861(aa)(2) of such Act).
``(e) Additional Preferences for Established Programs.--In awarding
grants and contracts under subsection (b)(2), the Secretary shall give
preference to entities that have a demonstrated record of training--
``(1) a high or significantly improved percentage of health
professionals who provide primary care;
``(2) individuals who are from disadvantaged backgrounds
(including racial and ethnic minorities underrepresented among
primary care professionals); or
``(3) individuals who practice in settings having the
principal focus of serving underserved areas or populations
experiencing health disparities (including serving patients
eligible for medical assistance under title XIX of the Social
Security Act or for child health assistance under title XXI of
such Act or those with special health care needs).
``(f) Period of Awards.--
``(1) In general.--The period of a grant or contract under
this section--
``(A) shall not exceed 3 years for awards under
subsection (b)(1); and
``(B) shall not exceed 5 years for awards under
subsection (b)(2).
``(2) Special rules.--
``(A) An award of a grant or contract under
subsection (b)(1) shall not be renewed.
``(B) The period of a grant or contract awarded to
an entity under subsection (b)(2) shall not overlap
with the period of any grant or contact awarded to the
same entity under subsection (b)(1).
``(g) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.
``(h) Definitions.--In this section:
``(1) Health disparities.--The term `health disparities'
has the meaning given the term in section 3171.
``(2) Primary care resident.--The term `primary care
resident' has the meaning given the term in section
1886(h)(5)(H) of the Social Security Act.
``(3) Primary care residency training program.--The term
`primary care residency training program' means an approved
medical residency training program described in section
1886(h)(5)(A) of the Social Security Act for primary care
residents that is--
``(A) in the case of entities seeking awards under
subsection (b)(1), actively applying to be accredited
by the Accreditation Council for Graduate Medical
Education or the American Osteopathic Association; or
``(B) in the case of entities seeking awards under
subsection (b)(2), so accredited.
``(i) Allocation of Funds.--Of the amount appropriated pursuant to
section 799C(a) for a fiscal year, not more than 17 percent of such
amount shall be made available to carry out this section.''.
SEC. 2215. TRAINING FOR GENERAL, PEDIATRIC, AND PUBLIC HEALTH DENTISTS
AND DENTAL HYGIENISTS.
Title VII (42 U.S.C. 292 et seq.) is amended--
(1) in section 791(a)(1), by striking ``747 and 750'' and
inserting ``747, 749, and 750''; and
(2) by inserting after section 748, as added, the
following:
``SEC. 749. TRAINING FOR GENERAL, PEDIATRIC, AND PUBLIC HEALTH DENTISTS
AND DENTAL HYGIENISTS.
``(a) Program.--The Secretary shall establish a training program
for oral health professionals consisting of awarding grants and
contracts under this section.
``(b) Support and Development of Oral Health Training Programs.--
The Secretary shall make grants to, or enter into contracts with,
eligible entities--
``(1) to plan, develop, operate, or participate in an
accredited professional training program for oral health
professionals;
``(2) to provide financial assistance to oral health
professionals who are in need thereof, who are participants in
any such program, and who plan to work in general, pediatric,
or public health dentistry, or dental hygiene;
``(3) to plan, develop, operate, or participate in a
program for the training of oral health professionals who plan
to teach in general, pediatric, or public health dentistry, or
dental hygiene;
``(4) to provide financial assistance in the form of
traineeships and fellowships to oral health professionals who
plan to teach in general, pediatric, or public health dentistry
or dental hygiene;
``(5) to establish, maintain, or improve--
``(A) academic administrative units (including
departments, divisions, or other appropriate units) in
the specialties of general, pediatric, or public health
dentistry; or
``(B) programs that improve clinical teaching in
such specialties;
``(6) to plan, develop, operate, or participate in
predoctoral and postdoctoral training in general, pediatric, or
public health dentistry programs;
``(7) to plan, develop, operate, or participate in a loan
repayment program for full-time faculty in a program of
general, pediatric, or public health dentistry; and
``(8) to provide technical assistance to pediatric dental
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.
``(c) Eligibility.--To be eligible for a grant or contract under
this section, an entity shall be--
``(1) an accredited school of dentistry, training program
in dental hygiene, or public or nonprofit private hospital;
``(2) a training program in dental hygiene at an accredited
institution of higher education;
``(3) a public or private nonprofit entity; or
``(4) a consortium of--
``(A) 1 or more of the entities described in
paragraphs (1) through (3); and
``(B) an accredited school of public health.
``(d) Preference.--In awarding grants or contracts under this
section, the Secretary shall give preference to entities that have a
demonstrated record of at least one of the following:
``(1) Training a high or significantly improved percentage
of oral health professionals who practice general, pediatric,
or public health dentistry.
``(2) Training individuals who are from disadvantaged
backgrounds (including racial and ethnic minorities
underrepresented among oral health professionals).
``(3) A high rate of placing graduates in practice settings
having the principal focus of serving in underserved areas or
populations experiencing health disparities (including serving
patients eligible for medical assistance under title XIX of the
Social Security Act or for child health assistance under title
XXI of such Act or those with special health care needs).
``(4) Supporting teaching programs that address the oral
health needs of vulnerable populations.
``(5) Providing instruction regarding the oral health
status, oral health care needs, and risk-based clinical disease
management of all pediatric populations with an emphasis on
underserved children.
``(e) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.
``(f) Definitions.--In this section:
``(1) The term `health disparities' has the meaning given
the term in section 3171.
``(2) The term `oral health professional' means an
individual training or practicing--
``(A) in general dentistry, pediatric dentistry,
public health dentistry, or dental hygiene; or
``(B) another oral health specialty, as deemed
appropriate by the Secretary.''.
SEC. 2216. AUTHORIZATION OF APPROPRIATIONS.
(a) In General.--Part F of title VII (42 U.S.C. 295j et seq.) is
amended by adding at the end the following:
``SEC. 799C. FUNDING THROUGH PUBLIC HEALTH INVESTMENT FUND.
``(a) Promotion of Primary Care and Dentistry.--For the purpose of
carrying out subpart XI of part D of title III and sections 747, 748,
and 749, in addition to any other amounts authorized to be appropriated
for such purpose, there are authorized to be appropriated, out of any
monies in the Public Health Investment Fund, the following:
``(1) $240,000,000 for fiscal year 2011.
``(2) $253,000,000 for fiscal year 2012.
``(3) $265,000,000 for fiscal year 2013.
``(4) $278,000,000 for fiscal year 2014.
``(5) $292,000,000 for fiscal year 2015.''.
(b) Existing Authorization of Appropriations.--Subsection (g)(1),
as so redesignated, of section 747 (42 U.S.C. 293k) is amended by
striking ``2002'' and inserting ``2015''.
SEC. 2217. STUDY ON EFFECTIVENESS OF SCHOLARSHIPS AND LOAN REPAYMENTS.
(a) Study.--The Comptroller General of the United States shall
conduct a study to determine the effectiveness of scholarship and loan
repayment programs under subparts III and XI of part D of title III of
the Public Health Service Act, as amended or added by sections 2201 and
2211, including whether scholarships or loan repayments are more
effective in--
(1) incentivizing physicians, and other providers, to
pursue careers in primary care specialties;
(2) retaining such primary care providers; and
(3) encouraging such primary care providers to practice in
underserved areas.
(b) Report.--Not later than 12 months after the date of the
enactment of this Act, the Comptroller General shall submit to the
Congress a report on the results of the study under subsection (a).
Subtitle B--Nursing Workforce
SEC. 2221. AMENDMENTS TO PUBLIC HEALTH SERVICE ACT.
(a) Definitions.--Section 801 (42 U.S.C. 296 et seq.) is amended--
(1) in paragraph (1), by inserting ``nurse-managed health
centers,'' after ``nursing centers,''; and
(2) by adding at the end the following:
``(16) Nurse-managed health center.--The term `nurse-
managed health center'--
``(A) means a nurse-practice arrangement, managed
by one or more advanced practice nurses, that provides
primary care or wellness services to underserved or
vulnerable populations and is associated with an
accredited school of nursing, Federally qualified
health center, or independent nonprofit health or
social services agency; and
``(B) shall not be construed as changing State law
requirements applicable to an advanced practice nurse
or the authorized scope of practice of such a nurse.''.
(b) Grants for Health Professions Education.--Title VIII (42 U.S.C.
296 et seq.) is amended by striking section 807.
(c) Reports.--Part A of title VIII (42 U.S.C. 296 et seq.) is
amended by adding at the end the following:
``SEC. 809. REPORTS.
``The Secretary shall submit to the Congress a separate annual
report on the activities carried out under each of sections 811, 821,
836, 846A, and 861.''.
(d) Advanced Education Nursing Grants.--Section 811(f) (42 U.S.C.
296j(f)) is amended--
(1) by striking paragraph (2);
(2) by redesignating paragraph (3) as paragraph (2); and
(3) in paragraph (2), as so redesignated, by striking
``that agrees'' and all that follows through the end and
inserting: ``that agrees to expend the award--
``(A) to train advanced education nurses who will
practice in health professional shortage areas
designated under section 332; or
``(B) to increase diversity among advanced
education nurses.''.
(e) Nurse Education, Practice, and Retention Grants.--Section 831
(42 U.S.C. 296p) is amended--
(1) in subsection (b), by amending paragraph (3) to read as
follows:
``(3) providing coordinated care, quality care, and other
skills needed to practice nursing; or''; and
(2) by striking subsection (e) and redesignating
subsections (f) through (h) as subsections (e) through (g),
respectively.
(f) Student Loans.--Subsection (a) of section 836 (42 U.S.C. 297b)
is amended--
(1) by striking ``$2,500'' and inserting ``$3,300'';
(2) by striking ``$4,000'' and inserting ``$5,200'';
(3) by striking ``$13,000'' and inserting ``$17,000''; and
(4) by adding at the end the following: ``Beginning with
fiscal year 2012, the dollar amounts specified in this
subsection shall be adjusted by an amount determined by the
Secretary on an annual basis to reflect inflation.''.
(g) Loan Repayment.--Section 846 (42 U.S.C. 297n) is amended--
(1) in subsection (a), by amending paragraph (3) to read as
follows:
``(3) who enters into an agreement with the Secretary to
serve for a period of not less than 2 years--
``(A) as a nurse at a health care facility with a
critical shortage of nurses; or
``(B) as a faculty member at an accredited school
of nursing;''; and
(2) in subsection (g)(1), by striking ``to provide health
services'' each place it appears and inserting ``to provide
health services or serve as a faculty member''.
(h) Nurse Faculty Loan Program.--Paragraph (2) of section 846A(c)
(42 U.S.C. 297n-1(c)) is amended by striking ``$30,000'' and all that
follows through the semicolon and inserting ``$35,000, plus, beginning
with fiscal year 2012, an amount determined by the Secretary on an
annual basis to reflect inflation;''.
(i) Public Service Announcements.--Title VIII (42 U.S.C. 296 et
seq.) is amended by striking part H.
(j) Technical and Conforming Amendments.--Title VIII (42 U.S.C. 296
et seq.) is amended--
(1) by moving section 810 (relating to prohibition against
discrimination by schools on the basis of sex) so that it
follows section 809, as added by subsection (c);
(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 H;
(8) in part G--
(A) by redesignating section 845 as section 851;
and
(B) by redesignating part G as part F; and
(9) in part I--
(A) by redesignating section 855 as section 861;
and
(B) by redesignating part I as part G.
(k) Funding.--
(1) In general.--Part H, as redesignated, of title VIII is
amended by adding at the end the following:
``SEC. 872. FUNDING THROUGH PUBLIC HEALTH INVESTMENT FUND.
``For the purpose of carrying out this title, in addition to any
other amounts authorized to be appropriated for such purpose, there are
authorized to be appropriated, out of any monies in the Public Health
Investment Fund, the following:
``(1) $115,000,000 for fiscal year 2011.
``(2) $122,000,000 for fiscal year 2012.
``(3) $127,000,000 for fiscal year 2013.
``(4) $134,000,000 for fiscal year 2014.
``(5) $140,000,000 for fiscal year 2015.''.
(2) Existing authorizations of appropriations.--
(A) Sections 831, 846, 846a, and 861.--Sections
831(g) (as so redesignated), 846(i)(1) (42 U.S.C.
297n(i)(1)), 846A(f) (42 U.S.C. 297n-1(f)), and 861(e)
(as so redesignated) are amended by striking ``2007''
each place it appears and inserting ``2015''.
(B) Section 871.--Section 871, as so redesignated
by subsection (j), is amended to read as follows:
``SEC. 871. FUNDING.
``For the purpose of carrying out parts B, C, and D (subject to
section 851(g)), there are authorized to be appropriated such sums as
may be necessary for each fiscal year through fiscal year 2015.''.
Subtitle C--Public Health Workforce
SEC. 2231. PUBLIC HEALTH WORKFORCE CORPS.
Part D of title III (42 U.S.C. 254b et seq.), as amended by section
2211, is amended by adding at the end the following:
``Subpart XII--Public Health Workforce
``SEC. 340L. PUBLIC HEALTH WORKFORCE CORPS.
``(a) Establishment.--There is established, within the Service, the
Public Health Workforce Corps (in this subpart referred to as the
`Corps'), for the purpose of ensuring an adequate supply of public
health professionals throughout the Nation. The Corps shall consist
of--
``(1) such officers of the Regular and Reserve Corps of the
Service as the Secretary may designate;
``(2) such civilian employees of the United States as the
Secretary may appoint; and
``(3) such other individuals who are not employees of the
United States.
``(b) Administration.--Except as provided in subsection (c), the
Secretary shall carry out this subpart acting through the Administrator
of the Health Resources and Services Administration.
``(c) Placement and Assignment.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention, shall
develop a methodology for placing and assigning Corps participants as
public health professionals. Such methodology may allow for placing and
assigning such participants in State, local, and tribal health
departments and Federally qualified health centers (as defined in
section 1861(aa)(4) of the Social Security Act).
``(d) Application of Certain Provisions.--The provisions of subpart
II shall, except as inconsistent with this subpart, apply to the Public
Health Workforce Corps in the same manner and to the same extent as
such provisions apply to the National Health Service Corps established
under section 331.
``(e) Report.--The Secretary shall submit to the Congress an annual
report on the programs carried out under this subpart.
``SEC. 340M. PUBLIC HEALTH WORKFORCE SCHOLARSHIP PROGRAM.
``(a) Establishment.--The Secretary shall establish the Public
Health Workforce Scholarship Program (referred to in this section as
the `Program') for the purpose described in section 340L(a).
``(b) Eligibility.--To be eligible to participate in the Program,
an individual shall--
``(1)(A) be accepted for enrollment, or be enrolled, as a
full-time or part-time student in a course of study or program
(approved by the Secretary) at an accredited graduate school or
program of public health; or
``(B) have demonstrated expertise in public health and be
accepted for enrollment, or be enrolled, as a full-time or
part-time student in a course of study or program (approved by
the Secretary) at--
``(i) an accredited graduate school or program of
nursing; health administration, management, or policy;
preventive medicine; laboratory science; veterinary
medicine; or dental medicine; or
``(ii) another accredited graduate school or
program, as deemed appropriate by the Secretary;
``(2) be eligible for, or hold, an appointment as a
commissioned officer in the Regular or Reserve Corps of the
Service or be eligible for selection for civilian service in
the Corps; and
``(3) sign and submit to the Secretary a written contract
(described in subsection (c)) to serve full-time as a public
health professional, upon the completion of the course of study
or program involved, for the period of obligated service
described in subsection (c)(2)(E).
``(c) Contract.--The written contract between the Secretary and an
individual under subsection (b)(3) shall contain--
``(1) an agreement on the part of the Secretary that the
Secretary will--
``(A) provide the individual with a scholarship for
a period of years (not to exceed 4 academic years)
during which the individual shall pursue an approved
course of study or program to prepare the individual to
serve in the public health workforce; and
``(B) accept (subject to the availability of
appropriated funds) the individual into the Corps;
``(2) an agreement on the part of the individual that the
individual will--
``(A) accept provision of such scholarship to the
individual;
``(B) maintain full-time or part-time enrollment in
the approved course of study or program described in
subsection (b)(1) until the individual completes that
course of study or program;
``(C) while enrolled in the approved course of
study or program, maintain an acceptable level of
academic standing (as determined by the educational
institution offering such course of study or program);
``(D) if applicable, complete a residency or
internship; and
``(E) serve full-time as a public health
professional for a period of time equal to the greater
of--
``(i) 1 year for each academic year for
which the individual was provided a scholarship
under the Program; or
``(ii) 2 years; and
``(3) an agreement by both parties as to the nature and
extent of the scholarship assistance, which may include--
``(A) payment of reasonable educational expenses of
the individual, including tuition, fees, books,
equipment, and laboratory expenses; and
``(B) payment of a stipend of not more than $1,269
(plus, beginning with fiscal year 2012, an amount
determined by the Secretary on an annual basis to
reflect inflation) per month for each month of the
academic year involved, with the dollar amount of such
a stipend determined by the Secretary taking into
consideration whether the individual is enrolled full-
time or part-time.
``(d) Application of Certain Provisions.--The provisions of subpart
III shall, except as inconsistent with this subpart, apply to the
scholarship program under this section in the same manner and to the
same extent as such provisions apply to the National Health Service
Corps Scholarship Program established under section 338A.
``SEC. 340N. 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') for the purpose described in section 340L(a).
``(b) Eligibility.--To be eligible to participate in the Program,
an individual shall--
``(1)(A) have a graduate degree from an accredited school
or program of public health;
``(B) have demonstrated expertise in public health and have
a graduate degree in a course of study or program (approved by
the Secretary) from--
``(i) an accredited school or program of nursing;
health administration, management, or policy;
preventive medicine; laboratory science; veterinary
medicine; or dental medicine; or
``(ii) another accredited school or program
approved by the Secretary; or
``(C) be enrolled as a full-time or part-time student in
the final year of a course of study or program (approved by the
Secretary) offered by a school or program described in
subparagraph (A) or (B), leading to a graduate degree;
``(2) be eligible for, or hold, an appointment as a
commissioned officer in the Regular or Reserve Corps of the
Service or be eligible for selection for civilian service in
the Corps;
``(3) if applicable, complete a residency or internship;
and
``(4) sign and submit to the Secretary a written contract
(described in subsection (c)) to serve full-time as a public
health professional for the period of obligated service
described in subsection (c)(2).
``(c) Contract.--The written contract between the Secretary and an
individual under subsection (b)(4) shall contain--
``(1) an agreement by the Secretary to repay on behalf of
the individual loans incurred by the individual in the pursuit
of the relevant public health workforce educational degree in
accordance with the terms of the contract;
``(2) an agreement by the individual to serve full-time as
a public health professional for a period of time equal to 2
years or such longer period as the individual may agree to; and
``(3) in the case of an individual described in subsection
(b)(1)(C) who is in the final year of study and who has
accepted employment as a public health professional, in
accordance with section 340L(c), an agreement on the part of
the individual to complete the education or training, maintain
an acceptable level of academic standing (as determined by the
educational institution offering the course of study or
training), and serve the period of obligated service described
in paragraph (2).
``(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 reasonable
educational expenses, including tuition, fees, books,
equipment, and laboratory expenses, incurred by the individual.
``(2) Payments for years served.--
``(A) In general.--For each year of obligated
service that an individual contracts to serve under
subsection (c), the Secretary may pay up to $35,000
(plus, beginning with fiscal year 2012, an amount
determined by the Secretary on an annual basis to
reflect inflation) on behalf of the individual for
loans described in paragraph (1).
``(B) Repayment schedule.--Any arrangement made by
the Secretary for the making of loan repayments in
accordance with this subsection shall provide that any
repayments for a year of obligated service shall be
made no later than the end of the fiscal year in which
the individual completes such year of service.
``(e) Application of Certain Provisions.--The provisions of subpart
III shall, except as inconsistent with this subpart, apply to the loan
repayment program under this section in the same manner and to the same
extent as such provisions apply to the National Health Service Corps
Loan Repayment Program established under section 338B.''.
SEC. 2232. ENHANCING THE PUBLIC HEALTH WORKFORCE.
Section 765 (42 U.S.C. 295) is amended to read as follows:
``SEC. 765. ENHANCING THE PUBLIC HEALTH WORKFORCE.
``(a) Program.--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 establish a public health workforce training and enhancement
program consisting of awarding grants and contracts under subsection
(b).
``(b) Grants and Contracts.--The Secretary shall award grants to,
or enter into contracts with, eligible entities--
``(1) to plan, develop, operate, or participate in, an
accredited professional training program in the field of public
health (including such a program in nursing; health
administration, management, or policy; preventive medicine;
laboratory science; veterinary medicine; or dental medicine)
for members of the public health workforce, including midcareer
professionals;
``(2) to provide financial assistance in the form of
traineeships and fellowships to students who are participants
in any such program and who plan to specialize or work in the
field of public health;
``(3) to plan, develop, operate, or participate in a
program for the training of public health professionals who
plan to teach in any program described in paragraph (1); and
``(4) to provide financial assistance in the form of
traineeships and fellowships to public health professionals who
are participants in any program described in paragraph (1) and
who plan to teach in the field of public health, including
nursing; health administration, management, or policy;
preventive medicine; laboratory science; veterinary medicine;
or dental medicine.
``(c) Eligibility.--To be eligible for a grant or contract under
this section, an entity shall be--
``(1) an accredited health professions school, including an
accredited school or program of public health; nursing; health
administration, management, or policy; preventive medicine;
laboratory science; veterinary medicine; or dental medicine;
``(2) a State, local, or tribal health department;
``(3) a public or private nonprofit entity; or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(d) Preference.--In awarding grants or contracts under this
section, the Secretary shall give preference to entities that have a
demonstrated record of at least one of the following:
``(1) Training a high or significantly improved percentage
of public health professionals who serve in underserved
communities.
``(2) Training individuals who are from disadvantaged
backgrounds (including racial and ethnic minorities
underrepresented among public health professionals).
``(3) Training individuals in public health specialties
experiencing a significant shortage of public health
professionals (as determined by the Secretary).
``(4) Training a high or significantly improved percentage
of public health professionals serving in the Federal
Government or a State, local, or tribal government.
``(e) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.''.
SEC. 2233. PUBLIC HEALTH TRAINING CENTERS.
Section 766 (42 U.S.C. 295a) is amended--
(1) in subsection (b)(1), by striking ``in furtherance of
the goals established by the Secretary for the year 2000'' and
inserting ``in furtherance of the goals established by the
Secretary in the national prevention and wellness strategy
under section 3121''; and
(2) by adding at the end the following:
``(d) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.''.
SEC. 2234. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING GRANT
PROGRAM.
Section 768 (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.''.
SEC. 2235. AUTHORIZATION OF APPROPRIATIONS.
(a) In General.--Section 799C, as added by section 2216 of this
Act, is amended by adding at the end the following:
``(b) Public Health Workforce.--For the purpose of carrying out
subpart XII of part D of title III and sections 765, 766, and 768, in
addition to any other amounts authorized to be appropriated for such
purpose, there are authorized to be appropriated, out of any monies in
the Public Health Investment Fund, the following:
``(1) $51,000,000 for fiscal year 2011.
``(2) $54,000,000 for fiscal year 2012.
``(3) $57,000,000 for fiscal year 2013.
``(4) $59,000,000 for fiscal year 2014.
``(5) $62,000,000 for fiscal year 2015.''.
(b) Existing Authorization of Appropriations.--Subsection (a) of
section 770 (42 U.S.C. 295e) is amended by striking ``2002'' and
inserting ``2015''.
Subtitle D--Adapting Workforce to Evolving Health System Needs
PART 1--HEALTH PROFESSIONS TRAINING FOR DIVERSITY
SEC. 2241. SCHOLARSHIPS FOR DISADVANTAGED STUDENTS, LOAN REPAYMENTS AND
FELLOWSHIPS REGARDING FACULTY POSITIONS, AND EDUCATIONAL
ASSISTANCE IN THE HEALTH PROFESSIONS REGARDING
INDIVIDUALS FROM DISADVANTAGED BACKGROUNDS.
Paragraph (1) of section 738(a) (42 U.S.C. 293b(a)) is amended by
striking ``not more than $20,000'' and all that follows through the end
of the paragraph and inserting: ``not more than $35,000 (plus,
beginning with fiscal year 2012, an amount determined by the Secretary
on an annual basis to reflect inflation) of the principal and interest
of the educational loans of such individuals.''.
SEC. 2242. NURSING WORKFORCE DIVERSITY GRANTS.
Subsection (b) of section 821 (42 U.S.C. 296m) is amended--
(1) in the heading, by striking ``Guidance'' and inserting
``Consultation''; and
(2) by striking ``shall take into consideration'' and all
that follows through ``consult with nursing associations'' and
inserting ``shall, as appropriate, consult with nursing
associations''.
SEC. 2243. COORDINATION OF DIVERSITY AND CULTURAL COMPETENCY PROGRAMS.
(a) In General.--Title VII (42 U.S.C. 292 et seq.) is amended by
inserting after section 739 the following:
``SEC. 739A. COORDINATION OF DIVERSITY AND CULTURAL COMPETENCY
PROGRAMS.
``The Secretary shall, to the extent practicable, coordinate the
activities carried out under this part and section 821 in order to
enhance the effectiveness of such activities and avoid duplication of
effort.''.
(b) Report.--Section 736 (42 U.S.C. 293) is amended--
(1) by redesignating subsection (h) as subsection (i); and
(2) by inserting after subsection (g) the following:
``(h) Report.--The Secretary shall submit to the Congress an annual
report on the activities carried out under this section.''.
PART 2--INTERDISCIPLINARY TRAINING PROGRAMS
SEC. 2251. CULTURAL AND LINGUISTIC COMPETENCY TRAINING FOR HEALTH
PROFESSIONALS.
Section 741 (42 U.S.C. 293e) is amended--
(1) in the section heading, by striking ``grants for health
professions education'' and inserting ``cultural and linguistic
competency training for health professionals'';
(2) by redesignating subsection (b) as subsection (h); and
(3) by striking subsection (a) and inserting the following:
``(a) Program.--The Secretary shall establish a cultural and
linguistic competency training program for health professionals,
including nurse professionals, consisting of awarding grants and
contracts under subsection (b).
``(b) Cultural and Linguistic Competency Training.--The Secretary
shall award grants to, or enter into contracts with, eligible
entities--
``(1) to test, develop, and evaluate models of cultural and
linguistic competency training (including continuing education)
for health professionals; and
``(2) to implement cultural and linguistic competency
training programs for health professionals developed under
paragraph (1) or otherwise.
``(c) Eligibility.--To be eligible for a grant or contract under
subsection (b), an entity shall be--
``(1) an accredited health professions school or program;
``(2) an academic health center;
``(3) a public or private nonprofit entity; or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(d) Preference.--In awarding grants and contracts under this
section, the Secretary shall give preference to entities that have a
demonstrated record of at least one of the following:
``(1) Addressing, or partnering with an entity with
experience addressing, the cultural and linguistic competency
needs of the population to be served through the grant or
contract.
``(2) Addressing health disparities.
``(3) Placing health professionals in regions experiencing
significant changes in the cultural and linguistic demographics
of populations, including communities along the United States-
Mexico border.
``(4) Carrying out activities described in subsection (b)
with respect to more than one health profession discipline,
specialty, or subspecialty.
``(e) Consultation.--The Secretary shall carry out this section in
consultation with the heads of appropriate health agencies and offices
in the Department of Health and Human Services, including the Office of
Minority Health and the National Center on Minority Health and Health
Disparities.
``(f) Definition.--In this section, the term `health disparities'
has the meaning given to the term in section 3171.
``(g) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.''.
SEC. 2252. INNOVATIONS IN INTERDISCIPLINARY CARE TRAINING.
Part D of title VII (42 U.S.C. 294 et seq.) is amended by adding at
the end the following:
``SEC. 759. INNOVATIONS IN INTERDISCIPLINARY CARE TRAINING.
``(a) Program.--The Secretary shall establish an innovations in
interdisciplinary care training program consisting of awarding grants
and contracts under subsection (b).
``(b) Training Programs.--The Secretary shall award grants to, or
enter into contracts with, eligible entities--
``(1) to test, develop, and evaluate health professional
training programs (including continuing education) designed to
promote--
``(A) the delivery of health services through
interdisciplinary and team-based models, which may
include patient-centered medical home models,
medication therapy management models, and models
integrating physical, mental, or oral health services;
and
``(B) coordination of the delivery of health care
within and across settings, including health care
institutions, community-based settings, and the
patient's home; and
``(2) to implement such training programs developed under
paragraph (1) or otherwise.
``(c) Eligibility.--To be eligible for a grant or contract under
subsection (b), an entity shall be--
``(1) an accredited health professions school or program;
``(2) an academic health center;
``(3) a public or private nonprofit entity (including an
area health education center or a geriatric education center);
or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(d) Preferences.--In awarding grants and contracts under this
section, the Secretary shall give preference to entities that have a
demonstrated record of at least one of the following:
``(1) Training a high or significantly improved percentage
of health professionals who serve in underserved communities.
``(2) Broad interdisciplinary team-based collaborations.
``(3) Addressing health disparities.
``(e) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.
``(f) Definitions.--In this section:
``(1) The term `health disparities' has the meaning given
the term in section 3171.
``(2) The term `interdisciplinary' means collaboration
across health professions and specialties, which may include
public health, nursing, allied health, dietetics or nutrition,
and appropriate health specialties.''.
PART 3--ADVISORY COMMITTEE ON HEALTH WORKFORCE EVALUATION AND
ASSESSMENT
SEC. 2261. HEALTH WORKFORCE EVALUATION AND ASSESSMENT.
Subpart 1 of part E of title VII (42 U.S.C. 294n et seq.) is
amended by adding at the end the following:
``SEC. 764. HEALTH WORKFORCE EVALUATION AND ASSESSMENT.
``(a) Advisory Committee.--The Secretary, acting through the
Assistant Secretary for Health, shall establish a permanent advisory
committee to be known as the Advisory Committee on Health Workforce
Evaluation and Assessment (referred to in this section as the `Advisory
Committee') to develop and implement an integrated, coordinated, and
strategic national health workforce policy reflective of current and
evolving health workforce needs.
``(b) Responsibilities.--The Advisory Committee shall--
``(1) not later than 1 year after the date of the
establishment of the Advisory Committee, submit recommendations
to the Secretary on--
``(A) classifications of the health workforce to
ensure consistency of data collection on the health
workforce; and
``(B) based on such classifications, standardized
methodologies and procedures to enumerate the health
workforce;
``(2) not later than 2 years after the date of the
establishment of the Advisory Committee, submit recommendations
to the Secretary on--
``(A) the supply, diversity, and geographic
distribution of the health workforce;
``(B) the retention and expansion of the health
workforce (on a short- and long-term basis) to ensure
quality and adequacy of such workforce; and
``(C) policies to carry out the recommendations
made pursuant to subparagraphs (A) and (B); and
``(3) not later than 4 years after the date of the
establishment of the Advisory Committee, and every 2 years
thereafter, submit updated recommendations to the Secretary
under paragraphs (1) and (2).
``(c) Role of Agency.--The Secretary shall provide ongoing
administrative, research, and technical support for the operations of
the Advisory Committee, including coordinating and supporting the
dissemination of the recommendations of the Advisory Committee.
``(d) Membership.--
``(1) Number; appointment.--The Secretary shall appoint 15
members to serve on the Advisory Committee.
``(2) Terms.--
``(A) In general.--The Secretary shall appoint
members of the Advisory Committee for a term of 3 years
and may reappoint such members, but the Secretary may
not appoint any member to serve more than a total of 6
years.
``(B) Staggered terms.--Notwithstanding
subparagraph (A), of the members first appointed to the
Advisory Committee under paragraph (1)--
``(i) 5 shall be appointed for a term of 1
year;
``(ii) 5 shall be appointed for a term of 2
years; and
``(iii) 5 shall be appointed for a term of
3 years.
``(3) Qualifications.--Members of the Advisory Committee
shall be appointed from among individuals who possess expertise
in at least one of the following areas:
``(A) Conducting and interpreting health workforce
market analysis, including health care labor workforce
analysis.
``(B) Conducting and interpreting health finance
and economics research.
``(C) Delivering and administering health care
services.
``(D) Delivering and administering health workforce
education and training.
``(4) Representation.--In appointing members of the
Advisory Committee, the Secretary shall--
``(A) include no less than one representative of
each of--
``(i) health professionals within the
health workforce;
``(ii) health care patients and consumers;
``(iii) employers;
``(iv) labor unions; and
``(v) third-party health payors; and
``(B) ensure that--
``(i) all areas of expertise described in
paragraph (3) are represented;
``(ii) the members of the Advisory
Committee include members who, collectively,
have significant experience working with--
``(I) populations in urban and
federally designated rural and
nonmetropolitan areas; and
``(II) populations who are
underrepresented in the health
professions, including underrepresented
minority groups; and
``(iii) individuals who are directly
involved in health professions education or
practice do not constitute a majority of the
members of the Advisory Committee.
``(5) Disclosure and conflicts of interest.--Members of the
Advisory Committee shall not be considered employees of the
Federal Government by reason of service on the Advisory
Committee, except members of the Advisory Committee shall be
considered to be special Government employees within the
meaning of section 107 of the Ethics in Government Act of 1978
(5 U.S.C. App.) and section 208 of title 18, United States
Code, for the purposes of disclosure and management of
conflicts of interest under those sections.
``(6) No pay; receipt of travel expenses.--Members of the
Advisory Committee shall not receive any pay for service on the
Committee, but may receive travel expenses, including a per
diem, in accordance with applicable provisions of subchapter I
of chapter 57 of title 5, United States Code.
``(e) Consultation.--In carrying out this section, the Secretary
shall consult with the Secretary of Education and the Secretary of
Labor.
``(f) Collaboration.--The Advisory Committee shall collaborate with
the advisory bodies at the Health Resources and Services
Administration, the National Advisory Council (as authorized in section
337), the Advisory Committee on Training in Primary Care Medicine and
Dentistry (as authorized in section 749A), the Advisory Committee on
Interdisciplinary, Community-Based Linkages (as authorized in section
756), the Advisory Council on Graduate Medical Education (as authorized
in section 762), and the National Advisory Council on Nurse Education
and Practice (as authorized in section 851).
``(g) FACA.--The Federal Advisory Committee Act (5 U.S.C. App.)
except for section 14 of such Act shall apply to the Advisory Committee
under this section only to the extent that the provisions of such Act
do not conflict with the requirements of this section.
``(h) Report.--The Secretary shall submit to the Congress an annual
report on the activities of the Advisory Committee.
``(i) Definition.--In this section, the term `health workforce'
includes all health care providers with direct patient care and support
responsibilities, including physicians, nurses, physician assistants,
pharmacists, oral health professionals (as defined in section
749(f)(2)), allied health professionals, mental and behavioral health
professionals (as defined in section 775(f)(2)), and public health
professionals (including veterinarians engaged in public health
practice).''.
PART 4--HEALTH WORKFORCE ASSESSMENT
SEC. 2271. HEALTH WORKFORCE ASSESSMENT.
(a) In General.--Section 761 (42 U.S.C. 294n) is amended--
(1) by redesignating subsection (c) as subsection (e); and
(2) by striking subsections (a) and (b) and inserting the
following:
``(a) In General.--The Secretary shall, based upon the
classifications and standardized methodologies and procedures developed
by the Advisory Committee on Health Workforce Evaluation and Assessment
under section 764(b)--
``(1) collect data on the health workforce (as defined in
section 764(i)), disaggregated by field, discipline, and
specialty, with respect to--
``(A) the supply (including retention) of health
professionals relative to the demand for such
professionals;
``(B) the diversity of health professionals
(including with respect to race, ethnic background, and
sex); and
``(C) the geographic distribution of health
professionals; and
``(2) collect such data on individuals participating in the
programs authorized by subtitles A, B, and C and part 1 of
subtitle D of title II of division C of the Affordable Health
Care for America Act.
``(b) Grants and Contracts for Health Workforce Analysis.--
``(1) In general.--The Secretary may award grants to, or
enter into contracts with, eligible entities to carry out
subsection (a).
``(2) Eligibility.--To be eligible for a grant or contract
under this subsection, an entity shall be--
``(A) an accredited health professions school or
program;
``(B) an academic health center;
``(C) a State, local, or tribal government;
``(D) a public or private entity; or
``(E) a consortium of 2 or more entities described
in subparagraphs (A) through (D).
``(c) Collaboration and Data Sharing.--The Secretary shall
collaborate with Federal departments and agencies, health professions
organizations (including health professions education organizations),
and professional medical societies for the purpose of carrying out
subsection (a).
``(d) Report.--The Secretary shall submit to the Congress an annual
report on the data collected under subsection (a).''.
(b) Period Before Completion of National Strategy.--Pending
completion of the classifications and standardized methodologies and
procedures developed by the Advisory Committee on Health Workforce
Evaluation and Assessment under section 764(b) of the Public Health
Service Act, as added by section 2261, the Secretary of Health and
Human Services, acting through the Administrator of the Health
Resources and Services Administration and in consultation with such
Advisory Committee, may make a judgment about the classifications,
methodologies, and procedures to be used for collection of data under
section 761(a) of the Public Health Service Act, as amended by this
section.
PART 5--AUTHORIZATION OF APPROPRIATIONS
SEC. 2281. AUTHORIZATION OF APPROPRIATIONS.
(a) In General.--Section 799C, as added and amended, is further
amended by adding at the end the following:
``(c) Health Professions Training for Diversity.--For the purpose
of carrying out sections 736, 737, 738, 739, and 739A, in addition to
any other amounts authorized to be appropriated for such purpose, there
are authorized to be appropriated, out of any monies in the Public
Health Investment Fund, the following:
``(1) $90,000,000 for fiscal year 2011.
``(2) $97,000,000 for fiscal year 2012.
``(3) $100,000,000 for fiscal year 2013.
``(4) $104,000,000 for fiscal year 2014.
``(5) $110,000,000 for fiscal year 2015.
``(d) Interdisciplinary Training Programs, Advisory Committee on
Health Workforce Evaluation and Assessment, and Health Workforce
Assessment.--For the purpose of carrying out sections 741, 759, 761,
and 764, in addition to any other amounts authorized to be appropriated
for such purpose, there are authorized to be appropriated, out of any
monies in the Public Health Investment Fund, the following:
``(1) $87,000,000 for fiscal year 2011.
``(2) $97,000,000 for fiscal year 2012.
``(3) $103,000,000 for fiscal year 2013.
``(4) $105,000,000 for fiscal year 2014.
``(5) $113,000,000 for fiscal year 2015.''.
(b) Existing Authorizations of Appropriations.--
(1) Section 736.--Paragraph (1) of section 736(i) (42
U.S.C. 293(h)), as redesignated, is amended by striking
``2002'' and inserting ``2015''.
(2) Sections 737, 738, and 739.--Subsections (a), (b), and
(c) of section 740 are amended by striking ``2002'' each place
it appears and inserting ``2015''.
(3) Section 741.--Subsection (h), as so redesignated, of
section 741 is amended--
(A) by striking ``and'' after ``fiscal year
2003,''; and
(B) by inserting ``, and such sums as may be
necessary for each subsequent fiscal year through the
end of fiscal year 2015'' before the period at the end.
(4) Section 761.--Subsection (e)(1), as so redesignated, of
section 761 is amended by striking ``2002'' and inserting
``2015''.
TITLE III--PREVENTION AND WELLNESS
SEC. 2301. PREVENTION AND WELLNESS.
(a) In General.--The Public Health Service Act (42 U.S.C. 201 et
seq.) is amended by inserting after title XXX the following:
``TITLE XXXI--PREVENTION AND WELLNESS
``Subtitle A--Prevention and Wellness Trust
``SEC. 3111. PREVENTION AND WELLNESS TRUST.
``(a) Deposits Into Trust.--There is established a Prevention and
Wellness Trust. There are authorized to be appropriated to the Trust--
``(1) out of the general fund of the Treasury, amounts
described in section 2002(b)(2)(A)(ii) of the Affordable Health
Care for America Act for each fiscal year; and
``(2) in addition, out of any monies in the Public Health
Investment Fund--
``(A) for fiscal year 2011, $2,400,000,000;
``(B) for fiscal year 2012, $2,845,000,000;
``(C) for fiscal year 2013, $3,100,000,000;
``(D) for fiscal year 2014, $3,455,000,000; and
``(E) for fiscal year 2015, $3,600,000,000.
``(b) Availability of Funds.--Amounts in the Prevention and
Wellness Trust shall be available, as provided in advance in
appropriation Acts, for carrying out this title.
``(c) Allocation.--Of the amounts authorized to be appropriated in
subsection (a)(2), there are authorized to be appropriated--
``(1) for carrying out subtitle C (Prevention Task Forces),
$30,000,000 for each of fiscal years 2011 through 2015;
``(2) for carrying out subtitle D (Prevention and Wellness
Research)--
``(A) for fiscal year 2011, $155,000,000;
``(B) for fiscal year 2012, $205,000,000;
``(C) for fiscal year 2013, $255,000,000;
``(D) for fiscal year 2014, $305,000,000; and
``(E) for fiscal year 2015, $355,000,000;
``(3) for carrying out subtitle E (Delivery of Community
Preventive and Wellness Services)--
``(A) for fiscal year 2011, $1,065,000,000;
``(B) for fiscal year 2012, $1,260,000,000;
``(C) for fiscal year 2013, $1,365,000,000;
``(D) for fiscal year 2014, $1,570,000,000; and
``(E) for fiscal year 2015, $1,600,000,000;
``(4) for carrying out section 3161 (Core Public Health
Infrastructure for State, Local, and Tribal Health
Departments)--
``(A) for fiscal year 2011, $800,000,000;
``(B) for fiscal year 2012, $1,000,000,000;
``(C) for fiscal year 2013, $1,100,000,000;
``(D) for fiscal year 2014, $1,200,000,000; and
``(E) for fiscal year 2015, $1,265,000,000; and
``(5) for carrying out section 3162 (Core Public Health
Infrastructure and Activities for CDC), $350,000,000 for each
of fiscal years 2011 through 2015.
``Subtitle B--National Prevention and Wellness Strategy
``SEC. 3121. NATIONAL PREVENTION AND WELLNESS STRATEGY.
``(a) In General.--The Secretary shall submit to the Congress
within one year after the date of the enactment of this section, and at
least every 2 years thereafter, a national strategy that is designed to
improve the Nation's health through evidence-based clinical and
community prevention and wellness activities (in this section referred
to as `prevention and wellness activities'), including core public
health infrastructure improvement activities.
``(b) Contents.--The strategy under subsection (a) shall include
each of the following:
``(1) Identification of specific national goals and
objectives in prevention and wellness activities that take into
account appropriate public health measures and standards,
including departmental measures and standards (including
Healthy People and National Public Health Performance
Standards).
``(2) Establishment of national priorities for prevention
and wellness, taking into account unmet prevention and wellness
needs.
``(3) Establishment of national priorities for research on
prevention and wellness, taking into account unanswered
research questions on prevention and wellness.
``(4) Identification of health disparities in prevention
and wellness.
``(5) Review of prevention payment incentives, the
prevention workforce, and prevention delivery system capacity.
``(6) A plan for addressing and implementing paragraphs (1)
through (5).
``(c) Consultation.--In developing or revising the strategy under
subsection (a), the Secretary shall consult with the following:
``(1) The heads of appropriate health agencies and offices
in the Department, including the Office of the Surgeon General
of the Public Health Service, the Office of Minority Health,
the Office on Women's Health, and the Substance Abuse and
Mental Health Services Administration.
``(2) As appropriate, the heads of other Federal
departments and agencies whose programs have a significant
impact upon health (as determined by the Secretary).
``(3) As appropriate, nonprofit and for-profit entities.
``(4) The Association of State and Territorial Health
Officials and the National Association of County and City
Health Officials.
``(5) The Task Force on Community Preventive Services and
the Task Force on Clinical Preventive Services.
``Subtitle C--Prevention Task Forces
``SEC. 3131. TASK FORCE ON CLINICAL PREVENTIVE SERVICES.
``(a) In General.--The Secretary, acting through the Director of
the Agency for Healthcare Research and Quality, shall establish a
permanent task force to be known as the Task Force on Clinical
Preventive Services (in this section referred to as the `Task Force').
``(b) Responsibilities.--The Task Force shall--
``(1) identify clinical preventive services for review;
``(2) review the scientific evidence related to the
benefits, effectiveness, appropriateness, and costs of clinical
preventive services identified under paragraph (1) for the
purpose of developing, updating, publishing, and disseminating
evidence-based recommendations on the use of such services;
``(3) as appropriate, take into account health disparities
in developing, updating, publishing, and disseminating
evidence-based recommendations on the use of such services;
``(4) identify gaps in clinical preventive services
research and evaluation and recommend priority areas for such
research and evaluation;
``(5) pursuant to section 3143(c), determine whether
subsidies and rewards meet the Task Force's standards for a
grade of A or B;
``(6) as appropriate, consult with the clinical prevention
stakeholders board in accordance with subsection (f);
``(7) consult with the Task Force on Community Preventive
Services established under section 3132; and
``(8) as appropriate, in carrying out this section,
consider the national strategy under section 3121.
``(c) Role of Agency.--The Secretary 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.
``(d) Membership.--
``(1) Number; appointment.--The Task Force shall be
composed of 30 members, appointed by the Secretary.
``(2) Terms.--
``(A) In general.--The Secretary shall appoint
members of the Task Force for a term of 6 years and may
reappoint such members, but the Secretary may not
appoint any member to serve more than a total of 12
years.
``(B) Staggered terms.--Notwithstanding
subparagraph (A), of the members first appointed to
serve on the Task Force after the enactment of this
title--
``(i) 10 shall be appointed for a term of 2
years;
``(ii) 10 shall be appointed for a term of
4 years; and
``(iii) 10 shall be appointed for a term of
6 years.
``(3) Qualifications.--Members of the Task Force shall be
appointed from among individuals who possess expertise in at
least one of the following areas:
``(A) Health promotion and disease prevention.
``(B) Evaluation of research and systematic
evidence reviews.
``(C) Application of systematic evidence reviews to
clinical decisionmaking or health policy.
``(D) Clinical primary care in child and adolescent
health.
``(E) Clinical primary care in adult health,
including women's health.
``(F) Clinical primary care in geriatrics.
``(G) Clinical counseling and behavioral services
for primary care patients.
``(4) Representation.--In appointing members of the Task
Force, the Secretary shall ensure that--
``(A) all areas of expertise described in paragraph
(3) are represented; and
``(B) the members of the Task Force include
individuals with expertise in health disparities.
``(e) Subgroups.--As appropriate to maximize efficiency, the Task
Force may delegate authority for conducting reviews and making
recommendations to subgroups consisting of Task Force members, subject
to final approval by the Task Force.
``(f) Clinical Prevention Stakeholders Board.--
``(1) In general.--The Task Force shall convene a clinical
prevention stakeholders board composed of representatives of
appropriate public and private entities with an interest in
clinical preventive services to advise the Task Force on
developing, updating, publishing, and disseminating evidence-
based recommendations on the use of clinical preventive
services.
``(2) Membership.--The members of the clinical prevention
stakeholders board shall include representatives of the
following:
``(A) Health care consumers and patient groups.
``(B) Providers of clinical preventive services,
including community-based providers.
``(C) Federal departments and agencies, including--
``(i) appropriate health agencies and
offices in the Department, including the Office
of the Surgeon General of the Public Health
Service, the Office of Minority Health, the
National Center on Minority Health and Health
Disparities, and the Office on Women's Health;
and
``(ii) as appropriate, other Federal
departments and agencies whose programs have a
significant impact upon health (as determined
by the Secretary).
``(D) Private health care payors.
``(3) Responsibilities.--In accordance with subsection
(b)(6), the clinical prevention stakeholders board shall--
``(A) recommend clinical preventive services for
review by the Task Force;
``(B) suggest scientific evidence for consideration
by the Task Force related to reviews undertaken by the
Task Force;
``(C) provide feedback regarding draft
recommendations by the Task Force; and
``(D) assist with efforts regarding dissemination
of recommendations by the Director of the Agency for
Healthcare Research and Quality.
``(g) Disclosure and Conflicts of Interest.--Members of the Task
Force or the clinical prevention stakeholders board shall not be
considered employees of the Federal Government by reason of service on
the Task Force or the clinical prevention stakeholders board, except
members of the Task Force or the clinical prevention stakeholders board
shall be considered to be special Government employees within the
meaning of section 107 of the Ethics in Government Act of 1978 (5
U.S.C. App.) and section 208 of title 18, United States Code, for the
purposes of disclosure and management of conflicts of interest under
those sections.
``(h) No Pay; Receipt of Travel Expenses.--Members of the Task
Force or the clinical prevention stakeholders board shall not receive
any pay for service on the Task Force, but may receive travel expenses,
including a per diem, in accordance with applicable provisions of
subchapter I of chapter 57 of title 5, United States Code.
``(i) Application of FACA.--The Federal Advisory Committee Act (5
U.S.C. App.) except for section 14 of such Act shall apply to the Task
Force to the extent that the provisions of such Act do not conflict
with the provisions of this title.
``(j) Report.--The Secretary shall submit to the Congress an annual
report on the Task Force, including with respect to gaps identified and
recommendations made under subsection (b)(4).
``SEC. 3132. TASK FORCE ON COMMUNITY PREVENTIVE SERVICES.
``(a) In General.--The Secretary, acting through the Director of
the Centers for Disease Control and Prevention, shall establish a
permanent task force to be known as the Task Force on Community
Preventive Services (in this section referred to as the `Task Force').
``(b) Responsibilities.--The Task Force shall--
``(1) identify community preventive services for review;
``(2) review the scientific evidence related to the
benefits, effectiveness, appropriateness, and costs of
community preventive services identified under paragraph (1)
for the purpose of developing, updating, publishing, and
disseminating evidence-based recommendations on the use of such
services;
``(3) as appropriate, take into account health disparities
in developing, updating, publishing, and disseminating
evidence-based recommendations on the use of such services;
``(4) identify gaps in community preventive services
research and evaluation and recommend priority areas for such
research and evaluation;
``(5) pursuant to section 3143(d), determine whether
subsidies and rewards are effective;
``(6) as appropriate, consult with the community prevention
stakeholders board in accordance with subsection (f);
``(7) consult with the Task Force on Clinical Preventive
Services established under section 3131; and
``(8) as appropriate, in carrying out this section,
consider the national strategy under section 3121.
``(c) Role of Agency.--The Secretary 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.
``(d) Membership.--
``(1) Number; appointment.--The Task Force shall be
composed of 30 members, appointed by the Secretary.
``(2) Terms.--
``(A) In general.--The Secretary shall appoint
members of the Task Force for a term of 6 years and may
reappoint such members, but the Secretary may not
appoint any member to serve more than a total of 12
years.
``(B) Staggered terms.--Notwithstanding
subparagraph (A), of the members first appointed to
serve on the Task Force after the enactment of this
section--
``(i) 10 shall be appointed for a term of 2
years;
``(ii) 10 shall be appointed for a term of
4 years; and
``(iii) 10 shall be appointed for a term of
6 years.
``(3) Qualifications.--Members of the Task Force shall be
appointed from among individuals who possess expertise in at
least one of the following areas:
``(A) Public health.
``(B) Evaluation of research and systematic
evidence reviews.
``(C) Disciplines relevant to community preventive
services, including health promotion; disease
prevention; chronic disease; worksite health; school-
site health; qualitative and quantitative analysis; and
health economics, policy, law, and statistics.
``(4) Representation.--In appointing members of the Task
Force, the Secretary--
``(A) shall ensure that all areas of expertise
described in paragraph (3) are represented;
``(B) shall ensure that such members include
sufficient representatives of each of--
``(i) State health officers;
``(ii) local health officers;
``(iii) health care practitioners; and
``(iv) public health practitioners; and
``(C) shall appoint individuals who have expertise
in health disparities.
``(e) Subgroups.--As appropriate to maximize efficiency, the Task
Force may delegate authority for conducting reviews and making
recommendations to subgroups consisting of Task Force members, subject
to final approval by the Task Force.
``(f) Community Prevention Stakeholders Board.--
``(1) In general.--The Task Force shall convene a community
prevention stakeholders board composed of representatives of
appropriate public and private entities with an interest in
community preventive services to advise the Task Force on
developing, updating, publishing, and disseminating evidence-
based recommendations on the use of community preventive
services.
``(2) Membership.--The members of the community prevention
stakeholders board shall include representatives of the
following:
``(A) Health care consumers and patient groups.
``(B) Providers of community preventive services,
including community-based providers.
``(C) Federal departments and agencies, including--
``(i) appropriate health agencies and
offices in the Department, including the Office
of the Surgeon General of the Public Health
Service, the Office of Minority Health, the
National Center on Minority Health and Health
Disparities, and the Office on Women's Health;
and
``(ii) as appropriate, other Federal
departments and agencies whose programs have a
significant impact upon health (as determined
by the Secretary).
``(D) Private health care payors.
``(3) Responsibilities.--In accordance with subsection
(b)(6), the community prevention stakeholders board shall--
``(A) recommend community preventive services for
review by the Task Force;
``(B) suggest scientific evidence for consideration
by the Task Force related to reviews undertaken by the
Task Force;
``(C) provide feedback regarding draft
recommendations by the Task Force; and
``(D) assist with efforts regarding dissemination
of recommendations by the Director of the Centers for
Disease Control and Prevention.
``(g) Disclosure and Conflicts of Interest.--Members of the Task
Force or the community prevention stakeholders board shall not be
considered employees of the Federal Government by reason of service on
the Task Force or the community prevention stakeholders board, except
members of the Task Force or the community prevention stakeholders
board shall be considered to be special Government employees within the
meaning of section 107 of the Ethics in Government Act of 1978 (5
U.S.C. App.) and section 208 of title 18, United States Code, for the
purposes of disclosure and management of conflicts of interest under
those sections.
``(h) No Pay; Receipt of Travel Expenses.--Members of the Task
Force or the community prevention stakeholders board shall not receive
any pay for service on the Task Force, but may receive travel expenses,
including a per diem, in accordance with applicable provisions of
subchapter I of chapter 57 of title 5, United States Code.
``(i) Application of FACA.--The Federal Advisory Committee Act (5
U.S.C. App.) except for section 14 of such Act shall apply to the Task
Force to the extent that the provisions of such Act do not conflict
with the provisions of this title.
``(j) Report.--The Secretary shall submit to the Congress an annual
report on the Task Force, including with respect to gaps identified and
recommendations made under subsection (b)(4).
``Subtitle D--Prevention and Wellness Research
``SEC. 3141. PREVENTION AND WELLNESS RESEARCH ACTIVITY COORDINATION.
``In conducting or supporting research on prevention and wellness,
the Director of the Centers for Disease Control and Prevention, the
Director of the National Institutes of Health, and the heads of other
agencies within the Department of Health and Human Services conducting
or supporting such research, shall take into consideration the national
strategy under section 3121 and the recommendations of the Task Force
on Clinical Preventive Services under section 3131 and the Task Force
on Community Preventive Services under section 3132.
``SEC. 3142. COMMUNITY PREVENTION AND WELLNESS RESEARCH GRANTS.
``(a) In General.--The Secretary, acting through the Director of
the Centers for Disease Control and Prevention, shall conduct, or award
grants to eligible entities to conduct, research in priority areas
identified by the Secretary in the national strategy under section 3121
or by the Task Force on Community Preventive Services as required by
section 3132.
``(b) Eligibility.--To be eligible for a grant under this section,
an entity shall be--
``(1) a State, local, or tribal department of health;
``(2) a public or private nonprofit entity; or
``(3) a consortium of 2 or more entities described in
paragraphs (1) and (2).
``(c) Report.--The Secretary shall submit to the Congress an annual
report on the program of research under this section.
``SEC. 3143. RESEARCH ON SUBSIDIES AND REWARDS TO ENCOURAGE WELLNESS
AND HEALTHY BEHAVIORS.
``(a) Research and Demonstration Projects.--
``(1) In general.--The Secretary shall conduct, or award
grants to public or nonprofit private entities to conduct,
research and demonstration projects on the use of financial and
in-kind subsidies and rewards to encourage individuals and
communities to promote wellness, adopt healthy behaviors, and
use evidence-based preventive health services.
``(2) Focus.--Research and demonstration projects under
paragraph (1) shall focus on--
``(A) tobacco use, obesity, and other prevention
and wellness priorities identified by the Secretary in
the national strategy under section 3121;
``(B) the initiation, maintenance, and long-term
sustainability of wellness promotion; adoption of
healthy behaviors; and use of evidence-based preventive
health services; and
``(C) populations at high risk of preventable
diseases and conditions.
``(b) Findings; Report.--
``(1) Submission of findings.--The Secretary shall submit
the findings of research and demonstration projects under
subsection (a) to--
``(A) the Task Force on Clinical Preventive
Services established under section 3131 or the Task
Force on Community Preventive Services established
under section 3132, as appropriate; and
``(B) the Health Benefits Advisory Committee
established by section 223 of the Affordable Health
Care for America Act.
``(2) Report to congress.--Not later than 18 months after
the initiation of research and demonstration projects under
subsection (a), the Secretary shall submit a report to the
Congress on the progress of such research and projects,
including any preliminary findings.
``(c) Inclusion in Essential Benefits Package.--If, on the basis of
the findings of research and demonstration projects under subsection
(a) or other sources consistent with section 3131, the Task Force on
Clinical Preventive Services determines that a subsidy or reward meets
the Task Force's standards for a grade A or B, the Secretary shall
ensure that the subsidy or reward is included in the essential benefits
package under section 222.
``(d) Inclusion as Allowable Use of Community Prevention and
Wellness Services Grants.--If, on the basis of the findings of research
and demonstration projects under subsection (a) or other sources
consistent with section 3132, the Task Force on Community Preventive
Services determines that a subsidy or reward is effective, the
Secretary shall ensure that the subsidy or reward becomes an allowable
use of grant funds under section 3151.
``(e) Nondiscrimination; No Tie to Premium or Cost Sharing.--In
carrying out this section, the Secretary shall ensure that any subsidy
or reward--
``(1) does not have a discriminatory effect on the basis of
any personal characteristic extraneous to the provision of
high-quality health care or related services; and
``(2) is not tied to the premium or cost sharing of an
individual under any qualified health benefits plan (as defined
in section 100(c)).
``Subtitle E--Delivery of Community Prevention and Wellness Services
``SEC. 3151. COMMUNITY PREVENTION AND WELLNESS SERVICES GRANTS.
``(a) In General.--The Secretary, acting through the Director of
the Centers for Disease Control and Prevention, shall establish a
program for the delivery of community prevention and wellness services
consisting of awarding grants to eligible entities--
``(1) to provide evidence-based, community prevention and
wellness services in priority areas identified by the Secretary
in the national strategy under section 3121; or
``(2) to plan such services.
``(b) Eligibility.--
``(1) Definition.--To be eligible for a grant under this
section, an entity shall be--
``(A) a State, local, or tribal department of
health;
``(B) a public or private entity; or
``(C) a consortium that--
``(i) consists of 2 or more entities
described in subparagraph (A) or (B); and
``(ii) may be a community partnership
representing a Health Empowerment Zone.
``(2) Health empowerment zone.--In this subsection, the
term `Health Empowerment Zone' means an area--
``(A) in which multiple community prevention and
wellness services are implemented in order to address
one or more health disparities, including those
identified by the Secretary in the national strategy
under section 3121; and
``(B) which is represented by a community
partnership that demonstrates community support and
coordination with State, local, or tribal health
departments and includes--
``(i) a broad cross section of
stakeholders;
``(ii) residents of the community; and
``(iii) representatives of entities that
have a history of working within and serving
the community.
``(c) Preferences.--In awarding grants under this section, the
Secretary shall give preference to entities that--
``(1) will address one or more goals or objectives
identified by the Secretary in the national strategy under
section 3121;
``(2) will address significant health disparities,
including those identified by the Secretary in the national
strategy under section 3121;
``(3) will address unmet community prevention and wellness
needs and avoid duplication of effort;
``(4) have been demonstrated to be effective in communities
comparable to the proposed target community;
``(5) will contribute to the evidence base for community
prevention and wellness services;
``(6) demonstrate that the community prevention and
wellness services to be funded will be sustainable; and
``(7) demonstrate coordination or collaboration across
governmental and nongovernmental partners.
``(d) Health Disparities.--Of the funds awarded under this section
for a fiscal year, the Secretary shall award not less than 50 percent
for planning or implementing community prevention and wellness services
whose primary purpose is to achieve a measurable reduction in one or
more health disparities, including those identified by the Secretary in
the national strategy under section 3121.
``(e) Emphasis on Recommended Services.--For fiscal year 2014 and
subsequent fiscal years, the Secretary shall award grants under this
section only for planning or implementing services recommended by the
Task Force on Community Preventive Services under section 3132 or
deemed effective based on a review of comparable rigor (as determined
by the Director of the Centers for Disease Control and Prevention).
``(f) Prohibited Uses of Funds.--An entity that receives a grant
under this section may not use funds provided through the grant--
``(1) to build or acquire real property or for
construction; or
``(2) for services or planning to the extent that payment
has been made, or can reasonably be expected to be made--
``(A) under any insurance policy;
``(B) under any Federal or State health benefits
program (including titles XIX and XXI of the Social
Security Act); or
``(C) by an entity which provides health services
on a prepaid basis.
``(g) Report.--The Secretary shall submit to the Congress an annual
report on the program of grants awarded under this section.
``(h) Definitions.--In this section, the term `evidence-based'
means that methodologically sound research has demonstrated a
beneficial health effect, in the judgment of the Director of the
Centers for Disease Control and Prevention.
``Subtitle F--Core Public Health Infrastructure
``SEC. 3161. CORE PUBLIC HEALTH INFRASTRUCTURE FOR STATE, LOCAL, AND
TRIBAL HEALTH DEPARTMENTS.
``(a) Program.--The Secretary, acting through the Director of the
Centers for Disease Control and Prevention, shall establish a core
public health infrastructure program consisting of awarding grants
under subsection (b).
``(b) Grants.--
``(1) Award.--For the purpose of addressing core public
health infrastructure needs, the Secretary--
``(A) shall award a grant to each State health
department; and
``(B) may award grants on a competitive basis to
State, local, or tribal health departments.
``(2) Allocation.--Of the total amount of funds awarded as
grants under this subsection for a fiscal year--
``(A) not less than 50 percent shall be for grants
to State health departments under paragraph (1)(A); and
``(B) not less than 30 percent shall be for grants
to State, local, or tribal health departments under
paragraph (1)(B).
``(c) Use of Funds.--The Secretary may award a grant to an entity
under subsection (b)(1) only if the entity agrees to use the grant to
address core public health infrastructure needs, including those
identified in the accreditation process under subsection (g).
``(d) Formula Grants to State Health Departments.--In making grants
under subsection (b)(1)(A), the Secretary shall award funds to each
State health department in accordance with--
``(1) a formula based on population size; burden of
preventable disease and disability; and core public health
infrastructure gaps, including those identified in the
accreditation process under subsection (g); and
``(2) application requirements established by the
Secretary, including a requirement that the State submit a plan
that demonstrates to the satisfaction of the Secretary that the
State's health department will--
``(A) address its highest priority core public
health infrastructure needs; and
``(B) as appropriate, allocate funds to local
health departments within the State.
``(e) Competitive Grants to State, Local, and Tribal Health
Departments.--In making grants under subsection (b)(1)(B), the
Secretary shall give priority to applicants demonstrating core public
health infrastructure needs identified in the accreditation process
under subsection (g).
``(f) Maintenance of Effort.--The Secretary may award a grant to an
entity under subsection (b) only if the entity demonstrates to the
satisfaction of the Secretary that--
``(1) funds received through the grant will be expended
only to supplement, and not supplant, non-Federal and Federal
funds otherwise available to the entity for the purpose of
addressing core public health infrastructure needs; and
``(2) with respect to activities for which the grant is
awarded, the entity will maintain expenditures of non-Federal
amounts for such activities at a level 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
the grant.
``(g) Establishment of a Public Health Accreditation Program.--
``(1) In general.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall--
``(A) develop, and periodically review and update,
standards for voluntary accreditation of State, local,
or tribal health departments and public health
laboratories for the purpose of advancing the quality
and performance of such departments and laboratories;
and
``(B) implement a program to accredit such health
departments and laboratories in accordance with such
standards.
``(2) Cooperative agreement.--The Secretary may enter into
a cooperative agreement with a private nonprofit entity to
carry out paragraph (1).
``(h) Report.--The Secretary shall submit to the Congress an annual
report on progress being made to accredit entities under subsection
(g), including--
``(1) a strategy, including goals and objectives, for
accrediting entities under subsection (g) and achieving the
purpose described in subsection (g)(1); and
``(2) identification of gaps in research related to core
public health infrastructure and recommendations of priority
areas for such research.
``SEC. 3162. CORE PUBLIC HEALTH INFRASTRUCTURE AND ACTIVITIES FOR CDC.
``(a) In General.--The Secretary, acting through the Director of
the Centers for Disease Control and Prevention, shall expand and
improve the core public health infrastructure and activities of the
Centers for Disease Control and Prevention to address unmet and
emerging public health needs.
``(b) Report.--The Secretary shall submit to the Congress an annual
report on the activities funded through this section.
``Subtitle G--General Provisions
``SEC. 3171. DEFINITIONS.
``In this title:
``(1) The term `core public health infrastructure' includes
workforce capacity and competency; laboratory systems; health
information, health information systems, and health information
analysis; communications; financing; other relevant components
of organizational capacity; and other related activities.
``(2) The terms `Department' and `departmental' refer to
the Department of Health and Human Services.
``(3) The term `health disparities' includes health and
health care disparities and means population-specific
differences in the presence of disease, health outcomes, or
access to health care. For purposes of the preceding sentence,
a population may be delineated by race, ethnicity, primary
language, sex, sexual orientation, gender identity, disability,
socioeconomic status, or rural, urban, or other geographic
setting, and any other population or subpopulation determined
by the Secretary to experience significant gaps in disease,
health outcomes, or access to health care.
``(4) The term `tribal' refers to an Indian tribe, a Tribal
organization, or an Urban Indian organization, as such terms
are defined in section 4 of the Indian Health Care Improvement
Act.''.
(b) Transition Provisions Applicable to Task Forces.--
(1) Functions, personnel, assets, liabilities, and
administrative actions.--All functions, personnel, assets, and
liabilities of, and administrative actions applicable to, the
Preventive Services Task Force convened under section 915(a) of
the Public Health Service Act and the Task Force on Community
Preventive Services (as such section and Task Forces were in
existence on the day before the date of the enactment of this
Act) shall be transferred to the Task Force on Clinical
Preventive Services and the Task Force on Community Preventive
Services, respectively, established under sections 3131 and
3132 of the Public Health Service Act, as added by subsection
(a).
(2) Recommendations.--All recommendations of the Preventive
Services Task Force and the Task Force on Community Preventive
Services, as in existence on the day before the date of the
enactment of this Act, shall be considered to be
recommendations of the Task Force on Clinical Preventive
Services and the Task Force on Community Preventive Services,
respectively, established under sections 3131 and 3132 of the
Public Health Service Act, as added by subsection (a).
(3) Members already serving.--
(A) Initial members.--The Secretary of Health and
Human Services may select those individuals already
serving on the Preventive Services Task Force and the
Task Force on Community Preventive Services, as in
existence on the day before the date of the enactment
of this Act, to be among the first members appointed to
the Task Force on Clinical Preventive Services and the
Task Force on Community Preventive Services,
respectively, under sections 3131 and 3132 of the
Public Health Service Act, as added by subsection (a).
(B) Calculation of total service.--In calculating
the total years of service of a member of a task force
for purposes of section 3131(d)(2)(A) or 3132(d)(2)(A)
of the Public Health Service Act, as added by
subsection (a), the Secretary of Health and Human
Services shall not include any period of service by the
member on the Preventive Services Task Force or the
Task Force on Community Preventive Services,
respectively, as in existence on the day before the
date of the enactment of this Act.
(c) Period Before Completion of National Strategy.--Pending
completion of the national strategy under section 3121 of the Public
Health Service Act, as added by subsection (a), the Secretary of Health
and Human Services, acting through the relevant agency head, may make a
judgment about how the strategy will address an issue and rely on such
judgment in carrying out any provision of subtitle C, D, E, or F of
title XXXI of such Act, as added by subsection (a), that requires the
Secretary--
(1) to take into consideration such strategy;
(2) to conduct or support research or provide services in
priority areas identified in such strategy; or
(3) to take any other action in reliance on such strategy.
(d) Conforming Amendments.--
(1) Paragraph (61) of section 3(b) of the Indian Health
Care Improvement Act (25 U.S.C. 1602) is amended by striking
``United States Preventive Services Task Force'' and inserting
``Task Force on Clinical Preventive Services''.
(2) Section 126 of the Medicare, Medicaid, and SCHIP
Benefits Improvement and Protection Act of 2000 (Appendix F of
Public Law 106-554) is amended by striking ``United States
Preventive Services Task Force'' each place it appears and
inserting ``Task Force on Clinical Preventive Services''.
(3) Paragraph (7) of section 317D(a) of the Public Health
Service Act (42 U.S.C. 247b-5(a)) is amended by striking
``United States Preventive Services Task Force'' and inserting
``Task Force on Clinical Preventive Services''.
(4) Section 915 of the Public Health Service Act (42 U.S.C.
299b-4) is amended by striking subsection (a).
(5) Subsections (s)(2)(AA)(iii)(II), (xx)(1), and
(ddd)(1)(B) of section 1861 of the Social Security Act (42
U.S.C. 1395x) are amended by striking ``United States
Preventive Services Task Force'' each place it appears and
inserting ``Task Force on Clinical Preventive Services''.
TITLE IV--QUALITY AND SURVEILLANCE
SEC. 2401. IMPLEMENTATION OF BEST PRACTICES IN THE DELIVERY OF HEALTH
CARE.
(a) In General.--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 redesignated, by striking ``931''
and inserting ``941''; and
(4) by inserting after part C the following:
``PART D--IMPLEMENTATION OF BEST PRACTICES IN THE DELIVERY OF HEALTH
CARE
``SEC. 931. CENTER FOR QUALITY IMPROVEMENT.
``(a) In General.--There is established the Center for Quality
Improvement (referred to in this part as the `Center'), to be headed by
the Director.
``(b) Prioritization.--
``(1) In general.--The Director shall prioritize areas for
the identification, development, evaluation, and implementation
of best practices (including innovative methodologies and
strategies) for quality improvement activities in the delivery
of health care services (in this section referred to as `best
practices').
``(2) Considerations.--In prioritizing areas under
paragraph (1), the Director shall consider--
``(A) the priorities established under section 1191
of the Social Security Act; and
``(B) the key health indicators identified by the
Assistant Secretary for Health Information under
section 1709.
``(3) Limitations.--In conducting its duties under this
subsection, the Center for Quality Improvement shall not
develop quality-adjusted life year measures or any other
methodologies that can be used to deny benefits to a
beneficiary against the beneficiary's wishes on the basis of
the beneficiary's age, life expectancy, present or predicted
disability, or expected quality of life.
``(c) Other Responsibilities.--The Director, acting directly or by
awarding a grant or contract to an eligible entity, shall--
``(1) identify existing best practices under subsection
(e);
``(2) develop new best practices under subsection (f);
``(3) evaluate best practices under subsection (g);
``(4) implement best practices under subsection (h);
``(5) ensure that best practices are identified, developed,
evaluated, and implemented under this section consistent with
standards adopted by the Secretary under section 3004 for
health information technology used in the collection and
reporting of quality information (including for purposes of the
demonstration of meaningful use of certified electronic health
record (EHR) technology by physicians and hospitals under the
Medicare program (under sections 1848(o)(2) and 1886(n)(3),
respectively, of the Social Security Act)); and
``(6) provide for dissemination of information and
reporting under subsections (i) and (j).
``(d) Eligibility.--To be eligible for a grant or contract under
subsection (c), an entity shall--
``(1) be a nonprofit entity;
``(2) agree to work with a variety of institutional health
care providers, physicians, nurses, and other health care
practitioners; and
``(3) if the entity is not the organization holding a
contract under section 1153 of the Social Security Act for the
area to be served, agree to cooperate with and avoid
duplication of the activities of such organization.
``(e) Identifying Existing Best Practices.--The Director shall
identify best practices that are--
``(1) currently utilized by health care providers
(including hospitals, physician and other clinician practices,
community cooperatives, and other health care entities) that
deliver consistently high-quality, efficient health care
services; and
``(2) easily adapted for use by other health care providers
and for use across a variety of health care settings.
``(f) Developing New Best Practices.--The Director shall develop
best practices that are--
``(1) based on a review of existing scientific evidence;
``(2) sufficiently detailed for implementation and
incorporation into the workflow of health care providers; and
``(3) designed to be easily adapted for use by health care
providers across a variety of health care settings.
``(g) Evaluation of Best Practices.--The Director shall evaluate
best practices identified or developed under this section. Such
evaluation--
``(1) shall include determinations of which best
practices--
``(A) most reliably and effectively achieve
significant progress in improving the quality of
patient care; and
``(B) are easily adapted for use by health care
providers across a variety of health care settings;
``(2) shall include regular review, updating, and
improvement of such best practices; and
``(3) may include in-depth case studies or empirical
assessments of health care providers (including hospitals,
physician and other clinician practices, community
cooperatives, and other health care entities) and simulations
of such best practices for determinations under paragraph (1).
``(h) Implementation of Best Practices.--
``(1) In general.--The Director shall enter into
arrangements with entities in a State or region to implement
best practices identified or developed under this section. Such
implementation--
``(A) may include forming collaborative multi-
institutional teams; and
``(B) shall include an evaluation of the best
practices being implemented, including the measurement
of patient outcomes before, during, and after
implementation of such best practices.
``(2) Preferences.--In carrying out this subsection, the
Director shall give priority to health care providers
implementing best practices that--
``(A) have the greatest impact on patient outcomes
and satisfaction;
``(B) are the most easily adapted for use by health
care providers across a variety of health care
settings;
``(C) promote coordination of health care
practitioners across the continuum of care; and
``(D) engage patients and their families in
improving patient care and outcomes.
``(i) Public Dissemination of Information.--The Director shall
provide for the public dissemination of information with respect to
best practices and activities under this section. Such information
shall be made available in appropriate formats and languages to reflect
the varying needs of consumers and diverse levels of health literacy.
``(j) Report.--
``(1) In general.--The Director shall submit an annual
report to the Congress and the Secretary on activities under
this section.
``(2) Content.--Each report under paragraph (1) shall
include--
``(A) information on activities conducted pursuant
to grants and contracts awarded;
``(B) summary data on patient outcomes before,
during, and after implementation of best practices; and
``(C) recommendations on the adaptability of best
practices for use by health providers.''.
(b) Initial Quality Improvement Activities and Initiatives To Be
Implemented.--Until the Director of the Agency for Healthcare Research
and Quality has established initial priorities under section 931(b) of
the Public Health Service Act, as added by subsection (a), the Director
shall, for purposes of such section, prioritize the following:
(1) Health care-associated infections.--Reducing health
care-associated infections, including infections in nursing
homes and outpatient settings.
(2) Surgery.--Increasing hospital and outpatient
perioperative patient safety, including reducing surgical-site
infections and surgical errors (such as wrong-site surgery and
retained foreign bodies).
(3) Emergency room.--Improving care in hospital emergency
rooms, including through the use of principles of efficiency of
design and delivery to improve patient flow.
(4) Obstetrics.--Improving the provision of obstetrical and
neonatal care, including the identification of interventions
that are effective in reducing the risk of preterm and
premature labor and the implementation of best practices for
labor and delivery care.
(5) Pediatrics.--Improving the provision of preventive and
developmental child health services, including interventions
that can reduce child health disparities (as defined in section
3171 of the Public Health Service Act, as added by section
2301) and reduce the risk of developing chronic health-
threatening conditions that affect an individual's life course
development.
(c) Report.--Not later than 18 months after the date of the
enactment of this Act, the Director of the Agency for Healthcare
Research and Quality shall submit a report to the Congress on the
impact of the nurse-to-patient ratio on the quality of care and patient
outcomes, including recommendations for further integration into
quality measurement and quality improvement activities.
SEC. 2402. ASSISTANT SECRETARY FOR HEALTH INFORMATION.
(a) Establishment.--Title XVII (42 U.S.C. 300u et seq.) is
amended--
(1) by redesignating sections 1709 and 1710 as sections
1710 and 1711, respectively; and
(2) by inserting after section 1708 the following:
``SEC. 1709. ASSISTANT SECRETARY FOR HEALTH INFORMATION.
``(a) In General.--There is established within the Department an
Assistant Secretary for Health Information (in this section referred to
as the `Assistant Secretary'), to be appointed by the Secretary.
``(b) Responsibilities.--The Assistant Secretary shall--
``(1) ensure the collection, collation, reporting, and
publishing of information (including full and complete
statistics) on key health indicators regarding the Nation's
health and the performance of the Nation's health care;
``(2) facilitate and coordinate the collection, collation,
reporting, and publishing of information regarding the Nation's
health and the performance of the Nation's health care (other
than information described in paragraph (1));
``(3)(A) develop standards for the collection of data
regarding the Nation's health and the performance of the
Nation's health care; and
``(B) in carrying out subparagraph (A)--
``(i) ensure appropriate specificity and
standardization for data collection at the national,
regional, State, and local levels;
``(ii) include standards, as appropriate, for the
collection of accurate data on health disparities;
``(iii) ensure, with respect to data on race and
ethnicity, consistency with the 1997 Office of
Management and Budget Standards for Maintaining,
Collecting and Presenting Federal Data on Race and
Ethnicity (or any successor standards); and
``(iv) in consultation with the Director of the
Office of Minority Health, and the Director of the
Office of Civil Rights of the Department, develop
standards for the collection of data on health and
health care with respect to primary language;
``(4) provide support to Federal departments and agencies
whose programs have a significant impact upon health (as
determined by the Secretary) for the collection and collation
of information described in paragraphs (1) and (2);
``(5) ensure the sharing of information described in
paragraphs (1) and (2) among the agencies of the Department;
``(6) facilitate the sharing of information described in
paragraphs (1) and (2) by Federal departments and agencies
whose programs have a significant impact upon health (as
determined by the Secretary);
``(7) identify gaps in information described in paragraphs
(1) and (2) and the appropriate agency or entity to address
such gaps;
``(8) facilitate and coordinate identification and
monitoring of health disparities by the agencies of the
Department to inform program and policy efforts to reduce such
disparities, including facilitating and funding analyses
conducted in cooperation with the Social Security
Administration, the Bureau of the Census, and other appropriate
agencies and entities;
``(9) consistent with privacy, proprietary, and other
appropriate safeguards, facilitate public accessibility of
datasets (such as de-identified Medicare datasets or publicly
available data on key health indicators) by means of the
Internet; and
``(10) award grants or contracts for the collection and
collation of information described in paragraphs (1) and (2)
(including through statewide surveys that provide standardized
information).
``(c) Key Health Indicators.--
``(1) In general.--In carrying out subsection (b)(1), the
Assistant Secretary shall--
``(A) identify, and reassess at least once every 3
years, key health indicators described in such
subsection;
``(B) publish statistics on such key health
indicators for the public--
``(i) not less than annually; and
``(ii) on a supplemental basis whenever
warranted by--
``(I) the rate of change for a key
health indicator; or
``(II) the need to inform policy
regarding the Nation's health and the
performance of the Nation's health
care; and
``(C) ensure consistency with the national strategy
developed by the Secretary under section 3121 and
consideration of the indicators specified in the
reports under sections 308, 903(a)(6), and 913(b)(2).
``(2) Release of key health indicators.--The regulations,
rules, processes, and procedures of the Office of Management
and Budget governing the review, release, and dissemination of
key health indicators shall be the same as the regulations,
rules, processes, and procedures of the Office of Management
and Budget governing the review, release, and dissemination of
Principal Federal Economic Indicators (or equivalent
statistical data) by the Bureau of Labor Statistics.
``(d) Coordination.--In carrying out this section, the Assistant
Secretary shall coordinate with--
``(1) public and private entities that collect and
disseminate information on health and health care, including
foundations; and
``(2) the head of the Office of the National Coordinator
for Health Information Technology to ensure optimal use of
health information technology.
``(e) Request for Information From Departments and Agencies.--
Consistent with applicable law, the Assistant Secretary may secure
directly from any Federal department or agency information necessary to
enable the Assistant Secretary to carry out this section.
``(f) Report.--
``(1) Submission.--The Assistant Secretary shall submit to
the Secretary and the Congress an annual report containing--
``(A) a description of national, regional, or State
changes in health or health care, as reflected by the
key health indicators identified under subsection
(c)(1);
``(B) a description of gaps in the collection,
collation, reporting, and publishing of information
regarding the Nation's health and the performance of
the Nation's health care;
``(C) recommendations for addressing such gaps and
identification of the appropriate agency within the
Department or other entity to address such gaps;
``(D) a description of analyses of health
disparities, including the results of completed
analyses, the status of ongoing longitudinal studies,
and proposed or planned research; and
``(E) a plan for actions to be taken by the
Assistant Secretary to address gaps described in
subparagraph (B).
``(2) Consideration.--In preparing a report under paragraph
(1), the Assistant Secretary shall take into consideration the
findings and conclusions in the reports under sections 308,
903(a)(6), and 913(b)(2).
``(g) Proprietary and Privacy Protections.--Nothing in this section
shall be construed to affect applicable proprietary or privacy
protections.
``(h) Consultation.--In carrying out this section, the Assistant
Secretary shall consult with--
``(1) the heads of appropriate health agencies and offices
in the Department, including the Office of the Surgeon General
of the Public Health Service, the Office of Minority Health,
and the Office on Women's Health; and
``(2) as appropriate, the heads of other Federal
departments and agencies whose programs have a significant
impact upon health (as determined by the Secretary).
``(i) Definition.--In this section:
``(1) The terms `agency' and `agencies' include an
epidemiology center established under section 214 of the Indian
Health Care Improvement Act.
``(2) The term `Department' means the Department of Health
and Human Services.
``(3) The term `health disparities' has the meaning given
to such term in section 3171.''.
(b) Other Coordination Responsibilities.--Title III (42 U.S.C. 241
et seq.) is amended--
(1) in paragraphs (1) and (2) of section 304(c) (42 U.S.C.
242b(c)), by inserting ``, acting through the Assistant
Secretary for Health Information,'' after ``The Secretary''
each place it appears; and
(2) in section 306(j) (42 U.S.C. 242k(j)), by inserting ``,
acting through the Assistant Secretary for Health
Information,'' after ``of this section, the Secretary''.
SEC. 2403. AUTHORIZATION OF APPROPRIATIONS.
Section 799C, as added and amended, is further amended by adding at
the end the following:
``(e) Quality and Surveillance.--For the purpose of carrying out
part D of title IX and section 1709, in addition to any other amounts
authorized to be appropriated for such purpose, there are authorized to
be appropriated, out of any monies in the Public Health Investment
Fund, $300,000,000 for each of fiscal years 2011 through 2015.''.
TITLE V--OTHER PROVISIONS
Subtitle A--Drug Discount for Rural and Other Hospitals; 340B Program
Integrity
SEC. 2501. EXPANDED PARTICIPATION IN 340B PROGRAM.
(a) Expansion of Covered Entities Receiving Discounted Prices.--
Section 340B(a)(4) (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).
``(O) An entity receiving funds under title V of
the Social Security Act (relating to maternal and child
health) for the provision of health services.
``(P) An entity receiving funds under subpart I of
part B of title XIX of the Public Health Service Act
(relating to comprehensive mental health services) for
the provision of community mental health services.
``(Q) An entity receiving funds under subpart II of
such part B (relating to the prevention and treatment
of substance abuse) for the provision of treatment
services for substance abuse.
``(R) An entity that is a Medicare-dependent, small
rural hospital (as defined in section 1886(d)(5)(G)(iv)
of the Social Security Act).
``(S) An entity that is a sole community hospital
(as defined in section 1886(d)(5)(D)(iii) of the Social
Security Act).
``(T) An entity that is classified as a rural
referral center under section 1886(d)(5)(C) of the
Social Security Act.''.
(b) Prohibition on Group Purchasing Arrangements.--Section 340B(a)
(42 U.S.C. 256b(a)) is amended--
(1) in paragraph (4)(L)--
(A) by adding ``and'' at the end of clause (i);
(B) by striking ``; and'' at the end of clause (ii)
and inserting a period; and
(C) by striking clause (iii); and
(2) in paragraph (5), by redesignating subparagraphs (C)
and (D) as subparagraphs (D) and (E), respectively, and by
inserting after subparagraph (B) the following:
``(C) Prohibiting use of group purchasing
arrangements.--A hospital described in subparagraph
(L), (M), (N), (R), (S), or (T) of paragraph (4) shall
not obtain covered outpatient drugs through a group
purchasing organization or other group purchasing
arrangement.''.
SEC. 2502. IMPROVEMENTS TO 340B PROGRAM INTEGRITY.
(a) Integrity Improvements.--Section 340B (42 U.S.C. 256b) is
amended--
(1) by striking subsections (c) and (d); and
(2) by inserting after subsection (b) the following:
``(c) 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 establishment of a process 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, 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) Conducting periodic
monitoring of sales transactions to
covered entities.
``(IV) Inquiring into any
discrepancies between ceiling prices
and manufacturer pricing data that may
be identified and taking, or requiring
manufacturers to take, corrective
action in response to such
discrepancies, including the issuance
of refunds pursuant to the procedures
set forth in clause (ii).
``(ii) The establishment of procedures for
the issuance of refunds to covered entities by
manufacturers in the event that the Secretary
finds there has been an overcharge, including
the following:
``(I) Submission to the Secretary
by manufacturers of 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.
``(iii) Notwithstanding any other provision
of law prohibiting the disclosure of ceiling
prices or data used to calculate the ceiling
price, the provision of access to covered
entities and State Medicaid agencies through an
Internet website of the Department of Health
and Human Services or contractor to the
applicable ceiling prices for covered drugs as
calculated and verified by the Secretary in a
manner that ensures protection of privileged
pricing data from unauthorized disclosure.
``(iv) The development of a mechanism by
which--
``(I) rebates, discounts, or other
price concessions 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 rebates, discounts, or other
price concessions have the effect of
lowering the applicable ceiling price
for the relevant quarter for the drugs
involved.
``(v) In addition to authorities under
section 1927(b)(3) of the Social Security Act,
the Secretary may conduct audits of
manufacturers and wholesalers to ensure the
integrity of the program under this section,
including audits on the market price of covered
drugs.
``(vi) The establishment of a requirement
that manufacturers and wholesalers use the
identification system developed by 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.
``(vii) The imposition of sanctions in the
form of civil monetary penalties, which--
``(I) shall be assessed according
to standards and procedures established
in regulations to be promulgated by the
Secretary within one year of the date
of the enactment of the Affordable
Health Care for America Act; and
``(II) shall apply to any
manufacturer with an agreement under
this section and shall not exceed
$100,000 for each instance where a
manufacturer knowingly charges a
covered entity a price for purchase of
a drug that exceeds the maximum
applicable price under subsection
(a)(1) or that knowingly violates any
other provision of this section, or
withholds or provides false information
to the Secretary or to covered entities
under this section.
``(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 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 update
at least annually the information on the
Internet Web site of the Department of Health
and Human Services relating to this section.
``(ii) The development of procedures for
the Secretary to verify the accuracy of
information regarding covered entities that is
listed on the Web site 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 the
form of civil monetary penalties, which--
``(I) shall be assessed according
to standards and procedures established
in regulations promulgated by the
Secretary;
``(II) shall not exceed $5,000 for
each violation; and
``(III) shall apply to any covered
entity that knowingly violates
subparagraph (a)(5)(B) or knowingly
violates any other provision of this
section.
``(vi) The exclusion of a covered entity
from participation in the program under this
section, for a period of time to be determined
by the Secretary, in cases in which the
Secretary determines, in accordance with
standards and procedures established in
regulations, that--
``(I) a violation of a requirement
of this section was repeated and
knowing; and
``(II) imposition of a monetary
penalty would be insufficient to
reasonably ensure compliance.
``(vii) The referral of matters as
appropriate to the Food and Drug
Administration, the Office of Inspector General
of Department of Health and Human Services, or
other Federal agencies.
``(3) Administrative dispute resolution process.--From
amounts appropriated under paragraph (4), the Secretary may
establish and implement an administrative process for the
resolution of the following:
``(A) Claims by covered entities that manufacturers
have violated the terms of their agreement with the
Secretary under subsection (a)(1).
``(B) Claims by manufacturers that covered entities
have violated subsection (a)(5)(A) or (a)(5)(B).
``(4) Authorization of appropriations.--There are
authorized to be appropriated to carry out this subsection,
such sums as may be necessary for fiscal year 2011 and each
succeeding fiscal year.''.
(b) Conforming Amendments.--
(1) Section 340B(a) (42 U.S.C. 256b(a)) is amended--
(A) by adding at the end of paragraph (1) the
following: ``Such agreement 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. Such agreement shall require that, if the
supply of a covered drug is insufficient to meet
demand, then the manufacturer may utilize an allocation
method that is reported in writing to the Secretary and
does not discriminate on the basis of the price paid by
covered entities or on any other basis related to an
entity's participation in the program under this
section. Notwithstanding any other provision of law, if
the Secretary requests a manufacturer to enter into a
new or amended agreement under this section that
complies with current law and if the manufacturer opts
not to sign the new or amended agreement, then any
existing agreement between the manufacturer and the
Secretary under this section is deemed to no longer
meet the requirements of this section for purposes of
this section and section 1927 of the Social Security
Act.''; and
(B) by adding at the end the following paragraph:
``(11) Quarterly reports.--An agreement described in
paragraph (1) shall require that the manufacturer furnish the
Secretary with reports on a quarterly basis that include the
following information:
``(A) 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').
``(B) The component information used to calculate
the ceiling price as determined necessary to administer
the requirements of the program under this section.
``(C) Rebates, discounts, and other price
concessions provided by manufacturers to other
purchasers subsequent to the sale of covered drugs to
covered entities.''.
(2) Section 1927(a)(5) of the Social Security Act (42
U.S.C. 1396r-8(a)(5)) is amended by striking subparagraph (D).
SEC. 2503. EFFECTIVE DATE.
(a) In General.--The amendments made by this subtitle shall take
effect on the date of the enactment of this Act, and sections 2501,
2502(a)(1), and 2502(b)(2) shall apply to drugs dispensed on or after
such date.
(b) Effectiveness.--The amendments made by this subtitle 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)), and of section
1927(a)(5) of the Social Security Act (42 U.S.C. 1396r-8(a)(5)),
notwithstanding any other provision of law.
Subtitle B--Programs
PART 1--GRANTS FOR CLINICS AND CENTERS
SEC. 2511. SCHOOL-BASED HEALTH CLINICS.
(a) In General.--Part Q of title III (42 U.S.C. 280h et seq.) is
amended by adding at the end the following:
``SEC. 399Z-1. SCHOOL-BASED HEALTH CLINICS.
``(a) Program.--The Secretary shall establish a school-based health
clinic program consisting of awarding grants to eligible entities to
support the operation of school-based health clinics (referred to in
this section as `SBHCs').
``(b) Eligibility.--To be eligible for a grant under this section,
an entity shall--
``(1) be an SBHC (as defined in subsection (l)(3)); and
``(2) submit an application at such time, in such manner,
and containing such information as the Secretary may require,
including at a minimum--
``(A) evidence that the applicant meets all
criteria necessary to be designated as 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 in
accordance with Federal, State, and local laws;
``(ii) the SBHC has established and
maintains collaborative relationships with
other health care providers in the catchment
area of the SBHC;
``(iii) the SBHC will provide onsite access
during the academic day when school is in
session and has an established network of
support and access to services with backup
health providers when the school or SBHC is
closed;
``(iv) the SBHC will be integrated into the
school environment and will coordinate health
services with appropriate school personnel and
other community providers co-located at the
school; and
``(v) the SBHC sponsoring facility assumes
all responsibility for the SBHC administration,
operations, and oversight; and
``(D) such other information as the Secretary may
require.
``(c) Use of Funds.--Funds awarded under a grant under this
section--
``(1) may be used for--
``(A) providing training related to the provision
of comprehensive primary health services and additional
health services;
``(B) the management and operation of SBHC
programs, including through subcontracts; and
``(C) the payment of salaries for health
professionals and other appropriate SBHC personnel; and
``(2) may not be used to provide abortions.
``(d) Consideration of Need.--In determining the amount of a grant
under this section, the Secretary shall take into consideration--
``(1) the financial need of the SBHC;
``(2) State, local, or other sources of funding provided to
the SBHC; and
``(3) other factors as determined appropriate by the
Secretary.
``(e) Preferences.--In awarding grants under this section, the
Secretary shall give preference to SBHCs that have a demonstrated
record of service to at least one of the following:
``(1) A high percentage of medically underserved children
and adolescents.
``(2) Communities or populations in which children and
adolescents have difficulty accessing health and mental health
services.
``(3) Communities with high percentages of children and
adolescents who are uninsured, underinsured, or eligible for
medical assistance under Federal or State health benefits
programs (including titles XIX and XXI of the Social Security
Act).
``(f) Matching Requirement.--The Secretary may award a grant to an
SBHC under this section only if the SBHC agrees to 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.
``(g) Supplement, Not Supplant.--The Secretary may award a grant to
an SBHC under this section only if the SBHC demonstrates to the
satisfaction of the Secretary that funds received through the grant
will be expended only to supplement, and not supplant, non-Federal and
Federal funds otherwise available to the SBHC for operation of the SBHC
(including each activity described in paragraph (1) or (2) of
subsection (c)).
``(h) Payor of Last Resort.--The Secretary may award a grant to an
SBHC under this section only if the SBHC demonstrates to the
satisfaction of the Secretary that funds received through the grant
will not be expended for any activity to the extent that payment has
been made, or can reasonably be expected to be made--
``(1) under any insurance policy;
``(2) under any Federal or State health benefits program
(including titles XIX and XXI of the Social Security Act); or
``(3) by an entity which provides health services on a
prepaid basis.
``(i) Regulations Regarding Reimbursement for Health Services.--The
Secretary shall issue regulations regarding the reimbursement for
health services provided by SBHCs to individuals eligible to receive
such services through the program under this section, including
reimbursement under any insurance policy or any Federal or State health
benefits program (including titles XIX and XXI of the Social Security
Act).
``(j) Technical Assistance.--The Secretary shall provide (either
directly or by grant or contract) technical and other assistance to
SBHCs to assist such SBHCs to meet the requirements of this section.
Such assistance may include fiscal and program management assistance,
training in fiscal and program management, operational and
administrative support, and the provision of information to the SBHCs
of the variety of resources available under this title and how those
resources can be best used to meet the health needs of the communities
served by the SBHCs.
``(k) Evaluation; Report.--The Secretary shall--
``(1) develop and implement a plan for evaluating SBHCs and
monitoring quality performances under the awards made under
this section; and
``(2) submit to the Congress on an annual basis a report on
the program under this section.
``(l) Definitions.--In this section:
``(1) Comprehensive primary health services.--The term
`comprehensive primary health services' means the core services
offered by SBHCs, which--
``(A) shall include--
``(i) comprehensive health assessments,
diagnosis, and treatment of minor, acute, and
chronic medical conditions and referrals to,
and followup for, specialty care; and
``(ii) mental health assessments, crisis
intervention, counseling, treatment, and
referral to a continuum of services including
emergency psychiatric care, community support
programs, inpatient care, and outpatient
programs; and
``(B) may include additional services, such as oral
health, social, and age-appropriate health education
services, including nutritional counseling.
``(2) Medically underserved children and adolescents.--The
term `medically underserved children and adolescents' means a
population of children and adolescents who are residents of an
area designated by the Secretary as an area with a shortage of
personal health services and health infrastructure for such
children and adolescents.
``(3) School-based health clinic.--The term `school-based
health clinic' means a health clinic that--
``(A) is located in, or is adjacent to, a school
facility of a local educational agency;
``(B) is organized through school, community, and
health provider relationships;
``(C) is administered by a sponsoring facility;
``(D) provides comprehensive primary health
services during school hours to children and
adolescents by health professionals in accordance with
State and local laws and regulations, established
standards, and community practice; and
``(E) does not perform abortion services.
``(4) Sponsoring facility.--The term `sponsoring facility'
is--
``(A) a hospital;
``(B) a public health department;
``(C) a community health center;
``(D) a nonprofit health care entity whose mission
is to provide access to comprehensive primary health
care services;
``(E) a local educational agency; or
``(F) a program administered by the Indian Health
Service or the Bureau of Indian Affairs or operated by
an Indian tribe or a tribal organization under the
Indian Self-Determination and Education Assistance Act,
a Native Hawaiian entity, or an urban Indian program
under title V of the Indian Health Care Improvement
Act.
``(m) Authorization of Appropriations.--For purposes of carrying
out this section, there are authorized to be appropriated $50,000,000
for fiscal year 2011 and such sums as may be necessary for each of
fiscal years 2012 through 2015.''.
(b) Effective Date.--The Secretary of Health and Human Services
shall begin awarding grants under section 399Z-1 of the Public Health
Service Act, as added by subsection (a), not later than July 1, 2010,
without regard to whether or not final regulations have been issued
under section 399Z-1(i) of such Act.
(c) Termination of Study.--Section 2(b) of the Health Care Safety
Net Act of 2008 (42 U.S.C. 254b note) is amended by striking paragraph
(2) (relating to a school-based health center study).
SEC. 2512. NURSE-MANAGED HEALTH CENTERS.
Title III (42 U.S.C. 241 et seq.) is amended by adding at the end
the following:
``PART S--NURSE-MANAGED HEALTH CENTERS
``SEC. 399FF. NURSE-MANAGED HEALTH CENTERS.
``(a) Program.--The Secretary, acting through the Administrator of
the Health Resources and Services Administration, shall establish a
nurse-managed health center program consisting of awarding grants to
entities under subsection (b).
``(b) Grant.--The Secretary shall award grants to entities--
``(1) to plan and develop a nurse-managed health center; or
``(2) to operate a nurse-managed health center.
``(c) Use of Funds.--Amounts received as a grant under subsection
(b) may be used for activities including the following:
``(1) Purchasing or leasing equipment.
``(2) Training and technical assistance related to the
provision of comprehensive primary care services and wellness
services.
``(3) Other activities for planning, developing, or
operating, as applicable, a nurse-managed health center.
``(d) Assurances Applicable to Both Planning and Operation
Grants.--
``(1) In general.--The Secretary may award a grant under
this section to an entity only if the entity demonstrates to
the Secretary's satisfaction that--
``(A) nurses, in addition to managing the center,
will be adequately represented as providers at the
center; and
``(B) not later than 90 days after receiving the
grant, the entity will establish a community advisory
committee composed of individuals, a majority of whom
are being served by the center, to provide input into
the nurse-managed health center's operations.
``(2) Matching requirement.--The Secretary may award a
grant under this section to an entity only if the entity agrees
to 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.
``(3) Payor of last resort.--The Secretary may award a
grant under this section to an entity only if the entity
demonstrates to the satisfaction of the Secretary that funds
received through the grant will not be expended for any
activity to the extent that payment has been made, or can
reasonably be expected to be made--
``(A) under any insurance policy;
``(B) under any Federal or State health benefits
program (including titles XIX and XXI of the Social
Security Act); or
``(C) by an entity which provides health services
on a prepaid basis.
``(4) Maintenance of effort.--The Secretary may award a
grant under this section to an entity only if the entity
demonstrates to the satisfaction of the Secretary that--
``(A) funds received through the grant will be
expended only to supplement, and not supplant, non-
Federal and Federal funds otherwise available to the
entity for the activities to be funded through the
grant; and
``(B) with respect to such activities, the entity
will maintain expenditures of non-Federal amounts for
such activities at a level not less than the lesser of
such expenditures maintained by the entity for the
fiscal year preceding the fiscal year for which the
entity receives the grant.
``(e) Additional Assurance for Planning Grants.--The Secretary may
award a grant under subsection (b)(1) to an entity only if the entity
agrees--
``(1) to assess the needs of the medically underserved
populations proposed to be served by the nurse-managed health
center; and
``(2) to design services and operations of the nurse-
managed health center for such populations based on such
assessment.
``(f) Additional Assurance for Operation Grants.--The Secretary may
award a grant under subsection (b)(2) to an entity only if the entity
assures that the nurse-managed health center will provide--
``(1) comprehensive primary care services, wellness
services, and other health care services deemed appropriate by
the Secretary;
``(2) care without respect to insurance status or income of
the patient; and
``(3) direct access to client-centered services offered by
advanced practice nurses, other nurses, physicians, physician
assistants, or other qualified health professionals.
``(g) Technical Assistance.--The Secretary shall provide (either
directly or by grant or contract) technical and other assistance to
nurse-managed health centers to assist such centers in meeting the
requirements of this section. Such assistance may include fiscal and
program management assistance, training in fiscal and program
management, operational and administrative support, and the provision
of information to nurse-managed health centers regarding the various
resources available under this section and how those resources can best
be used to meet the health needs of the communities served by nurse-
managed health centers.
``(h) Report.--The Secretary shall submit to the Congress an annual
report on the program under this section.
``(i) Definitions.--In this section:
``(1) Comprehensive primary care services.--The term
`comprehensive primary care services' has the meaning given to
the term `required primary health services' in section
330(b)(1).
``(2) Medically underserved population.--The term
`medically underserved population' has the meaning given to
such term in section 330(b)(3).
``(3) Nurse-managed health center.--The term `nurse-managed
health center' has the meaning given to such term in section
801.
``(4) Wellness services.--The term `wellness services'
means any health-related service or intervention, not including
primary care, which is designed to reduce identifiable health
risks and increase healthy behaviors intended to prevent the
onset of disease or lessen the impact of existing chronic
conditions by teaching more effective management techniques
that focus on individual self-care and patient-driven
decisionmaking.
``(j) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated such sums as may be necessary
for each of fiscal years 2011 through 2015.''.
SEC. 2513. FEDERALLY QUALIFIED BEHAVIORAL HEALTH CENTERS.
Section 1913 (42 U.S.C. 300x-3) is amended--
(1) in subsection (a)(2)(A), by striking ``community mental
health services'' and inserting ``behavioral health services
(of the type offered by federally qualified behavioral health
centers consistent with subsection (c)(3))'';
(2) in subsection (b)--
(A) by striking paragraph (1) and inserting the
following:
``(1) services under the plan will be provided only through
appropriate, qualified community programs (which may include
federally qualified behavioral health centers, child mental
health programs, psychosocial rehabilitation programs, mental
health peer-support programs, and mental health primary
consumer-directed programs); and''; and
(B) in paragraph (2), by striking ``community
mental health centers'' and inserting ``federally
qualified behavioral health centers''; and
(3) by striking subsection (c) and inserting the following:
``(c) Criteria for Federally Qualified Behavioral Health Centers.--
``(1) In general.--The Administrator shall certify, and
recertify at least every 5 years, federally qualified
behavioral health centers as meeting the criteria specified in
this subsection.
``(2) Regulations.--Not later than 18 months after the date
of the enactment of the Affordable Health Care for America Act,
the Administrator shall issue final regulations for certifying
centers under paragraph (1).
``(3) Criteria.--The criteria referred to in subsection
(b)(2) are that the center performs each of the following:
``(A) Provide services in locations that ensure
services will be available and accessible promptly and
in a manner which preserves human dignity and assures
continuity of care.
``(B) Provide services in a mode of service
delivery appropriate for the target population.
``(C) Provide individuals with a choice of service
options where there is more than one efficacious
treatment.
``(D) Employ a core staff of clinical staff that is
multidisciplinary and culturally and linguistically
competent.
``(E) Provide services, within the limits of the
capacities of the center, to any individual residing or
employed in the service area of the center.
``(F) Provide, directly or through contract, to the
extent covered for adults in the State Medicaid plan
and for children in accordance with section 1905(r) of
the Social Security Act regarding early and periodic
screening, diagnosis, and treatment, each of the
following services:
``(i) Screening, assessment, and diagnosis,
including risk assessment.
``(ii) Person-centered treatment planning
or similar processes, including risk assessment
and crisis planning.
``(iii) Outpatient clinic mental health
services, including screening, assessment,
diagnosis, psychotherapy, substance abuse
counseling, medication management, and
integrated treatment for mental illness and
substance abuse which shall be evidence-based
(including cognitive behavioral therapy,
dialectical behavioral therapy, motivational
interviewing, and other such therapies which
are evidence-based).
``(iv) Outpatient clinic primary care
services, including screening and monitoring of
key health indicators and health risk
(including screening for diabetes,
hypertension, and cardiovascular disease and
monitoring of weight, height, body mass index
(BMI), blood pressure, blood glucose or HbA1C,
and lipid profile).
``(v) Crisis mental health services,
including 24-hour mobile crisis teams,
emergency crisis intervention services, and
crisis stabilization.
``(vi) Targeted case management (services
to assist individuals gaining access to needed
medical, social, educational, and other
services and applying for income security and
other benefits to which they may be entitled).
``(vii) Psychiatric rehabilitation services
including skills training, assertive community
treatment, family psychoeducation, disability
self-management, supported employment,
supported housing services, therapeutic foster
care services, multisystemic therapy, and such
other evidence-based practices as the Secretary
may require.
``(viii) Peer support and counselor
services and family supports.
``(G) Maintain linkages, and where possible enter
into formal contracts with, inpatient psychiatric
facilities and substance abuse detoxification and
residential programs.
``(H) Make available to individuals served by the
center, directly, through contract, or through linkages
with other programs, each of the following:
``(i) Adult and youth peer support and
counselor services.
``(ii) Family support services for families
of children with serious mental disorders.
``(iii) Other community or regional
services, supports, and providers, including
schools, child welfare agencies, juvenile and
criminal justice agencies and facilities,
housing agencies and programs, employers, and
other social services.
``(iv) Onsite or offsite access to primary
care services.
``(v) Enabling services, including
outreach, transportation, and translation.
``(vi) Health and wellness services,
including services for tobacco cessation.''.
PART 2--OTHER GRANT PROGRAMS
SEC. 2521. COMPREHENSIVE PROGRAMS TO PROVIDE EDUCATION TO NURSES AND
CREATE A PIPELINE TO NURSING.
(a) Purposes.--It is the purpose of this section to authorize
grants to--
(1) address the projected shortage of nurses by funding
comprehensive programs to create a career ladder to nursing
(including certified nurse assistants, licensed practical
nurses, licensed vocational nurses, and registered nurses) for
incumbent ancillary health care workers;
(2) increase the capacity for educating nurses by
increasing both nurse faculty and clinical opportunities
through collaborative programs between staff nurse
organizations, health care providers, and accredited schools of
nursing; and
(3) provide training programs through education and
training organizations jointly administered by health care
providers and health care labor organizations or other
organizations representing staff nurses and frontline health
care workers, working in collaboration with accredited schools
of nursing and academic institutions.
(b) Grants.--Not later than 6 months after the date of the
enactment of this Act, the Secretary of Labor (referred to in this
section as the ``Secretary'') shall establish a partnership grant
program to award grants to eligible entities to carry out comprehensive
programs to provide education to nurses and create a pipeline to
nursing for incumbent ancillary health care workers who wish to advance
their careers, and to otherwise carry out the purposes of this section.
(c) Eligibility.--To be eligible for a grant under this section, an
entity shall be--
(1) a health care entity that is jointly administered by a
health care employer and a labor union representing the health
care employees of the employer and that carries out activities
using labor-management training funds as provided for under
section 302(c)(6) of the Labor Management Relations Act, 1947
(29 U.S.C. 186(c)(6));
(2) an entity that operates a training program that is
jointly administered by--
(A) one or more health care providers or
facilities, or a trade association of health care
providers; and
(B) one or more organizations which represent the
interests of direct care health care workers or staff
nurses and in which the direct care health care workers
or staff nurses have direct input as to the leadership
of the organization;
(3) a State training partnership program that consists of
nonprofit organizations that include equal participation from
industry, including public or private employers, and labor
organizations including joint labor-management training
programs, and which may include representatives from local
governments, worker investment agency one-stop career centers,
community-based organizations, community colleges, and
accredited schools of nursing; or
(4) a school of nursing (as defined in section 801 of the
Public Health Service Act (42 U.S.C. 296)).
(d) Additional Requirements for Health Care Employer Described in
Subsection (c).--To be eligible for a grant under this section, a
health care employer described in subsection (c) shall demonstrate that
it--
(1) has an established program within its facility to
encourage the retention of existing nurses;
(2) provides wages and benefits to its nurses that are
competitive for its market or that have been collectively
bargained with a labor organization; and
(3) supports programs funded under this section through 1
or more of the following:
(A) The provision of paid leave time and continued
health coverage to incumbent health care workers to
allow their participation in nursing career ladder
programs, including certified nurse assistants,
licensed practical nurses, licensed vocational nurses,
and registered nurses.
(B) Contributions to a joint labor-management
training fund which administers the program involved.
(C) The provision of paid release time, incentive
compensation, or continued health coverage to staff
nurses who desire to work full- or part-time in a
faculty position.
(D) The provision of paid release time for staff
nurses to enable them to obtain a bachelor of science
in nursing degree, other advanced nursing degrees,
specialty training, or certification program.
(E) The payment of tuition assistance which is
managed by a joint labor-management training fund or
other jointly administered program.
(e) Other Requirements.--
(1) Matching requirement.--
(A) In general.--The Secretary may not make a grant
under this section unless the applicant involved
agrees, with respect to the costs to be incurred by the
applicant in carrying out the program under the grant,
to make available non-Federal contributions (in cash or
in kind under subparagraph (B)) toward such costs in an
amount equal to not less than $1 for each $1 of Federal
funds provided in the grant. Such contributions may be
made directly or through donations from public or
private entities, or may be provided through the cash
equivalent of paid release time provided to incumbent
worker students.
(B) Determination of amount of non-federal
contribution.--Non-Federal contributions required in
subparagraph (A) may be in cash or in kind (including
paid release time), 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.
(2) Required collaboration.--Entities carrying out or
overseeing programs carried out with assistance provided under
this section shall demonstrate collaboration with accredited
schools of nursing which may include community colleges and
other academic institutions providing associate's, bachelor's,
or advanced nursing degree programs or specialty training or
certification programs.
(f) Use of Funds.--Amounts awarded to an entity under a grant under
this section shall be used for the following:
(1) To carry out programs that provide education and
training to establish nursing career ladders to educate
incumbent health care workers to become nurses (including
certified nurse assistants, licensed practical nurses, licensed
vocational nurses, and registered nurses). Such programs shall
include one or more of the following:
(A) Preparing incumbent workers to return to the
classroom through English-as-a-second-language
education, GED education, precollege counseling,
college preparation classes, and support with entry
level college classes that are a prerequisite to
nursing.
(B) Providing tuition assistance with preference
for dedicated cohort classes in community colleges,
universities, and accredited schools of nursing with
supportive services including tutoring and counseling.
(C) Providing assistance in preparing for and
meeting all nursing licensure tests and requirements.
(D) Carrying out orientation and mentorship
programs that assist newly graduated nurses in
adjusting to working at the bedside to ensure their
retention postgraduation, and ongoing programs to
support nurse retention.
(E) Providing stipends for release time and
continued health care coverage to enable incumbent
health care workers to participate in these programs.
(2) To carry out programs that assist nurses in obtaining
advanced degrees and completing specialty training or
certification programs and to establish incentives for nurses
to assume nurse faculty positions on a part-time or full-time
basis. Such programs shall include one or more of the
following:
(A) Increasing the pool of nurses with advanced
degrees who are interested in teaching by funding
programs that enable incumbent nurses to return to
school.
(B) Establishing incentives for advanced degree
bedside nurses who wish to teach in nursing programs so
they can obtain a leave from their bedside position to
assume a full- or part-time position as adjunct or
full-time faculty without the loss of salary or
benefits.
(C) Collaboration with accredited schools of
nursing which may include community colleges and other
academic institutions providing associate's,
bachelor's, or advanced nursing degree programs, or
specialty training or certification programs, for
nurses to carry out innovative nursing programs which
meet the needs of bedside nursing and health care
providers.
(g) Preference.--In awarding grants under this section the
Secretary shall give preference to programs that--
(1) provide for improving nurse retention;
(2) provide for improving the diversity of the new nurse
graduates to reflect changes in the demographics of the patient
population;
(3) provide for improving the quality of nursing education
to improve patient care and safety;
(4) have demonstrated success in upgrading incumbent health
care workers to become nurses or which have established
effective programs or pilots to increase nurse faculty; or
(5) are modeled after or affiliated with such programs
described in paragraph (4).
(h) Evaluation.--
(1) Program evaluations.--An entity that receives a grant
under this section shall annually evaluate, and submit to the
Secretary a report on, the activities carried out under the
grant and the outcomes of such activities. Such outcomes may
include--
(A) an increased number of incumbent workers
entering an accredited school of nursing and in the
pipeline for nursing programs;
(B) an increasing number of graduating nurses and
improved nurse graduation and licensure rates;
(C) improved nurse retention;
(D) an increase in the number of staff nurses at
the health care facility involved;
(E) an increase in the number of nurses with
advanced degrees in nursing;
(F) an increase in the number of nurse faculty;
(G) improved measures of patient quality (which may
include staffing ratios of nurses, patient satisfaction
rates, and patient safety measures); and
(H) an increase in the diversity of new nurse
graduates relative to the patient population.
(2) General report.--Not later than 2 years after the date
of the enactment of this Act, and annually thereafter, the
Secretary of Labor shall, using data and information from the
reports received under paragraph (1), submit to the Congress a
report concerning the overall effectiveness of the grant
program carried out under this section.
(i) 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. 2522. MENTAL AND BEHAVIORAL HEALTH TRAINING.
Part E of title VII (42 U.S.C. 294n et seq.) is amended by adding
at the end the following:
``Subpart 3--Mental and Behavioral Health Training
``SEC. 775. MENTAL AND BEHAVIORAL HEALTH TRAINING PROGRAM.
``(a) Program.--The Secretary, acting through the Administrator of
the Health Resources and Services Administration and in consultation
with the Administrator of the Substance Abuse and Mental Health
Services Administration, shall establish an interdisciplinary mental
and behavioral health training program consisting of awarding grants
and contracts under subsection (b).
``(b) Support and Development of Mental and Behavioral Health
Training Programs.--The Secretary shall make grants to, or enter into
contracts with, eligible entities--
``(1) to plan, develop, operate, or participate in an
accredited professional training program for mental and
behavioral health professionals to promote--
``(A) interdisciplinary training; and
``(B) coordination of the delivery of health care
within and across settings, including health care
institutions, community-based settings, and the
patient's home;
``(2) to provide financial assistance to mental and
behavioral health professionals, who are participants in any
such program, and who plan to work in the field of mental and
behavioral health;
``(3) to plan, develop, operate, or participate in an
accredited program for the training of mental and behavioral
health professionals who plan to teach in the field of mental
and behavioral health; and
``(4) to provide financial assistance in the form of
traineeships and fellowships to mental and behavioral health
professionals who are participants in any such program and who
plan to teach in the field of mental and behavioral health.
``(c) Eligibility.--To be eligible for a grant or contract under
subsection (b), an entity shall be--
``(1) an accredited health professions school, including an
accredited school or program of psychology, psychiatry, social
work, marriage and family therapy, professional mental health
or substance abuse counseling, or addiction medicine;
``(2) an accredited public or nonprofit private hospital;
``(3) a public or private nonprofit entity; or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(d) Preference.--In awarding grants or contracts under this
section, the Secretary shall give preference to entities that have a
demonstrated record of at least one of the following:
``(1) Training a high or significantly improved percentage
of health professionals who serve in underserved communities.
``(2) Supporting teaching programs that address the health
care needs of vulnerable populations.
``(3) Training individuals who are from disadvantaged
backgrounds (including racial and ethnic minorities
underrepresented among mental and behavioral health
professionals).
``(4) Training individuals who serve geriatric populations
with an emphasis on underserved elderly.
``(5) Training individuals who serve pediatric populations
with an emphasis on underserved children.
``(e) Report.--The Secretary shall submit to the Congress an annual
report on the program under this section.
``(f) Definition.--In this section:
``(1) The term `interdisciplinary' means collaboration
across health professions, specialties, and subspecialties,
which may include public health, nursing, allied health,
dietetics or nutrition, and appropriate health specialties.
``(2) The term `mental and behavioral health professional'
means an individual training or practicing--
``(A) in psychology; general, geriatric, child or
adolescent psychiatry; social work; marriage and family
therapy; professional mental health or substance abuse
counseling; or addiction medicine; or
``(B) another mental and behavioral health
specialty, as deemed appropriate by the Secretary.
``(g) Authorization of Appropriations.--To carry out this section,
there is authorized to be appropriated $60,000,000 for each of fiscal
years 2011 through 2015. Of the amounts appropriated to carry out this
section for a fiscal year, not less than 15 percent shall be used for
training programs in psychology.''.
SEC. 2523. REAUTHORIZATION OF TELEHEALTH AND TELEMEDICINE GRANT
PROGRAMS.
(a) Telehealth Network and Telehealth Resource Centers Grant
Programs.--Section 330I (42 U.S.C. 254c-14) is amended--
(1) in subsection (a)--
(A) by striking paragraph (3) (relating to frontier
communities); and
(B) by inserting after paragraph (2) the following:
``(3) Health disparities.--The term `health disparities'
has the meaning given such term in section 3171.'';
(2) in subsection (d)(1)--
(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:
``(D) reduce health disparities.'';
(3) in subsection (f)(1)(B)(iii)--
(A) in subclause (VII), by inserting ``, including
skilled nursing facilities'' before the period at the
end;
(B) in subclause (IX), by inserting ``, including
county mental health and public mental health
facilities'' before the period at the end; and
(C) by adding at the end the following:
``(XIII) Renal dialysis
facilities.'';
(4) by amending subsection (i) to read as follows:
``(i) Preferences.--
``(1) Telehealth networks.--In awarding grants under
subsection (d)(1) for projects involving telehealth networks,
the Secretary shall give preference to eligible entities
meeting at least one of the following:
``(A) Network.--The eligible entity is a health
care provider in, or proposing to form, a health care
network that furnishes services in a medically
underserved area or a health professional shortage
area.
``(B) Broad geographic coverage.--The eligible
entity demonstrates broad geographic coverage in the
rural or medically underserved areas of the State or
States in which the entity is located.
``(C) Health disparities.--The eligible entity
demonstrates how the project to be funded through the
grant will address health disparities.
``(D) Linkages.--The eligible entity agrees to use
the grant to establish or develop plans for telehealth
systems that will link rural hospitals and rural health
care providers to other hospitals, health care
providers, and patients.
``(E) Efficiency.--The eligible entity agrees to
use the grant to promote greater efficiency in the use
of health care resources.
``(F) Viability.--The eligible entity demonstrates
the long-term viability of projects through--
``(i) availability of non-Federal funding
sources; or
``(ii) institutional and community support
for the telehealth network.
``(G) Services.--The eligible entity provides a
plan for coordinating system use by eligible entities
and prioritizes use of grant funds for health care
services over nonclinical uses.
``(2) Telehealth resource centers.--In awarding grants
under subsection (d)(2) for projects involving telehealth
resource centers, the Secretary shall give preference to
eligible entities meeting at least one of the following:
``(A) Provision of a broad range of services.--The
eligible entity has a record of success in the
provision of a broad range of telehealth services to
medically underserved areas or populations.
``(B) Provision of telehealth technical
assistance.--The eligible entity has a record of
success in the provision of technical assistance to
providers serving medically underserved communities or
populations in the establishment and implementation of
telehealth services.
``(C) Collaboration and sharing of expertise.--The
eligible entity has a demonstrated record of
collaborating and sharing expertise with providers of
telehealth services at the national, regional, State,
and local levels.'';
(5) in subsection (j)(2)(B), by striking ``such projects
for fiscal year 2001'' and all that follows through the period
and inserting ``such projects for fiscal year 2010.'';
(6) in subsection (k)(1)--
(A) in subparagraph (E)(i), by striking
``transmission of medical data'' and inserting
``transmission and electronic archival of medical
data''; and
(B) by amending subparagraph (F) to read as
follows:
``(F) developing projects to use telehealth
technology to--
``(i) facilitate collaboration between
health care providers;
``(ii) promote telenursing services; or
``(iii) promote patient understanding and
adherence to national guidelines for chronic
disease and self-management of such
conditions;'';
(7) in subsection (q), by striking ``Not later than
September 30, 2005'' and inserting ``Not later than 1 year
after the date of the enactment of the Affordable Health Care
for America Act, and annually thereafter'';
(8) by striking subsection (r);
(9) by redesignating subsection (s) as subsection (r); and
(10) in subsection (r) (as so redesignated)--
(A) in paragraph (1)--
(i) by striking ``and'' before ``such
sums''; and
(ii) by inserting ``, $10,000,000 for
fiscal year 2011, and such sums as may be
necessary for each of fiscal years 2012 through
2015'' before the semicolon; and
(B) in paragraph (2)--
(i) by striking ``and'' before ``such
sums''; and
(ii) by inserting ``, $10,000,000 for
fiscal year 2011, and such sums as may be
necessary for each of fiscal years 2012 through
2015'' before the period.
(b) Telemedicine; Incentive Grants Regarding Coordination Among
States.--Subsection (b) of section 330L (42 U.S.C. 254c-18) is amended
by inserting ``, $10,000,000 for fiscal year 2011, and such sums as may
be necessary for each of fiscal years 2012 through 2015'' before the
period at the end.
SEC. 2524. NO CHILD LEFT UNIMMUNIZED AGAINST INFLUENZA: DEMONSTRATION
PROGRAM USING ELEMENTARY AND SECONDARY SCHOOLS AS
INFLUENZA VACCINATION CENTERS.
(a) Purpose.--The Secretary of Health and Human Services in
consultation with the Secretary of Education, shall award grants to
eligible partnerships to carry out demonstration programs designed to
test the feasibility of using the Nation's elementary schools and
secondary schools as influenza vaccination centers.
(b) In General.--The Secretary shall coordinate with the Secretary
of Labor, the Secretary of Education, State Medicaid agencies, State
insurance agencies, and private insurers to carry out a program
consisting of awarding grants under subsection (c) to ensure that
children have coverage for all reasonable and customary expenses
related to influenza vaccinations, including the costs of purchasing
and administering the vaccine incurred when influenza vaccine is
administered outside of the physician's office in a school or other
related setting.
(c) Program Description.--
(1) Grants.--From amounts appropriated pursuant to
subsection (l), the Secretary shall award grants to eligible
partnerships to be used to provide influenza vaccinations to
children in elementary and secondary schools, in coordination
with school nurses, school health care programs, community
health care providers, State insurance agencies, or private
insurers.
(2) ACIP recommendations.--The program under this section
shall be designed to administer vaccines consistent with the
recommendations of the Centers for Disease Control and
Prevention's Advisory Committee on Immunization Practices
(ACIP) for the annual vaccination of all children 5 through 19
years of age.
(3) Participation voluntary.--Participation by a school or
an individual shall be voluntary.
(d) Use of Funds.--Eligible partnerships receiving a grant under
this section shall ensure the maximum number of children access
influenza vaccinations as follows:
(1) Covered children.--To the extent to which payment of
the costs of purchasing or administering the influenza vaccine
for children is not covered through other federally funded
programs or through private insurance, eligible partnerships
receiving a grant shall use funds to purchase and administer
influenza vaccinations.
(2) Children covered by other federal programs.--For
children who are eligible under other federally funded programs
for payment of the costs of purchasing or administering the
influenza vaccine, eligible partnerships receiving a grant
shall not use funds provided under this section for such costs.
(3) Children covered by private health insurance.--For
children who have private insurance, eligible partnerships
receiving a grant shall offer assistance in accessing coverage
for vaccinations administered through the program under this
section.
(e) Privacy.--The Secretary shall ensure that the program under
this section adheres to confidentiality and privacy requirements of
section 264 of the Health Insurance Portability and Accountability Act
of 1996 (42 U.S.C. 1320d-2 note) and section 444 of the General
Education Provisions Act (20 U.S.C. 1232g; commonly referred to as the
``Family Educational Rights and Privacy Act of 1974'').
(f) Application.--An eligible partnership desiring 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.
(g) Duration.--Eligible partnerships receiving a grant shall
administer a demonstration program funded through this section over a
period of 2 consecutive school years.
(h) Choice of Vaccine.--The program under this section shall not
restrict the discretion of a health care provider to administer any
influenza vaccine approved by the Food and Drug Administration for use
in pediatric populations.
(i) Awards.--The Secretary shall award--
(1) a minimum of 10 grants in 10 different States to
eligible partnerships that each include one or more public
schools serving primarily low-income students; and
(2) a minimum of 5 grants in 5 different States to eligible
partnerships that each include one or more public schools
located in a rural local educational agency.
(j) Report.--Not later than 90 days following the completion of the
program under this section, the Secretary shall submit to the
Committees on Education and Labor, Energy and Commerce, and
Appropriations of the House of Representatives and to the Committees on
Health, Education, Labor, and Pensions and Appropriations of the Senate
a report on the results of the program. The report shall include--
(1) an assessment of the influenza vaccination rates of
school-age children in localities where the program is
implemented, compared to the national average influenza
vaccination rates for school-aged children, including whether
school-based vaccination assists in achieving the
recommendations of the Advisory Committee on Immunization
Practices;
(2) an assessment of the utility of employing elementary
schools and secondary schools as a part of a multistate,
community-based pandemic response program that is consistent
with existing Federal and State pandemic response plans;
(3) an assessment of the feasibility of using existing
Federal and private insurance funding in establishing a
multistate, school-based vaccination program for seasonal
influenza vaccination;
(4) an assessment of the number of education days gained by
students as a result of seasonal vaccinations based on
absenteeism rates;
(5) a determination of whether the program under this
section--
(A) increased vaccination rates in the
participating localities; and
(B) was implemented for sufficient time for
gathering enough valid data; and
(6) a recommendation on whether the program should be
continued, expanded, or terminated.
(k) Definitions.--In this section:
(1) Eligible partnership.--The term ``eligible
partnership'' means a local public health department, or
another health organization defined by the Secretary as
eligible to submit an application, and one or more elementary
and secondary schools.
(2) Elementary school.--The terms ``elementary school'' and
``secondary school'' have the meanings given such terms in
section 9101 of the Elementary and Secondary Education Act of
1965 (20 U.S.C. 7801).
(3) Low-income.--The term ``low-income'' means a student,
age 5 through 19, eligible for free or reduced-price lunch
under the National School Lunch Act (42 U.S.C. 1751 et seq.).
(4) Rural local educational agency.--The term ``rural local
educational agency'' means an eligible local educational agency
described in section 6211(b)(1) of the Elementary and Secondary
Education Act of 1965 (20 U.S.C. 7345(b)(1)).
(5) Secretary.--Except as otherwise specified, the term
``Secretary'' means the Secretary of Health and Human Services.
(l) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated such sums as may be necessary
for each of fiscal years 2011 through 2015.
SEC. 2525. EXTENSION OF WISEWOMAN PROGRAM.
Section 1509 of the Public Health Service Act (42 U.S.C. 300n-4a)
is amended--
(1) in subsection (a)--
(A) by striking the heading and inserting ``In
General.--''; and
(B) in the matter preceding paragraph (1), by
striking ``may make grants'' and all that follows
through ``purpose'' and inserting the following: ``may
make grants to such States for the purpose''; and
(2) in subsection (d)(1), by striking ``there are
authorized'' and all that follows through the period and
inserting ``there are authorized to be appropriated $70,000,000
for fiscal year 2011, $73,500,000 for fiscal year 2012,
$77,000,000 for fiscal year 2013, $81,000,000 for fiscal year
2014, and $85,000,000 for fiscal year 2015.''.
SEC. 2526. HEALTHY TEEN INITIATIVE TO PREVENT TEEN PREGNANCY.
Part B of title III (42 U.S.C. 243 et seq.) is amended by inserting
after section 317T the following:
``SEC. 317U. HEALTHY TEEN INITIATIVE TO PREVENT TEEN PREGNANCY.
``(a) Program.--To the extent and in the amount of appropriations
made in advance in appropriations Acts, the Secretary, acting through
the Director of the Centers for Disease Control and Prevention, shall
establish a program consisting of making grants, in amounts determined
under subsection (c), to each State that submits an application in
accordance with subsection (d) for an evidence-based education program
described in subsection (b).
``(b) Use of Funds.--Amounts received by a State under this section
shall be used to conduct or support evidence-based education programs
(directly or through grants or contracts to public or private nonprofit
entities, including schools and community-based and faith-based
organizations) to reduce teen pregnancy or sexually transmitted
diseases.
``(c) Distribution of Funds.--The Director shall, for fiscal year
2011 and each subsequent fiscal year, make a grant to each State
described in subsection (a) in an amount equal to the product of--
``(1) the amount appropriated to carry out this section for
the fiscal year; and
``(2) the percentage determined for the State under section
502(c)(1)(B)(ii) of the Social Security Act.
``(d) Application.--To seek a grant under this section, a State
shall submit an application at such time, in such manner, and
containing such information and assurance of compliance with this
section as the Secretary may require. At a minimum, an application
shall to the satisfaction of the Secretary--
``(1) describe how the State's proposal will address the
needs of at-risk teens in the State;
``(2) identify the evidence-based education program or
programs selected from the registry developed under subsection
(g) that will be used to address risks in priority populations;
``(3) describe how the program or programs will be
implemented and any adaptations to the evidence-based model
that will be made;
``(4) list any private and public entities with whom the
State proposes to work, including schools and community-based
and faith-based organizations, and demonstrate their capacity
to implement the proposed program or programs; and
``(5) identify an independent entity that will evaluate the
impact of the program or programs.
``(e) Evaluation.--
``(1) Requirement.--As a condition on receipt of a grant
under this section, a State shall agree--
``(A) to arrange for an independent evaluation of
the impact of the programs to be conducted or supported
through the grant; and
``(B) submit reports to the Secretary on such
programs and the results of evaluation of such
programs.
``(2) Funding limitation.--Of the amounts made available to
a State through a grant under this section for any fiscal year,
not more than 10 percent may be used for such evaluation.
``(f) Rule of Construction.--This section shall not be construed to
preempt or limit any State law regarding parental involvement and
decisionmaking in children's education.
``(g) Registry of Eligible Programs.--The Secretary shall develop
not later than 180 days after the date of the enactment of the
Affordable Health Care for America Act, and periodically update
thereafter, a publicly available registry of programs described in
subsection (b) that, as determined by the Secretary--
``(1) meet the definition of the term `evidence-based' in
subsection (i);
``(2) are medically and scientifically accurate; and
``(3) provide age-appropriate information.
``(h) Matching Funds.--The Secretary may award a grant to a State
under this section for a fiscal year only if the State agrees to
provide, from non-Federal sources, an amount equal to $1 (in cash or in
kind) for each $4 provided through the grant to carry out the
activities supported by the grant.
``(i) Definition.--In this section, the term `evidence-based' means
based on a model that has been found, in methodologically sound
research--
``(1) to delay initiation of sex;
``(2) to decrease number of partners;
``(3) to reduce teen pregnancy;
``(4) to reduce sexually transmitted infection rates; or
``(5) to improve rates of contraceptive use.
``(j) Authorization of Appropriations.--To carry out this section,
there is authorized to be appropriated $50,000,000 for each of fiscal
years 2011 through 2015.''.
SEC. 2527. NATIONAL TRAINING INITIATIVES ON AUTISM SPECTRUM DISORDERS.
Title I of the Developmental Disabilities Assistance and Bill of
Rights Act of 2000 (42 U.S.C. 15001 et seq.) is amended by adding at
the end the following:
``Subtitle F--National Training Initiative on Autism Spectrum Disorders
``SEC. 171. NATIONAL TRAINING INITIATIVE.
``(a) Grants and Technical Assistance.--
``(1) Grants.--
``(A) In general.--The Secretary, in consultation
with the Interagency Autism Coordinating Committee,
shall award multiyear grants to eligible entities to
provide individuals (including parents and health,
allied health, vocational, and educational
professionals) with interdisciplinary training,
continuing education, technical assistance, and
information for the purpose of improving services
rendered to children and adults with autism, and their
families, to address unmet needs related to autism.
``(B) Eligible entity.--To be eligible to receive a
grant under this subsection, an entity shall be--
``(i) a University Center for Excellence in
Developmental Disabilities Education, Research,
and Service; or
``(ii) a comparable interdisciplinary
education, research, and service entity.
``(C) Application requirements.--An entity that
desires to receive a grant for a program under this
paragraph shall submit to the Secretary an
application--
``(i) demonstrating that the entity has
capacity to--
``(I) provide training and
technical assistance in evidence-based
practices to evaluate, and provide
effective interventions, services,
treatments, and supports to, children
and adults with autism and their
families;
``(II) include individuals with
autism and their families as part of
the program to ensure that an
individual- and family-centered
approach is used;
``(III) share and disseminate
materials and practices that are
developed for, and evaluated to be
effective in, the provision of training
and technical assistance; and
``(IV) provide training, technical
assistance, interventions, services,
treatments, and supports under this
subsection statewide.
``(ii) providing assurances that the entity
will--
``(I) provide trainees under this
subsection with an appropriate balance
of interdisciplinary academic and
community-based experiences; and
``(II) provide to the Secretary, in
the manner prescribed by the Secretary,
data regarding the number of
individuals who have benefitted from,
and outcomes of, the provision of
training and technical assistance under
this subsection;
``(iii) providing assurances that training,
technical assistance, dissemination of
information, and services under this subsection
will be--
``(I) consistent with the goals of
this Act, the Americans with
Disabilities Act of 1990, the
Individuals with Disabilities Education
Act, and the Elementary and Secondary
Education Act of 1965; and
``(II) conducted in coordination
with relevant State agencies,
institutions of higher education, and
service providers; and
``(iv) containing such other information
and assurances as the Secretary may require.
``(D) Use of funds.--A grant received under this
subsection shall be used to provide individuals
(including parents and health, allied health,
vocational, and educational professionals) with
interdisciplinary training, continuing education,
technical assistance, and information for the purpose
of improving services rendered to children and adults
with autism, and their families, to address unmet needs
related to autism. Such training, education,
assistance, and information shall include each of the
following:
``(i) Training health, allied health,
vocational, and educational professionals to
identify, evaluate the needs of, and develop
interventions, services, treatments, and
supports for, children and adults with autism.
``(ii) Developing model services and
supports that demonstrate evidence-based
practices.
``(iii) Developing systems and products
that allow for the interventions, services,
treatments, and supports to be evaluated for
fidelity of implementation.
``(iv) Working to expand the availability
of evidence-based, lifelong interventions;
educational, employment, and transition
services; and community supports.
``(v) Providing statewide technical
assistance in collaboration with relevant State
agencies, institutions of higher education,
autism advocacy groups, and community-based
service providers.
``(vi) Working to develop comprehensive
systems of supports and services for
individuals with autism and their families,
including seamless transitions between
education and health systems across the
lifespan.
``(vii) Promoting training, technical
assistance, dissemination of information,
supports, and services.
``(viii) Developing mechanisms to provide
training and technical assistance, including
for-credit courses, intensive summer
institutes, continuing education programs,
distance based programs, and Web-based
information dissemination strategies.
``(ix) Promoting activities that support
community-based family and individual services
and enable individuals with autism and related
developmental disabilities to fully participate
in society and achieve good quality-of-life
outcomes.
``(x) Collecting data on the outcomes of
training and technical assistance programs to
meet statewide needs for the expansion of
services to children and adults with autism.
``(E) Amount of grants.--The amount of a grant to
any entity for a fiscal year under this section shall
be not less than $250,000.
``(2) Technical assistance.--The Secretary shall reserve 2
percent of the amount appropriated to carry out this subsection
for a fiscal year to make a grant to a national organization
with demonstrated capacity for providing training and technical
assistance to--
``(A) assist in national dissemination of specific
information, including evidence-based best practices,
from interdisciplinary training programs, and when
appropriate, other entities whose findings would inform
the work performed by entities awarded grants;
``(B) compile and disseminate strategies and
materials that prove to be effective in the provision
of training and technical assistance so that the entire
network can benefit from the models, materials, and
practices developed in individual centers;
``(C) assist in the coordination of activities of
grantees under this subsection;
``(D) develop a Web portal that will provide
linkages to each of the individual training initiatives
and provide access to training modules, promising
training, and technical assistance practices and other
materials developed by grantees;
``(E) serve as a research-based resource for
Federal and State policymakers on information
concerning the provision of training and technical
assistance for the assessment, and provision of
supports and services for, children and adults with
autism;
``(F) convene experts from multiple
interdisciplinary training programs, individuals with
autism, and the families of such individuals to discuss
and make recommendations with regard to training issues
related to assessment, interventions, services,
treatment, and supports for children and adults with
autism; and
``(H) undertake any other functions that the
Secretary determines to be appropriate.
``(3) Authorization of appropriations.--To carry out this
subsection, there are authorized to be appropriated $17,000,000
for fiscal year 2011 and such sums as may be necessary for each
of fiscal years 2012 through 2015.
``(b) Expansion of the Number of University Centers for Excellence
in Developmental Disabilities Education, Research, and Service.--
``(1) Grants.--To provide for the establishment of up to 4
new University Centers for Excellence in Developmental
Disabilities Education, Research, and Service, the Secretary
shall award up to 4 grants to institutions of higher education.
``(2) Applicable provisions.--Except for subsection (a)(3),
the provisions of subsection (a) shall apply with respect to
grants under this subsection to the same extent and in the same
manner as such provisions apply with respect to grants under
subsection (a).
``(3) Priority.--In awarding grants under this subsection,
the Secretary shall give priority to applicants that--
``(A) are minority institutions that have
demonstrated capacity to meet the requirements of this
section and provide services to individuals with autism
and their families; or
``(B) are located in a State with one or more
underserved populations.
``(4) Authorization of appropriations.--To carry out this
subsection, there is authorized to be appropriated $2,000,000
for each of fiscal years 2011 through 2015.
``(c) Definitions.--In this section:
``(1) The term `autism' means an autism spectrum disorder
or a related developmental disability.
``(2) The term `interventions' means educational methods
and positive behavioral support strategies designed to improve
or ameliorate symptoms associated with autism.
``(3) The term `minority institution' has the meaning given
to such term in section 365 of the Higher Education Act of
1965.
``(4) The term `services' means services to assist
individuals with autism to live more independently in their
communities.
``(5) The term `treatments' means health services,
including mental health services, designed to improve or
ameliorate symptoms associated with autism.
``(6) The term `University Center for Excellence in
Developmental Disabilities Education, Research, and Service'
means a University Center for Excellence in Development
Disabilities Education, Research, and Service that has been or
is funded through subtitle D or subsection (b).''.
SEC. 2528. IMPLEMENTATION OF MEDICATION MANAGEMENT SERVICES IN
TREATMENT OF CHRONIC DISEASES.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary''), acting through the
Director of the Agency for Health Care Research and Quality, shall
establish a program to provide grants to eligible entities to implement
medication management services (referred to in this section as ``MTM
services'') provided by licensed pharmacists, as a part of a
collaborative, multidisciplinary, interprofessional 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 grant program not later than
May 1, 2011.
(b) Eligible Entities.--To be eligible to receive a grant 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 with other local providers and where applicable,
through or in collaboration with the Medicare Medical Home
Pilot program as established by section 1866F of the Social
Security Act, as added by section 1302(a) of this Act;
(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 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 as are allowed under
the scopes of practice for pharmacists for purposes of other
Federal programs.
(d) Targeted Individuals.--MTM services provided by licensed
pharmacists under a grant awarded under subsection (a) shall be offered
to targeted individuals who--
(1) take 4 or more prescribed medications (including over-
the-counter 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 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
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, 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 of
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) Grant To Fund Development of Performance Measures.--The
Secretary may 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. 2529. POSTPARTUM DEPRESSION.
(a) Expansion and Intensification of Activities.--
(1) Continuation of activities.--The Secretary is
encouraged to expand and intensify activities on postpartum
conditions.
(2) Programs for postpartum conditions.--In carrying out
paragraph (1), the Secretary is encouraged to continue research
to expand the understanding of the causes of, and treatments
for, postpartum conditions, including 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
professionals and the public, which may include a
coordinated national campaign that--
(i) is designed to increase the awareness
and knowledge of postpartum conditions;
(ii) may include public service
announcements through television, radio, and
other means; and
(iii) may 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.
(b) Report by the Secretary.--
(1) Study.--The Secretary shall conduct a study on the
benefits of screening for postpartum conditions.
(2) Report.--Not later than 2 years after the date of the
enactment of this Act, the Secretary shall complete the study
required by paragraph (1) and submit a report to the Congress
on the results of such study.
(c) Sense of Congress Regarding Longitudinal Study of Relative
Mental Health Consequences for Women of Resolving a Pregnancy.--
(1) Sense of congress.--It is the sense of the Congress
that the Director of the National Institute of Mental Health
may conduct a nationally representative longitudinal study
(during the period of fiscal years 2011 through 2020) on 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.
(2) Report.--Beginning not later than 3 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.
(d) Definitions.--In this section:
(1) The term ``postpartum condition'' means postpartum
depression or postpartum psychosis.
(2) The term ``Secretary'' means the Secretary of Health
and Human Services.
(e) Authorization of Appropriations.--For the purpose of carrying
out this section, in addition to any other amounts authorized to be
appropriated for such purpose, there are authorized to be appropriated
such sums as may be necessary for each of fiscal years 2011 through
2013.
SEC. 2530. GRANTS TO PROMOTE POSITIVE HEALTH BEHAVIORS AND OUTCOMES.
Part P of title III (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 Secretary, in collaboration with the
Director of the Centers for Disease Control and Prevention and other
Federal officials determined appropriate by the Secretary, is
authorized to award grants to eligible entities to promote positive
health behaviors 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, especially racial and ethnic
minority populations;
``(2) to educate, guide, and provide experiential learning
opportunities that target behavioral risk factors including--
``(A) poor nutrition;
``(B) physical inactivity;
``(C) being overweight or obese;
``(D) tobacco use;
``(E) alcohol and substance use;
``(F) injury and violence;
``(G) risky sexual behavior;
``(H) untreated mental health problems;
``(I) untreated dental and oral health problems;
and
``(J) understanding informed consent;
``(3) to educate and provide guidance regarding effective
strategies to promote positive health behaviors within the
family;
``(4) to educate and provide outreach regarding enrollment
in health insurance including the State 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;
``(5) to educate and refer underserved populations to
appropriate health care agencies and community-based programs
and organizations in order to increase access to quality health
care services, including preventive health services, and to
eliminate duplicative care; or
``(6) to educate, guide, and provide home visitation
services regarding maternal health and prenatal care.
``(c) Application.--
``(1) In general.--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.
``(2) Contents.--Each application submitted pursuant to
paragraph (1) shall--
``(A) describe the activities for which assistance
is sought under this section;
``(B) contain an assurance that, with respect to
each community health worker program receiving funds
under the grant, such program will provide training and
supervision to community health workers to enable such
workers to provide authorized program services;
``(C) contain an assurance that the applicant will
evaluate the effectiveness of community health worker
programs receiving funds under the grant;
``(D) contain an assurance that each community
health worker program receiving funds under the grant
will provide services in the cultural context most
appropriate for the individuals served by the program;
``(E) contain a plan to document and disseminate
project descriptions and results to other States and
organizations as identified by the Secretary; and
``(F) describe plans to enhance the capacity of
individuals to utilize health services and health-
related social services under Federal, State, and local
programs by--
``(i) assisting individuals in establishing
eligibility under the programs and in receiving
the services or other benefits of the programs;
and
``(ii) providing other services as the
Secretary determines to be appropriate, that
may include transportation and translation
services.
``(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 including pulmonary
conditions, hypertension, heart disease, mental
disorders, diabetes, and asthma; and
``(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.--The Secretary
shall encourage community health worker programs receiving funds under
this section to collaborate with academic institutions, especially
those that graduate a disproportionate number of health and health care
students from underrepresented racial and ethnic minority backgrounds.
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 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 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) Report to Congress.--
``(1) In general.--Not later than 4 years after the date on
which the Secretary first awards grants under subsection (a),
the Secretary shall submit to Congress a report regarding the
grant project.
``(2) Contents.--The report required under paragraph (1)
shall include the following:
``(A) A description of the programs for which grant
funds were used.
``(B) The number of individuals served under such
programs.
``(C) An evaluation of--
``(i) the effectiveness of such programs;
``(ii) the cost of such programs; and
``(iii) the impact of the programs on the
health outcomes of the community residents.
``(D) Recommendations for sustaining the community
health worker programs developed or assisted under this
section.
``(E) Recommendations regarding training to enhance
career opportunities for community health workers.
``(k) Definitions.--In this section:
``(1) Community health worker.--The term `community health
worker' 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 health care agencies;
``(B) by providing guidance and social assistance
to community residents;
``(C) by enhancing community residents' ability to
effectively communicate with health care providers;
``(D) by providing culturally and linguistically
appropriate health or nutrition education;
``(E) by advocating for individual and community
health, including oral and mental, or nutrition needs;
and
``(F) by providing referral and followup services
or otherwise coordinating care.
``(2) Community setting.--The term `community setting'
means a home or a community organization located in the
neighborhood in which a participant resides.
``(3) Medically underserved community.--The term `medically
underserved community' means a community identified by a State,
United States territory or possession, or federally recognized
Indian tribe--
``(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.
``(4) Support.--The term `support' means the provision of
training, supervision, and materials needed to effectively
deliver the services described in subsection (b), reimbursement
for services, and other benefits.
``(5) Eligible entity.--The term `eligible entity' means a
public or private nonprofit entity (including a State or public
subdivision of a State, a public health department, or a
federally qualified health center), or a consortium of any of
such entities, located in the United States or territory
thereof.
``(l) Authorization of Appropriations.--There is authorized to be
appropriated to carry out this section $30,000,000 for each of fiscal
years 2011 through 2015.''.
SEC. 2531. MEDICAL LIABILITY ALTERNATIVES.
(a) Incentive Payments for Medical Liability Reform.--
(1) In general.--To the extent and in the amounts made
available in advance in appropriations Acts, the Secretary
shall make an incentive payment, in an amount determined by the
Secretary, to each State that has an alternative medical
liability law in compliance with this section.
(2) Determination by secretary.--The Secretary shall
determine that a State has an alternative medical liability law
in compliance with this section if the Secretary is satisfied
that--
(A) the State enacted the law after the date of the
enactment of this Act and is implementing the law;
(B) the law is effective; and
(C) the contents of the law are in accordance with
paragraph (4).
(3) Considerations for determining effectiveness.--In
determining whether an alternative medical liability law is
effective under paragraph (2)(B), the Secretary shall consider
whether the law--
(A) makes the medical liability system more
reliable through prevention of, or prompt and fair
resolution of, disputes;
(B) encourages the disclosure of health care
errors; and
(C) maintains access to affordable liability
insurance.
(4) Contents of alternative medical liability law.--The
contents of an alternative liability law are in accordance with
this paragraph if--
(A) the litigation alternatives contained in the
law consist of certificate of merit, early offer, or
both; and
(B) the law does not limit attorneys' fees or
impose caps on damages.
(b) Use of Incentive Payments.--Amounts received by a State as an
incentive payment under this section shall be used to improve health
care in that State.
(c) Technical Assistance.--The Secretary may provide technical
assistance to the States applying for or receiving an incentive payment
under this section.
(d) Reports.--Beginning not later than one year after the date of
the enactment of this Act, the Secretary shall submit to the Congress
an annual report on the progress States have made in enacting and
implementing alternative medical liability laws in compliance with this
section. Such reports shall contain sufficient documentation regarding
the effectiveness of such laws to enable an objective comparative
analysis of such laws.
(e) Definition.--In this section--
(1) the term ``Secretary'' means the Secretary of Health
and Human Services; and
(2) the term ``State'' includes the several States,
District of Columbia, the Commonwealth of Puerto Rico, and each
other territory or possession of the United States.
(f) Authorization of Appropriations.--There are authorized to be
appropriated to carry out this section such sums as may be necessary,
to remain available until expended.
SEC. 2532. INFANT MORTALITY PILOT PROGRAMS.
(a) In General.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary''), acting through the
Director, shall award grants to eligible entities to create, implement,
and oversee infant mortality pilot programs.
(b) Period of a Grant.--The period of a grant under this section
shall be 5 consecutive fiscal years.
(c) Preference.--In awarding grants under this section, the
Secretary shall give preference to eligible entities proposing to serve
any of the 15 counties or groups of counties with the highest rates of
infant mortality in the United States in the past 3 years.
(d) Use of Funds.--Any infant mortality pilot program funded under
this section may--
(1) include the development of a plan that identifies the
individual needs of each community to be served and strategies
to address those needs;
(2) provide outreach to at-risk mothers through programs
deemed appropriate by the Director;
(3) develop and implement standardized systems for improved
access, utilization, and quality of social, educational, and
clinical services to promote healthy pregnancies, full term
births, and healthy infancies delivered to women and their
infants, such as--
(A) counseling on infant care, feeding, and
parenting;
(B) postpartum care;
(C) prevention of premature delivery; and
(D) additional counseling for at-risk mothers,
including smoking cessation programs, drug treatment
programs, alcohol treatment programs, nutrition and
physical activity programs, postpartum depression and
domestic violence programs, social and psychological
services, dental care, and parenting programs;
(4) establish a rural outreach program to provide care to
at-risk mothers in rural areas;
(5) establish a regional public education campaign,
including a campaign to--
(A) prevent preterm births; and
(B) educate the public about infant mortality; and
(6) provide for any other activities, programs, or
strategies as identified by the community plan.
(e) Limitation.--Of the funds received through a grant under this
section for a fiscal year, an eligible entity shall not use more than
10 percent for program evaluation.
(f) Reports on Pilot Programs.--
(1) In general.--Not later than 1 year after receiving a
grant, and annually thereafter for the duration of the grant
period, each entity that receives a grant under subsection (a)
shall submit a report to the Secretary detailing its infant
mortality pilot program.
(2) Contents of report.--The reports required under
paragraph (1) shall include information such as the methodology
of, and outcomes and statistics from, the grantee's infant
mortality pilot program.
(3) Evaluation.--The Secretary shall use the reports
required under paragraph (1) to evaluate, and conduct
statistical research on, infant mortality pilot programs funded
through this section.
(g) Definitions.--For the purposes of this section:
(1) Director.--The term ``Director'' means the Director of
the Centers for Disease Control and Prevention.
(2) Eligible entity.--The term ``eligible entity'' means a
State, county, city, territorial, or tribal health department
that has submitted a proposal to the Secretary that the
Secretary deems likely to reduce infant mortality rates within
the standard metropolitan statistical area involved.
(3) Tribal.--The term ``tribal'' refers to an Indian tribe,
a Tribal organization, or an Urban Indian organization, as such
terms are defined in section 4 of the Indian Health Care
Improvement Act.
(h) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated $10,000,000 for each of fiscal
years 2011 through 2015.
SEC. 2533. SECONDARY SCHOOL HEALTH SCIENCES TRAINING PROGRAM.
(a) Program.--The Secretary of Health and Human Services, acting
through the Administrator of the Health Resources and Services
Administration, and in consultation with the Secretary of Education,
may establish a health sciences training program consisting of awarding
grants and contracts under subsection (b) to prepare secondary school
students for careers in health professions.
(b) Development and Implementation of Health Sciences Curricula.--
The Secretary may make grants to, or enter into contracts with,
eligible entities--
(1) to plan, develop, or implement secondary school health
sciences curricula, including curricula in biology, chemistry,
physiology, mathematics, nutrition, and other courses deemed
appropriate by the Secretary to prepare students for
associate's or bachelor's degree programs in health professions
or bachelor's degree programs in health professions-related
majors; and
(2) to increase the interest of secondary school students
in applying to, and enrolling in, accredited associate's or
bachelor's degree programs in health professions or bachelor's
degree programs in health professions-related majors, including
through--
(A) work-study programs;
(B) programs to increase awareness of careers in
health professions; and
(C) other activities to increase such interest.
(c) Eligibility.--To be eligible for a grant or contract under
subsection (b), an entity shall--
(1) be a local educational agency; and
(2) provide assurances that activities under the grant or
contract will be carried out in partnership with an accredited
health professions school or program, public or private
nonprofit hospital, or public or private nonprofit entity.
(d) Preference.--In awarding grants and contracts under subsection
(b), the Secretary shall give preference to entities that have a
demonstrated record of at least one of the following:
(1) Graduating a high or significantly improved percentage
of students who have exhibited mastery in secondary school
State science standards.
(2) Graduating students from disadvantaged backgrounds,
including racial and ethnic minorities who are underrepresented
in--
(A) associate's or bachelor's degree programs in
health professions or bachelor's degree programs in
health professions-related majors; or
(B) health professions.
(e) Report.--The Secretary shall submit to the Congress an annual
report on the program carried out under this section.
(f) Definitions.--In this section:
(1) The term ``health profession'' means the profession of
any member of the health workforce, as defined in section
764(i) of the Public Health Service Act, as added by section
2261.
(2) The term ``local educational agency'' has the meaning
given to the term in section 9101 of the Elementary and
Secondary Education Act of 1965 (20 U.S.C. 7801).
(3) The term ``secondary school''--
(A) means a secondary school, as defined in section
9101 of the Elementary and Secondary Education Act of
1965 (20 U.S.C. 7801); and
(B) includes any such school that is a middle
school.
(4) The term ``Secretary'' means the Secretary of Health
and Human Services except as otherwise specified.
(g) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated such sums as may be necessary
for each of fiscal years 2011 through 2015.
SEC. 2534. COMMUNITY-BASED COLLABORATIVE CARE NETWORKS.
(a) Purpose.--The purpose of this subtitle is to establish and
provide assistance to community-based collaborative care networks--
(1) to develop or strengthen coordination of services to
allow all individuals, including the uninsured and low-income,
to receive efficient and higher quality care and to gain entry
into and receive services from a comprehensive system of care;
(2) to develop efficient and sustainable infrastructure for
a health care delivery system characterized by effective
collaboration, information sharing, and clinical and financial
coordination among providers of care in the community;
(3) to develop or strengthen activities related to
providing coordinated care for individuals with chronic
conditions; and
(4) to reduce the use of emergency departments, inpatient
and other expensive resources of hospitals and other providers.
(b) Creation of the Community-Based Collaborative Care Network
Program.--Part D of title III (42 U.S.C. 254b et seq.), as amended, is
further amended by inserting after subpart XII the following new
subpart:
``Subpart XIII--Community-Based Collaborative Care Network Program
``SEC. 340O. COMMUNITY-BASED COLLABORATIVE CARE NETWORK PROGRAM.
``(a) In General.--The Secretary may award grants to eligible
entities for the purpose of establishing model projects to accomplish
the following goals:
``(1) To reduce unnecessary use of items and services
furnished in emergency departments of hospitals (especially to
ensure that individuals without health insurance coverage or
with inadequate health insurance coverage do not use the
services of such department instead of the services of a
primary care provider) through methods such as--
``(A) screening individuals who seek emergency
department services for possible eligibility under
relevant governmental health programs or for subsidies
under such programs; and
``(B) providing such individuals referrals for
followup care and chronic condition care.
``(2) To manage chronic conditions to reduce their
severity, negative health outcomes, and expense.
``(3) To encourage health care providers to coordinate
their efforts so that the most vulnerable patient populations
seek and obtain primary care.
``(4) To provide more comprehensive and coordinated care to
vulnerable low-income individuals and individuals without
health insurance coverage or with inadequate coverage.
``(5) To provide mechanisms for improving both quality and
efficiency of care for low-income individuals and families,
with an emphasis on those most likely to remain uninsured
despite the existence of government programs to make health
insurance more affordable.
``(6) To increase preventive services, including screening
and counseling, to those who would otherwise not receive such
screening, in order to improve health status and reduce long-
term complications and costs.
``(7) To ensure the availability of community-wide safety
net services, including emergency and trauma care.
``(b) Eligibility and Grantee Selection.--
``(1) Application.--A community-based collaborative care
network described in subsection (d) shall submit to the
Secretary an application in such form and manner and containing
such information as specified by the Secretary. Such
information shall at least--
``(A) identify the health care providers
participating in the community-based collaborative care
network proposed by the applicant and, if a provider
designated in paragraph (d)(1)(B) is not included, the
reason such provider is not so included;
``(B) include a description of how the providers
plan to collaborate to provide comprehensive and
integrated care for low-income individuals, including
uninsured and underinsured individuals;
``(C) include a description of the organizational
and joint governance structure of the community-based
collaborative care network in a manner so that it is
clear how decisions will be made, and how the
decisionmaking process of the network will include
appropriate representation of the participating
entities;
``(D) define the geographic areas and populations
that the network intends to serve;
``(E) define the scope of services that the network
intends to provide and identify any reasons why such
services would not include a suggested core service
identified by the Secretary under paragraph (3);
``(F) demonstrate the network's ability to meet the
requirements of this section; and
``(G) provide assurances that grant funds received
shall be used to support the entire community-based
collaborative care network.
``(2) Selection of grantees.--
``(A) In general.--The Secretary shall select
community-based collaborative care networks to receive
grants from applications submitted under paragraph (1)
on the basis of quality of the proposal involved,
geographic diversity (including different States and
regions served and urban and rural diversity), and the
number of low-income and uninsured individuals that the
proposal intends to serve.
``(B) Priority.--The Secretary shall give priority
to proposals from community-based collaborative care
networks that--
``(i) include the capability to provide the
broadest range of services to low-income
individuals; and
``(ii) include providers that currently
serve a high volume of low-income individuals.
``(C) Renewal.--In subsequent years, based on the
performance of grantees, the Secretary may provide
renewal grants to prior year grant recipients.
``(3) Suggested core services.--For purposes of paragraph
(1)(E), the Secretary shall develop a list of suggested core
patient and core network services to be provided by a
community-based collaborative care network. The Secretary may
select a community-based collaborative care network under
paragraph (2), the application of which does not include all
such services, if such application provides a reasonable
explanation why such services are not proposed to be included,
and the Secretary determines that the application is otherwise
high quality.
``(4) Termination authority.--The Secretary may terminate
selection of a community-based collaborative care network under
this section for good cause. Such good cause shall include a
determination that the network--
``(A) has failed to provide a comprehensive range
of coordinated and integrated health care services as
required under subsection (d)(2);
``(B) has failed to meet reasonable quality
standards;
``(C) has misappropriated funds provided under this
section; or
``(D) has failed to make progress toward
accomplishing goals set out in subsection (a).
``(c) Use of Funds.--
``(1) Use by grantees.--Grant funds are provided to
community-based collaborative care networks to carry out the
following activities:
``(A) Assist low-income individuals without
adequate health care coverage to--
``(i) access and appropriately use health
services;
``(ii) enroll in applicable public or
private health insurance programs;
``(iii) obtain referrals to and see a
primary care provider in case such an
individual does not have a primary care
provider; and
``(iv) obtain appropriate care for chronic
conditions.
``(B) Improve heath care by providing case
management, application assistance, and appropriate
referrals such as through methods to--
``(i) create and meaningfully use a health
information technology network to track
patients across collaborative providers;
``(ii) perform health outreach, such as by
using neighborhood health workers who may
inform individuals about the availability of
safety net and primary care providers available
through the community-based collaborative care
network;
``(iii) provide for followup outreach to
remind patients of appointments or follow-up
care instructions;
``(iv) provide transportation to
individuals to and from the site of care;
``(v) expand the capacity to provide care
at any provider participating in the community-
based collaborative care network, including
telehealth, hiring new clinical or
administrative staff, providing access to
services after-hours, on weekends, or otherwise
providing an urgent care alternative to an
emergency department; and
``(vi) provide a primary care provider or
medical home for each network patient.
``(C) Provide direct patient care services as
described in their application and approved by the
Secretary.
``(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 (in this
section referred to as `HRSA') or impose other requirements on
HRSA grantees participating in a community-based collaborative
care network as may be necessary for consistency with the
requirements of such programs.
``(3) Reservation of funds for national program purposes.--
The Secretary may use not more than 7 percent of funds
appropriated to carry out this section for providing technical
assistance to grantees, obtaining assistance of experts and
consultants, holding meetings, developing of tools,
disseminating of information, and evaluation.
``(d) Community-Based Collaborative Care Networks.--
``(1) In general.--
``(A) Description.--A community-based collaborative
care network described in this subsection is a
consortium of health care providers with a joint
governance structure that provides a comprehensive
range of coordinated and integrated health care
services for low-income patient populations or
medically underserved communities (whether or not such
individuals receive benefits under title XVIII, XIX, or
XXI of the Social Security Act, private or other health
insurance or are uninsured or underinsured) and that
complies with any applicable minimum eligibility
requirements that the Secretary may determine
appropriate.
``(B) Required inclusion.--Each such network shall
include the following providers that serve the
community (unless such provider does not exist within
the community, declines or refuses to participate, or
places unreasonable conditions on their
participation)--
``(i) A safety net hospital that provides
services to a high volume of low-income
patients, as demonstrated by meeting the
criteria in section 1923(b)(1) of the Social
Security Act, or other similar criteria
determined by the Secretary; and
``(ii) All Federally qualified health
centers (as defined in section 1861(aa) of the
Social Security Act (42 U.S.C. 1395x(aa)))
located in the geographic area served by the
Coordinated Care Network;
``(C) Additional inclusions.--Each such network may
include any of the following additional providers:
``(i) A hospital, including a critical
access hospital (as defined in section
1820(c)(2) of the Social Security Act (42
U.S.C. 1395i-4(c)(2))).
``(ii) A county or municipal department of
health.
``(iii) A rural health clinic or a rural
health network (as defined in sections 1861(aa)
and 1820(d) of the Social Security Act,
respectively (42 U.S.C. 1395x(aa), 1395i-
4(d))).
``(iv) A community clinic, including a
mental health clinic, substance abuse clinic,
or a reproductive health clinic.
``(v) A health center controlled network as
defined by section 330(e)(1)(C) of the Public
Health Service Act
``(vi) A private practice physician or
group practice.
``(vii) A nurse or physician assistant or
group practice.
``(viii) An adult day care center.
``(ix) A home health provider.
``(x) Any other type of provider specified
by the Secretary, which has a desire to serve
low-income and uninsured patients.
``(D) Construction.--
``(i) Nothing in this section shall
prohibit a single entity from qualifying as
community-based collaborative care network so
long as such single entity meets the criteria
of a community-based collaborative care
network. If the network does not include the
providers referenced in clauses (i) and (ii) of
subparagraph (B) of this paragraph, the
application must explain the reason pursuant to
subsection (b)(1)(A).
``(ii) Participation in a community-based
collaborative care network shall not affect
Federally qualified health centers' obligation
to comply with the governance requirements
under section 330 of the Public Health Service
Act (42 U.S.C. 254b).
``(iii) Federally qualified health centers
participating in a community-based
collaborative care network may not be required
to provide services beyond their Federal Health
Center scope of project approved by HRSA.
``(iv) Nothing in this section shall be
construed to expand medical malpractice
liability protection under the Federal Tort
Claims Act for Section 330-funded Federally
qualified health centers.
``(2) Comprehensive range of coordinated and integrated
health care services.--The Secretary shall define criteria for
evaluating whether the services offered by a community-based
collaborative care network qualify as a comprehensive range of
coordinated and integrated health care services. Such criteria
may vary based on the needs of the geographic areas and
populations to be served by the network and may include the
following:
``(A) Requiring community-based collaborative care
networks to include at least the suggested core
services identified under subsection (b)(3), or
whichever subset of the suggested core services is
applicable to a particular network.
``(B) Requiring such networks to assign each
patient of the network to a primary care provider
responsible for managing that patient's care.
``(C) Requiring the services provided by a
community-based collaborative care network to include
support services appropriate to meet the health needs
of low-income populations in the network's community,
which may include chronic care management, nutritional
counseling, transportation, language services,
enrollment counselors, social services and other
services as proposed by the network.
``(D) Providing that the services provided by a
community-based collaborative care network may also
include long-term care services and other services not
specified in this subsection.
``(E) Providing for the approval by the Secretary
of a scope of community-based collaborative care
network services for each network that addresses an
appropriate minimum scope of work consistent with the
setting of the network and the health professionals
available in the community the network serves.
``(3) Clarification.--Participation in a community-based
collaborative care network shall not disqualify a health care
provider from reimbursement under title XVIII, XIX, or XXI of
the Social Security Act with respect to services otherwise
reimbursable under such title. Nothing in this section shall
prevent a community-based collaborative care network that is
otherwise eligible to contract with Medicare, a private health
insurer, or any other appropriate entity to provide care under
Medicare, under health insurance coverage offered by the
insurer, or otherwise.
``(e) Evaluations.--
``(1) Grantee reports.--Beginning in the third year
following an initial grant, each community-based collaborative
care network shall submit to the Secretary, with respect to
each year the grantee has received a grant, an evaluation on
the activities carried out by the community-based collaborative
care network under the community-based collaborative care
network program and shall include--
``(A) the number of people served;
``(B) the most common health problems treated;
``(C) any reductions in emergency department use;
``(D) any improvements in access to primary care;
``(E) an accounting of how amounts received were
used, including identification of amounts used for
patient care services as may be required for HRSA
grantees; and
``(F) to the extent requested by the Secretary, any
quality measures or any other measures specified by the
Secretary.
``(2) Program reports.--The Secretary shall submit to
Congress an annual evaluation (beginning not later than 6
months after the first reports under paragraph (1) are
submitted) on the extent to which emergency department use was
reduced as a result of the activities carried out by the
community-based collaborative care network under the program.
Each such evaluation shall also include information on--
``(A) the prevalence of certain chronic conditions
in various populations, including a comparison of such
prevalence in the general population versus in the
population of individuals with inadequate health
insurance coverage;
``(B) demographic characteristics of the population
of uninsured and underinsured individuals served by the
community-based collaborative care network involved;
and
``(C) the conditions of such individuals for whom
services were requested at such emergency departments
of participating hospitals.
``(3) Audit authority.--The Secretary may conduct periodic
audits and request periodic spending reports of community-based
collaborative care networks under the community-based
collaborative care network program.
``(f) Clarification.--Nothing in this section requires a provider
to report individually identifiable information of an individual to
government agencies, unless the individual consents, consistent with
HIPAA privacy and security law, as defined in section 3009(a)(2).
``(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 2011 through 2015.''.
SEC. 2535. COMMUNITY-BASED OVERWEIGHT AND OBESITY PREVENTION PROGRAM.
Part Q of title III (42 U.S.C. 280h et seq.) is amended by
inserting after section 399W the following:
``SEC. 399W-1. COMMUNITY-BASED OVERWEIGHT AND OBESITY PREVENTION
PROGRAM.
``(a) Program.--The Secretary shall establish a community-based
overweight and obesity prevention program consisting of awarding grants
and contracts under subsection (b).
``(b) Grants.--The Secretary shall award grants to, or enter into
contracts with, eligible entities--
``(1) to plan evidence-based programs for the prevention of
overweight and obesity among children and their families
through improved nutrition and increased physical activity; or
``(2) to implement such programs.
``(c) Eligibility.--To be eligible for a grant or contract under
subsection (b), an entity shall be a community partnership that
demonstrates community support and includes--
``(1) a broad cross section of stakeholders, such as--
``(A) hospitals, health care systems, community
health centers, or other health care providers;
``(B) universities, local educational agencies, or
childcare providers;
``(C) State, local, and tribal health departments;
``(D) State, local, and tribal park and recreation
departments;
``(E) employers; and
``(F) health insurance companies;
``(2) residents of the community; and
``(3) representatives of public and private entities that
have a history of working within and serving the community.
``(d) Period of Awards.--
``(1) In general.--The period of a grant or contract under
this section shall be 5 years, subject to renewal under
paragraph (2).
``(2) Renewal.--At the end of each fiscal year, the
Secretary may renew a grant or contract award under this
section only if the grant or contract recipient demonstrates to
the Secretary's satisfaction that the recipient has made
appropriate, measurable progress in preventing overweight and
obesity.
``(e) Requirements.--
``(1) In general.--The Secretary may award a grant or
contract under this section to an entity only if the entity
demonstrates to the Secretary's satisfaction that--
``(A) not later than 90 days after receiving the
grant or contract, the entity will establish a steering
committee to provide input on the assessment of, and
recommendations on improvements to, the entity's
program funded through the grant or contract; and
``(B) the entity has conducted or will conduct an
assessment of the overweight and obesity problem in its
community, including the extent of the problem and
factors contributing to the problem.
``(2) Matching requirement.--The Secretary may award a
grant or contract to an eligible entity under this section only
if the entity agrees to provide, from non-Federal sources, an
amount equal to $1 (in cash or in kind) for each $9 provided
through the grant or contract to carry out the activities
supported by the grant or contract.
``(3) Payor of last resort.--The Secretary may award a
grant or contract under this section to an entity only if the
entity demonstrates to the satisfaction of the Secretary that
funds received through the grant or contract will not be
expended for any activity to the extent that payment has been
made, or can reasonably be expected to be made--
``(A) under any insurance policy;
``(B) under any Federal or State health benefits
program (including titles XIX and XXI of the Social
Security Act); or
``(C) by an entity which provides health services
on a prepaid basis.
``(4) Maintenance of effort.--The Secretary may award a
grant or contract under this section to an entity only if the
entity demonstrates to the satisfaction of the Secretary that--
``(A) funds received through the grant or contract
will be expended only to supplement, and not supplant,
non-Federal and Federal funds otherwise available to
the entity for the activities to be funded through the
grant or contract; and
``(B) with respect to such activities, the entity
will maintain expenditures of non-Federal amounts for
such activities at a level not less than the lesser of
such expenditures maintained by the entity for the
fiscal year preceding the fiscal year for which the
entity receives the grant or contract.
``(f) Preferences.--In awarding grants and contracts under this
section, the Secretary shall give preference to eligible entities
that--
``(1) will serve communities with high levels of overweight
and obesity and related chronic diseases; or
``(2) will plan or implement activities for the prevention
of overweight and obesity in school or workplace settings.
``(g) Report.--The Secretary shall submit to the Congress an annual
report on the program of grants and contracts awarded under this
section.
``(h) Definitions.--In this section:
``(1) The term `evidence-based' means that methodologically
sound research has demonstrated a beneficial health effect in
the judgment of the Secretary and includes the Ways to Enhance
Children's Activity and Nutrition (We Can) program and
curriculum of the National Institutes of Health.
``(2) The term `local educational agency' has the meaning
given to the term in section 9101 of the Elementary and
Secondary Education Act of 1965.
``(i) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated $10,000,000 for fiscal year
2011 and such sums as may be necessary for each of fiscal years 2012
through 2015.''.
SEC. 2536. REDUCING STUDENT-TO-SCHOOL NURSE RATIOS.
(a) Demonstration Grants.--
(1) In general.--The Secretary of Education, in
consultation with the Secretary of Health and Human Services
and the Director of the Centers for Disease Control and
Prevention, may make demonstration grants to eligible local
educational agencies for the purpose of reducing the student-
to-school nurse ratio in public elementary and secondary
schools.
(2) Special consideration.--In awarding grants under this
section, the Secretary of Education shall give special
consideration to applications submitted by high-need local
educational agencies that demonstrate the greatest need for new
or additional nursing services among children in the public
elementary and secondary schools served by the agency, in part
by providing information on current ratios of students to
school nurses.
(3) Matching funds.--The Secretary of Education may require
recipients of grants under this subsection to provide matching
funds from non-Federal sources, and shall permit the recipients
to match funds in whole or in part with in-kind contributions.
(b) Report.--Not later than 24 months after the date on which
assistance is first made available to local educational agencies under
this section, the Secretary of Education shall submit to the Congress a
report on the results of the demonstration grant program carried out
under this section, including an evaluation of the effectiveness of the
program in improving the student-to-school nurse ratios described in
subsection (a) and an evaluation of the impact of any resulting
enhanced health of students on learning.
(c) Definitions.--For purposes of this section:
(1) The terms ``elementary school'', ``local educational
agency'', and ``secondary school'' have the meanings given to
those terms in section 9101 of the Elementary and Secondary
Education Act of 1965 (20 U.S.C. 7801).
(2) The term ``eligible local educational agency'' means a
local educational agency in which the student-to-school nurse
ratio in the public elementary and secondary schools served by
the agency is 750 or more students to every school nurse.
(3) The term ``high-need local educational agency'' means a
local educational agency--
(A) that serves not fewer than 10,000 children from
families with incomes below the poverty line; or
(B) for which not less than 20 percent of the
children served by the agency are from families with
incomes below the poverty line.
(4) The term ``nurse'' means a licensed nurse, as defined
under State law.
(d) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated such sums as may be necessary
for each of fiscal years 2011 through 2015.
SEC. 2537. MEDICAL-LEGAL PARTNERSHIPS.
(a) In General.--The Secretary shall establish a nationwide
demonstration project consisting of--
(1) awarding grants to, and entering into contracts with,
medical-legal partnerships to assist patients and their
families to navigate health-related programs and activities;
and
(2) evaluating the effectiveness of such partnerships.
(b) Use of Funds.--Amounts received as a grant or contract under
this section shall be used to assist patients and their families to
navigate health care-related programs and activities and thereby
achieve one or more of the following goals:
(1) Enhancing access to health care services.
(2) Improving health outcomes for low-income individuals.
(3) Reducing health disparities.
(4) Enhancing wellness and prevention of chronic
conditions.
(c) Prohibition.--No funds under this section may be used--
(1) for any medical malpractice or other civil action or
proceeding; or
(2) to assist individuals who are not lawfully present in
the United States.
(d) Report.--Not later than 5 years after the date of the enactment
of this Act, the Secretary shall submit a report to the Congress on the
results of the demonstration project under this section. Such report
shall include the following:
(1) A description of the extent to which medical-legal
partnerships funded through this section achieved the goals
described in subsection (b).
(2) Recommendations on the possibility of extending or
expanding the demonstration project.
(e) Definitions.--In this section:
(1) The term ``health disparities'' has the meaning given
to the term in section 3171 of the Public Health Service Act,
as added by section 2301.
(2) The term ``medical-legal partnership'' means an
entity--
(A) that is a collaboration between--
(i) a community health center, public
hospital, children's hospital, or other
provider of health care services to a
significant number of low-income beneficiaries;
and
(ii) one or more attorneys; and
(B) whose primary mission is to assist patients and
their families navigate health care-related programs
and activities.
(3) The term ``Secretary'' means the Secretary of Health
and Human Services.
(f) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated such sums as may be necessary
for each of fiscal years 2011 through 2015.
PART 3--EMERGENCY CARE-RELATED PROGRAMS
SEC. 2551. TRAUMA CARE CENTERS.
(a) Grants for Trauma Care Centers.--Section 1241 (42 U.S.C. 300d-
41) is amended to read as follows:
``SEC. 1241. GRANTS FOR CERTAIN TRAUMA CENTERS.
``(a) In General.--The Secretary shall establish a trauma center
program consisting of awarding grants under section (b).
``(b) Grants.--The Secretary shall award grants as follows:
``(1) Existing centers.--Grants to public, private
nonprofit, Indian Health Service, Indian tribal, and urban
Indian trauma centers--
``(A) to further the core missions of such centers;
or
``(B) to provide emergency relief to ensure the
continued and future availability of trauma services by
trauma centers--
``(i) at risk of closing or operating in an
area where a closing has occurred within their
primary service area; or
``(ii) in need of financial assistance
following a natural disaster or other
catastrophic event, such as a terrorist attack.
``(2) New centers.--Grants to local governments and public
or private nonprofit entities to establish new trauma centers
in urban areas with a substantial degree of trauma resulting
from violent crimes.
``(c) Minimum Qualifications of Trauma Centers.--
``(1) Participation in trauma care system operating under
certain professional guidelines.--
``(A) Limitation.--Subject to subparagraph (B), the
Secretary may not award a grant to an existing trauma
center under this section unless the center is a
participant in a trauma care system that substantially
complies with section 1213.
``(B) Exemption.--Subparagraph (A) shall not apply
to trauma centers that are located in States with no
existing trauma care system.
``(2) Designation.--The Secretary may not award a grant
under this section to an existing trauma center unless the
center is--
``(A) verified as a trauma center by the American
College of Surgeons; or
``(B) designated as a trauma center by the
applicable State health or emergency medical services
authority.''.
(b) Considerations in Making Grants.--Section 1242 (42 U.S.C. 300d-
42) is amended to read as follows:
``SEC. 1242. CONSIDERATIONS IN MAKING GRANTS.
``(a) Core Mission Awards.--
``(1) In general.--In awarding grants under section
1241(b)(1)(A), the Secretary shall--
``(A) reserve a minimum of 25 percent of the amount
allocated for such grants for level III and level IV
trauma centers in rural or underserved areas;
``(B) reserve a minimum of 25 percent of the amount
allocated for such grants for level I and level II
trauma centers in urban areas; and
``(C) give preference to any application made by a
trauma center--
``(i) in a geographic area where growth in
demand for trauma services exceeds capacity;
``(ii) that demonstrates the financial
support of the State or political subdivision
involved;
``(iii) that has at least 1 graduate
medical education fellowship in trauma or
trauma-related specialties, including
neurological surgery, surgical critical care,
vascular surgery, and spinal cord injury, for
which demand is exceeding supply; or
``(iv) that demonstrates a substantial
commitment to serving vulnerable populations.
``(2) Financial support.--For purposes of paragraph
(1)(C)(ii), financial support may be demonstrated by State or
political subdivision funding for the trauma center's capital
or operating expenses (including through State trauma regional
advisory coordination activities, Medicaid funding designated
for trauma services, or other governmental funding). State
funding derived from Federal support shall not constitute State
or local financial support for purposes of preferential
treatment under this subsection.
``(3) Use of funds.--The recipient of a grant under section
1241(b)(1)(A) shall carry out, consistent with furthering the
core missions of the center, one or more of the following
activities:
``(A) Providing 24-hour-a-day, 7-day-a-week trauma
care availability.
``(B) Reducing overcrowding related to throughput
of trauma patients.
``(C) Enhancing trauma surge capacity.
``(D) Ensuring physician and essential personnel
availability.
``(E) Trauma education and outreach.
``(F) Coordination with local and regional trauma
care systems.
``(G) Such other activities as the Secretary may
deem appropriate.
``(b) Emergency Awards; New Centers.--In awarding grants under
paragraphs (1)(B) and (2) of section 1241(b), the Secretary shall--
``(1) give preference to any application submitted by an
applicant that demonstrates the financial support (in
accordance with subsection (a)(2)) of the State or political
subdivision involved for the activities to be funded through
the grant for each fiscal year during which payments are made
to the center under the grant; and
``(2) give preference to any application submitted for a
trauma center that--
``(A) is providing or will provide trauma care in a
geographic area in which the availability of trauma
care has either significantly decreased as a result of
a trauma center in the area permanently ceasing
participation in a system described in section
1241(c)(1) as of a date occurring during the 2-year
period preceding the fiscal year for which the trauma
center is applying to receive a grant, or in geographic
areas where growth in demand for trauma services
exceeds capacity;
``(B) will, in providing trauma care during the 1-
year period beginning on the date on which the
application for the grant is submitted, incur
substantial uncompensated care costs in an amount that
renders the center unable to continue participation in
such system and results in a significant decrease in
the availability of trauma care in the geographic area;
``(C) operates or will operate in rural areas where
trauma care availability will significantly decrease if
the center is forced to close or downgrade service and
substantial costs are contributing to a likelihood of
such closure or downgradation;
``(D) is in a geographic location substantially
affected by a natural disaster or other catastrophic
event such as a terrorist attack; or
``(E) will establish a new trauma service in an
urban area with a substantial degree of trauma
resulting from violent crimes.
``(c) Designations of Levels of Trauma Centers in Certain States.--
In the case of a State which has not designated 4 levels of trauma
centers, any reference in this section to--
``(1) a level I or level II trauma center is deemed to be a
reference to a trauma center within the highest 2 levels of
trauma centers designated under State guidelines; and
``(2) a level III or IV trauma center is deemed to be a
reference to a trauma center not within such highest 2
levels.''.
(c) Certain Agreements.--Section 1243 (42 U.S.C. 300d-43) is
amended to read as follows:
``SEC. 1243. CERTAIN AGREEMENTS.
``(a) Commitment Regarding Continued Participation in Trauma Care
System.--The Secretary may not award a grant to an applicant under
section 1241(b) unless the applicant agrees that--
``(1) the trauma center involved will continue
participation, or in the case of a new center will participate,
in the system described in section 1241(c)(1), except as
provided in section 1241(c)(1)(B), throughout the grant period
beginning on the date that the center first receives payments
under the grant; and
``(2) if the agreement made pursuant to paragraph (1) is
violated by the center, the center will be liable to the United
States for an amount equal to the sum of--
``(A) the amount of assistance provided to the
center under section 1241; and
``(B) an amount representing interest on the amount
specified in subparagraph (A).
``(b) Maintenance of Financial Support.--With respect to activities
for which funds awarded through a grant under section 1241 are
authorized to be expended, the Secretary may not award such a grant
unless the applicant agrees that, during the period in which the trauma
center involved is receiving payments under the grant, the center will
maintain access to trauma services at levels not less than the levels
for the prior year, taking into account--
``(1) reasonable volume fluctuation that is not caused by
intentional trauma boundary reduction;
``(2) downgrading of the level of services; and
``(3) whether such center diverts its incoming patients
away from such center 5 percent or more of the time during
which the center is in operation over the course of the year.
``(c) Trauma Care Registry.--The Secretary may not award a grant to
a trauma center under section 1241(b)(1) unless the center agrees
that--
``(1) not later than 6 months after the date on which the
center submits a grant application to the Secretary, the center
will establish and operate a registry of trauma cases in
accordance with guidelines developed by the American College of
Surgeons; and
``(2) in carrying out paragraph (1), the center will
maintain information on the number of trauma cases treated by
the center and, for each such case, the extent to which the
center incurs uncompensated costs in providing trauma care.''.
(d) General Provisions.--Section 1244 (42 U.S.C. 300d-44) is
amended to read as follows:
``SEC. 1244. GENERAL PROVISIONS.
``(a) Limitation on Duration of Support.--The period during which a
trauma center receives payments under a grant under section 1241(b)(1)
shall be for 3 fiscal years, except that the Secretary may waive such
requirement for the center and authorize the center to receive such
payments for 1 additional fiscal year.
``(b) Eligibility.--The acquisition of, or eligibility for, a grant
under section 1241(b) shall not preclude a trauma center's eligibility
for another grant described in such section.
``(c) Funding Distribution.--Of the total amount appropriated for a
fiscal year under section 1245--
``(1) 90 percent shall be used for grants under paragraph
(1)(A) of section 1241(b); and
``(2) 10 percent shall be used for grants under paragraphs
(1)(B) and (2) of section 1241(b).
``(d) Report.--Beginning 2 years after the date of the enactment of
the Affordable Health Care for America Act, and every 2 years
thereafter, the Secretary shall biennially--
``(1) report to Congress on the status of the grants made
pursuant to section 1241;
``(2) evaluate and report to Congress on the overall
financial stability of trauma centers in the United States;
``(3) report on the populations using trauma care centers
and include aggregate patient data on income, race, ethnicity,
and geography; and
``(4) evaluate the effectiveness and efficiency of trauma
care center activities using standard public health measures
and evaluation methodologies.''.
(e) Authorization of Appropriations.--Section 1245 (42 U.S.C. 300d-
45) is amended to read as follows:
``SEC. 1245. AUTHORIZATION OF APPROPRIATIONS.
``(a) In General.--For the purpose of carrying out this part, there
are authorized to be appropriated $100,000,000 for fiscal year 2011,
and such sums as may be necessary for each of fiscal years 2012 through
2015. Such authorization of appropriations is in addition to any other
authorization of appropriations or amounts that are available for such
purpose.
``(b) Reallocation.--The Secretary shall reallocate for grants
under section 1241(b)(1)(A) any funds appropriated for grants under
paragraph (1)(B) or (2) of section 1241(b), but not obligated due to
insufficient applications eligible for funding.''.
SEC. 2552. EMERGENCY CARE COORDINATION.
(a) In General.--Subtitle B of title XXVIII (42 U.S.C. 300hh-10 et
seq.) is amended by adding at the end the following:
``SEC. 2816. EMERGENCY CARE COORDINATION.
``(a) Emergency Care Coordination Center.--
``(1) Establishment.--The Secretary shall establish, within
the Office of the Assistant Secretary for Preparedness and
Response, an Emergency Care Coordination Center (in this
section referred to as the `Center'), to be headed by a
director.
``(2) Duties.--The Secretary, acting through the Director
of the Center, in coordination with the Federal Interagency
Committee on Emergency Medical Services, shall--
``(A) promote and fund research in emergency
medicine and trauma health care;
``(B) promote regional partnerships and more
effective emergency medical systems in order to enhance
appropriate triage, distribution, and care of routine
community patients; and
``(C) promote local, regional, and State emergency
medical systems' preparedness for and response to
public health events.
``(b) Council of Emergency Care.--
``(1) Establishment.--The Secretary, acting through the
Director of the Center, shall establish a Council of Emergency
Care to provide advice and recommendations to the Director on
carrying out this section.
``(2) Composition.--The Council shall be comprised of
employees of the departments and agencies of the Federal
Government who are experts in emergency care and management.
``(c) Report.--
``(1) Submission.--Not later than 12 months after the date
of the enactment of the Affordable Health Care for America Act,
the Secretary shall submit to the Congress an annual report on
the activities carried out under this section.
``(2) Considerations.--In preparing a report under
paragraph (1), the Secretary shall consider factors including--
``(A) emergency department crowding and boarding;
and
``(B) delays in care following presentation.
``(d) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated such sums as may be necessary
for each of fiscal years 2011 through 2015.''.
(b) Functions, Personnel, Assets, Liabilities, and Administrative
Actions.--All functions, personnel, assets, and liabilities of, and
administrative actions applicable to, the Emergency Care Coordination
Center, as in existence on the day before the date of the enactment of
this Act, shall be transferred to the Emergency Care Coordination
Center established under section 2816(a) of the Public Health Service
Act, as added by subsection (a).
SEC. 2553. PILOT PROGRAMS TO IMPROVE EMERGENCY MEDICAL CARE.
Part B of title III (42 U.S.C. 243 et seq.) is amended by inserting
after section 314 the following:
``SEC. 315. REGIONALIZED COMMUNICATION 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 demonstration programs that design, implement, and evaluate
innovative models of regionalized, comprehensive, and accountable
emergency care systems.
``(b) Eligible Entity; Region.--
``(1) Eligible entity.--In this section, the term `eligible
entity' means a State or a partnership of 1 or more States and
1 or more local governments.
``(2) Region.--In this section, 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.
``(c) Demonstration Program.--The Secretary shall award a contract
or grant under subsection (a) to an eligible entity that proposes a
demonstration program to design, implement, and evaluate an emergency
medical system that--
``(1) coordinates with public safety services, public
health services, emergency medical services, medical
facilities, and other entities within a region;
``(2) coordinates an approach to emergency medical system
access throughout the region, including 9-1-1 public safety
answering points and emergency medical dispatch;
``(3) includes a mechanism, such as a regional medical
direction or transport communications system, that operates
throughout the region to ensure that the correct patient is
taken to the medically appropriate facility (whether an initial
facility or a higher level facility) in a timely fashion;
``(4) allows for the tracking of prehospital and hospital
resources, including inpatient bed capacity, emergency
department capacity, on-call specialist coverage, ambulance
diversion status, and the coordination of such tracking with
regional communications and hospital destination decisions; and
``(5) includes a consistent regionwide prehospital,
hospital, and interfacility data management system that--
``(A) complies with 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 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) is compatible with the applicable
State emergency medical services system;
``(iii) includes consistent indirect and
direct medical oversight of prehospital,
hospital, and interfacility transport
throughout the region;
``(iv) coordinates prehospital treatment
and triage, hospital destination, and
interfacility transport throughout the region;
``(v) includes a categorization or
designation system for special medical
facilities throughout the region that is--
``(I) consistent with State laws
and regulations; and
``(II) integrated with the
protocols for transport and destination
throughout the region; and
``(vi) includes a regional medical
direction system, a patient tracking system,
and a resource allocation system that--
``(I) support day-to-day emergency
care system operation;
``(II) can manage surge capacity
during a major event or disaster; and
``(III) are integrated with other
components of the national and State
emergency preparedness system;
``(B) an agreement to make available non-Federal
contributions in accordance with subsection (e); and
``(C) such other information as the Secretary may
require.
``(e) Matching Funds.--
``(1) In general.--With respect to the costs of the
activities to be carried out each year with a contract or grant
under subsection (a), a condition for the receipt of the
contract or grant is that the eligible entity involved agrees
to make available (directly or through donations from public or
private entities) non-Federal contributions toward such costs
in an amount that is not less than 25 percent of such costs.
``(2) Determination of amount contributed.--Non-Federal
contributions required in paragraph (1) may be in cash or in
kind, fairly evaluated, including plant, 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 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 medically underserved population (as defined in
section 330(b)(3)).
``(g) Report.--Not later than 90 days after the completion of a
demonstration program under subsection (a), the recipient of such
contract or grant described in such subsection 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 system on patient outcomes for various critical care
categories, such as trauma, stroke, cardiac 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 system;
``(4) the State and local legislation necessary to
implement and to maintain the system; and
``(5) the barriers to developing regionalized, accountable
emergency care systems, as well as the methods to overcome such
barriers.
``(h) Evaluation.--The Secretary, acting through the Assistant
Secretary for Preparedness and Response, shall enter into a contract
with an academic institution or other entity to conduct an independent
evaluation of the demonstration programs funded under subsection (a),
including an evaluation of--
``(1) the performance of the eligible entities receiving
the funds; and
``(2) the impact of the demonstration programs.
``(i) 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 (h).
``(j) Authorization of Appropriations.--
``(1) In general.--There is authorized to be appropriated
to carry out this section $12,000,000 for each of fiscal years
2011 through 2015.
``(2) Reservation.--Of the amount appropriated to carry out
this section for a fiscal year, the Secretary shall reserve 3
percent of such amount to carry out subsection (h) (relating to
an independent evaluation).''.
SEC. 2554. ASSISTING VETERANS WITH MILITARY EMERGENCY MEDICAL TRAINING
TO BECOME STATE-LICENSED OR CERTIFIED EMERGENCY MEDICAL
TECHNICIANS (EMTS).
(a) In General.--Part B of title III (42 U.S.C. 243 et seq.), as
amended, is amended by inserting after section 315 the following:
``SEC. 315A. ASSISTING VETERANS WITH MILITARY EMERGENCY MEDICAL
TRAINING TO BECOME STATE-LICENSED OR CERTIFIED EMERGENCY
MEDICAL TECHNICIANS (EMTS).
``(a) Program.--The Secretary shall establish a program consisting
of awarding grants to States to assist veterans who received and
completed military emergency medical training while serving in the
Armed Forces of the United States to become, upon their discharge or
release from active duty service, State-licensed or certified emergency
medical technicians.
``(b) Use of Funds.--Amounts received as a grant under this section
may be used to assist veterans described in subsection (a) to become
State-licensed or certified emergency medical technicians as follows:
``(1) Providing training.
``(2) Providing reimbursement for costs associated with--
``(A) training; or
``(B) applying for licensure or certification.
``(3) Expediting the licensing or certification process.
``(c) Eligibility.--To be eligible for a grant under this section,
a State shall demonstrate to the Secretary's satisfaction that the
State has a shortage of emergency medical technicians.
``(d) Report.--The Secretary shall submit to the Congress an annual
report on the program under this section.
``(e) Authorization of Appropriations.--To carry out this section,
there are authorized to be appropriated such sums as may be necessary
for each of fiscal years 2011 through 2015.''.
(b) GAO Study and Report.--The Comptroller General of the United
States shall--
(1) conduct a study on the barriers experienced by veterans
who received training as medical personnel while serving in the
Armed Forces of the United States and, upon their discharge or
release from active duty service, seek to become licensed or
certified in a State as civilian health professionals; and
(2) not later than 2 years after the date of the enactment
of this Act, submit to the Congress a report on the results of
such study, including recommendations on whether the program
established under section 315A of the Public Health Service
Act, as added by subsection (a), should be expanded to assist
veterans seeking to become licensed or certified in a State as
health providers other than emergency medical technicians.
SEC. 2555. DENTAL EMERGENCY RESPONDERS: PUBLIC HEALTH AND MEDICAL
RESPONSE.
(a) National Health Security Strategy.--Section 2802(b)(3) (42
U.S.C. 300hh-1(b)(3)) is amended--
(1) in the matter preceding subparagraph (A), by inserting
``dental and'' before ``mental health facilities''; and
(2) in subparagraph (D), by inserting ``and dental'' after
``medical''.
(b) All-Hazards Public Health and Medical Response Curricula and
Training.--Section 319F(a)(5)(B) (42 U.S.C. 247d-6(a)(5)(B)) is amended
by striking ``public health or medical'' and inserting ``public health,
medical, or dental''.
SEC. 2556. DENTAL EMERGENCY RESPONDERS: HOMELAND SECURITY.
(a) National Response Framework.--Paragraph (6) of section 2 of the
Homeland Security Act of 2002 (6 U.S.C. 101) is amended by inserting
``and dental'' after ``emergency medical''.
(b) National Preparedness System.--Subparagraph (B) of section
653(b)(4) of the Post-Katrina Emergency Management Reform Act of 2006
(6 U.S.C. 753(b)(4)) is amended by striking ``public health and
medical'' and inserting ``public health, medical, and dental''.
(c) Chief Medical Officer.--Paragraph (5) of section 516(c) of the
Homeland Security Act of 2002 (6 U.S.C. 321e(c)) is amended by striking
``medical community'' and inserting ``medical and dental communities''.
PART 4--PAIN CARE AND MANAGEMENT PROGRAMS
SEC. 2561. INSTITUTE OF MEDICINE CONFERENCE ON PAIN.
(a) Convening.--Not later than June 30, 2011, 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 section referred to as ``the Conference'').
(b) Purposes.--The purposes of the Conference shall be to--
(1) increase the recognition of pain as a significant
public health problem in the United States;
(2) 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;
(3) identify barriers to appropriate pain care, including--
(A) lack of understanding and education among
employers, patients, health care providers, regulators,
and third-party payors;
(B) barriers to access to care at the primary,
specialty, and tertiary care levels, including
barriers--
(i) specific to those populations that are
disproportionately undertreated for pain;
(ii) related to physician concerns over
regulatory and law enforcement policies
applicable to some pain therapies; and
(iii) attributable to benefit, coverage,
and payment policies in both the public and
private sectors; and
(C) gaps in basic and clinical research on the
symptoms and causes of pain, and potential assessment
methods and new treatments to improve pain care; and
(4) 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.
(c) Other Appropriate Entity.--If the Institute of Medicine
declines to enter into an agreement under subsection (a), the Secretary
of Health and Human Services may enter into such agreement with another
appropriate entity.
(d) Report.--A report summarizing the Conference's findings and
recommendations shall be submitted to the Congress not later than June
30, 2012.
(e) Authorization of Appropriations.--For the purpose of carrying
out this section, there is authorized to be appropriated $500,000 for
each of fiscal years 2011 and 2012.
SEC. 2562. PAIN RESEARCH AT NATIONAL INSTITUTES OF HEALTH.
Part B of title IV (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 as follows:
``(I) The Director of the Centers
for Disease Control and Prevention.
``(II) The Director of the National
Institutes of Health and the directors
of such national research institutes
and national centers as the Secretary
determines appropriate.
``(III) The heads of such other
agencies of the Department of Health
and Human Services as the Secretary
determines appropriate.
``(IV) Representatives of other
Federal agencies that conduct or
support pain care research and
treatment, including the Department of
Defense and the Department of Veterans
Affairs.
``(ii) Twelve additional voting members
appointed under subparagraph (B).
``(B) Additional members.--The Committee shall
include additional voting members appointed by the
Secretary as follows:
``(i) Six members shall be appointed from
among scientists, physicians, and other health
professionals, who--
``(I) are not officers or employees
of the United States;
``(II) represent multiple
disciplines, including clinical, basic,
and public health sciences;
``(III) represent different
geographical regions of the United
States; and
``(IV) are from practice settings,
academia, manufacturers, or other
research settings.
``(ii) Six 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, including the Department of
Defense and the Department of Veteran Affairs, 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, including Federal
agencies, and private entities to expand collaborative,
crosscutting research.
``(6) Review.--The Secretary shall review the necessity of
the Committee at least once every 2 years.''.
SEC. 2563. PUBLIC AWARENESS CAMPAIGN ON PAIN MANAGEMENT.
Part B of title II (42 U.S.C. 238 et seq.) is amended by adding at
the end the following:
``SEC. 249. NATIONAL EDUCATION OUTREACH AND AWARENESS CAMPAIGN ON PAIN
MANAGEMENT.
``(a) Establishment.--Not later than 12 months after the date of
the enactment of this section, the Secretary shall establish and
implement a national pain care education outreach and awareness
campaign described in subsection (b).
``(b) Requirements.--The Secretary shall design the public
awareness campaign under this section to educate consumers, patients,
their families, and other caregivers with respect to--
``(1) the incidence and importance of pain as a national
public health problem;
``(2) the adverse physical, psychological, emotional,
societal, and financial consequences that can result if pain is
not appropriately assessed, diagnosed, treated, or managed;
``(3) the availability, benefits, and risks of all pain
treatment and management options;
``(4) having pain promptly assessed, appropriately
diagnosed, treated, and managed, and regularly reassessed with
treatment adjusted as needed;
``(5) the role of credentialed pain management specialists
and subspecialists, and of comprehensive interdisciplinary
centers of treatment expertise;
``(6) the availability in the public, nonprofit, and
private sectors of pain management-related information,
services, and resources for consumers, employers, third-party
payors, patients, their families, and caregivers, including
information on--
``(A) appropriate assessment, diagnosis, treatment,
and management options for all types of pain and pain-
related symptoms; and
``(B) conditions for which no treatment options are
yet recognized; and
``(7) other issues the Secretary deems appropriate.
``(c) Consultation.--In designing and implementing the public
awareness campaign required by this section, the Secretary shall
consult with organizations representing patients in pain and other
consumers, employers, physicians including physicians specializing in
pain care, other pain management professionals, medical device
manufacturers, and pharmaceutical companies.
``(d) Coordination.--
``(1) Lead official.--The Secretary shall designate one
official in the Department of Health and Human Services to
oversee the campaign established under this section.
``(2) Agency coordination.--The Secretary shall ensure the
involvement in the public awareness campaign under this section
of the Surgeon General of the Public Health Service, the
Director of the Centers for Disease Control and Prevention, and
such other representatives of offices and agencies of the
Department of Health and Human Services as the Secretary
determines appropriate.
``(e) Underserved Areas and Populations.--In designing the public
awareness campaign under this section, the Secretary shall--
``(1) take into account the special needs of geographic
areas and racial, ethnic, gender, age, and other demographic
groups that are currently underserved; and
``(2) provide resources that will reduce disparities in
access to appropriate diagnosis, assessment, and treatment.
``(f) Grants and Contracts.--The Secretary may make awards of
grants, cooperative agreements, and contracts to public agencies and
private nonprofit organizations to assist with the development and
implementation of the public awareness campaign under this section.
``(g) Evaluation and Report.--Not later than the end of fiscal year
2012, the Secretary shall prepare and submit to the Congress a report
evaluating the effectiveness of the public awareness campaign under
this section in educating the general public with respect to the
matters described in subsection (b).
``(h) Authorization of Appropriations.--For purposes of carrying
out this section, there are authorized to be appropriated $2,000,000
for fiscal year 2011 and $4,000,000 for each of fiscal years 2012 and
2015.''.
Subtitle C--Food and Drug Administration
PART 1--IN GENERAL
SEC. 2571. NATIONAL MEDICAL DEVICE REGISTRY.
(a) Registry.--
(1) In general.--Section 519 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 360i) is amended--
(A) by redesignating subsection (g) as subsection
(h); and
(B) by inserting after subsection (f) the
following:
``National Medical Device Registry
``(g)(1)(A) The Secretary shall establish a national medical device
registry (in this subsection referred to as the `registry') to
facilitate analysis of postmarket safety and outcomes data on each
covered device.
``(B) In this subsection, the term `covered device'--
``(i) shall include each class III device; and
``(ii) may include, as the Secretary determines appropriate
and specifies in regulation, a class II device that is life-
supporting or life-sustaining.
``(C) Notwithstanding subparagraph (B)(i), the Secretary may by
order exempt a class III device from the provisions of this subsection
if the Secretary concludes that inclusion of information on the device
in the registry will not provide useful information on safety or
effectiveness.
``(2) In developing the registry, the Secretary shall, in
consultation with the Commissioner of Food and Drugs, the Administrator
of the Centers for Medicare & Medicaid Services, the Administrator of
the Agency for Healthcare Research and Quality, the head of the Office
of the National Coordinator for Health Information Technology, and the
Secretary of Veterans Affairs, determine the best methods for--
``(A) including in the registry, in a manner consistent
with subsection (f), appropriate information to identify each
covered device by type, model, and serial number or other
unique identifier;
``(B) validating methods for analyzing patient safety and
outcomes data from multiple sources and for linking such data
with the information included in the registry as described in
subparagraph (A), including, to the extent feasible, use of--
``(i) data provided to the Secretary under other
provisions of this chapter; and
``(ii) information from public and private sources
identified under paragraph (3);
``(C) integrating the activities described in this
subsection (so as to avoid duplication) with--
``(i) activities under paragraph (3) of section
505(k) (relating to active postmarket risk
identification);
``(ii) activities under paragraph (4) of section
505(k) (relating to advanced analysis of drug safety
data);
``(iii) other postmarket device surveillance
activities of the Secretary authorized by this chapter;
and
``(iv) registries carried out by or for the Agency
for Healthcare Research and Quality; and
``(D) providing public access to the data and analysis
collected or developed through the registry in a manner and
form that protects patient privacy and proprietary information
and is comprehensive, useful, and not misleading to patients,
physicians, and scientists.
``(3)(A) To facilitate analyses of postmarket safety and patient
outcomes for covered devices, the Secretary shall, in collaboration
with public, academic, and private entities, develop methods to--
``(i) obtain access to disparate sources of patient
safety and outcomes data, including--
``(I) Federal health-related electronic
data (such as data from the Medicare program
under title XVIII of the Social Security Act or
from the health systems of the Department of
Veterans Affairs);
``(II) private sector health-related
electronic data (such as pharmaceutical
purchase data and health insurance claims
data); and
``(III) other data as the Secretary deems
necessary to permit postmarket assessment of
device safety and effectiveness; and
``(ii) link data obtained under clause (i) with
information in the registry.
``(B) In this paragraph, the term `data' refers to information
respecting a covered device, including claims data, patient survey
data, standardized analytic files that allow for the pooling and
analysis of data from disparate data environments, electronic health
records, and any other data deemed appropriate by the Secretary.
``(4) The Secretary shall promulgate regulations for establishment
and operation of the registry under paragraph (1). Such regulations--
``(A)(i) in the case of covered devices that are sold on or
after the date of the enactment of this subsection, shall
require manufacturers of such devices to submit information to
the registry, including, for each such device, the type, model,
and serial number or, if required under subsection (f), other
unique device identifier; and
``(ii) in the case of covered devices that are sold before
such date, may require manufacturers of such devices to submit
such information to the registry, if deemed necessary by the
Secretary to protect the public health;
``(B) shall establish procedures--
``(i) to permit linkage of information submitted
pursuant to subparagraph (A) with patient safety and
outcomes data obtained under paragraph (3); and
``(ii) to permit analyses of linked data;
``(C) may require covered device manufacturers to submit
such other information as is necessary to facilitate postmarket
assessments of device safety and effectiveness and notification
of device risks;
``(D) shall establish requirements for regular and timely
reports to the Secretary, which shall be included in the
registry, concerning adverse event trends, adverse event
patterns, incidence and prevalence of adverse events, and other
information the Secretary determines appropriate, which may
include data on comparative safety and outcomes trends; and
``(E) shall establish procedures to permit public access to
the information in the registry in a manner and form that
protects patient privacy and proprietary information and is
comprehensive, useful, and not misleading to patients,
physicians, and scientists.
``(5)(A) The Secretary shall promulgate final regulations under
paragraph (4) not later than 36 months after the date of the enactment
of this subsection.
``(B) Before issuing the notice of proposed rulemaking preceding
the final regulations described in subparagraph (A), the Secretary
shall hold a public hearing before an advisory committee on the issue
of which class II devices to include in the definition of covered
devices.
``(C) The Secretary shall include in any regulation under this
subsection an explanation demonstrating that the requirements of such
regulation--
``(i) do not duplicate other Federal requirements; and
``(ii) do not impose an undue burden on device
manufacturers.
``(6) With respect to any entity that submits or is required to
submit a safety report or other information in connection with the
safety of a device under this section (and any release by the Secretary
of that report or information), such report or information shall not be
construed to reflect necessarily a conclusion by the entity or the
Secretary that the report or information constitutes an admission that
the product involved malfunctioned, caused or contributed to an adverse
experience, or otherwise caused or contributed to a death, serious
injury, or serious illness. Such an entity need not admit, and may
deny, that the report or information submitted by the entity
constitutes an admission that the product involved malfunctioned,
caused or contributed to an adverse experience, or caused or
contributed to a death, serious injury, or serious illness.
``(7) To carry out this subsection, there are authorized to be
appropriated such sums as may be necessary for each of fiscal years
2011 and 2012.''.
(2) Effective date.--The Secretary of Health and Human
Services shall establish and begin implementation of the
registry under section 519(g) of the Federal Food, Drug, and
Cosmetic Act, as added by paragraph (1), by not later than the
date that is 36 months after the date of the enactment of this
Act, without regard to whether or not final regulations to
establish and operate the registry have been promulgated by
such date.
(3) Conforming amendment.--Section 303(f)(1)(B)(ii) of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C.
333(f)(1)(B)(ii)) is amended by striking ``519(g)'' and
inserting ``519(h)''.
(b) Electronic Exchange and Use in Certified Electronic Health
Records of Unique Device Identifiers.--
(1) Recommendations.--The HIT Policy Committee established
under section 3002 of the Public Health Service Act (42 U.S.C.
300jj-12) shall recommend to the head of the Office of the
National Coordinator for Health Information Technology
standards, implementation specifications, and certification
criteria for the electronic exchange and use in certified
electronic health records of a unique device identifier for
each covered device (as defined under section 519(g)(1)(B) of
the Federal Food, Drug, and Cosmetic Act, as added by
subsection (a)).
(2) Standards, implementation criteria, and certification
criteria.--The Secretary of Health and Human Services, acting
through the head of the Office of the National Coordinator for
Health Information Technology, shall adopt standards,
implementation specifications, and certification criteria for
the electronic exchange and use in certified electronic health
records of a unique device identifier for each covered device
referred to in paragraph (1), if such an identifier is required
by section 519(f) of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. 360i(f)) for the device.
(c) Unique Device Identification System.--The Secretary of Health
and Human Services, acting through the Commissioner of Food and Drugs,
shall issue proposed regulations to implement section 519(f) of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360i(f)) not later than
6 months after the date of the enactment of this Act.
SEC. 2572. NUTRITION LABELING OF STANDARD MENU ITEMS AT CHAIN
RESTAURANTS AND OF ARTICLES OF FOOD SOLD FROM VENDING
MACHINES.
(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 subclause (i), by inserting ``except as provided in
clause (H)(ii)(III),'' after ``(i)'' ; and
(2) in subclause (ii), by inserting ``except as provided in
clause (H)(ii)(III),'' after ``(ii)''.
(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.--Clause (C) shall apply to
any regulations promulgated under subclauses (ii)(III)
and (vi).
``(viii) Vending machines.--In the case of an article of
food sold from a vending machine that--
``(I) 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
``(II) 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 the
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 the 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
section 403A(a)(4) of such Act;
(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. 2573. PROTECTING CONSUMER ACCESS TO GENERIC DRUGS.
(a) Findings; Purpose.--
(1) Findings.--The Congress finds the following:
(A) In 1984, the Drug Price Competition and Patent
Term Restoration Act (Pub. L. 98-417; in this
subsection referred to as the ``1984 Act'') was enacted
with the intent of facilitating the early entry of
generic drugs while preserving incentives for
innovation.
(B) Prescription drugs make up 10 percent of
national health care spending, but for the past decade
have been one of the fastest growing segments of health
care expenditures.
(C) Until recently, the 1984 Act was successful in
facilitating generic competition to the benefit of
consumers and health care payers--although 67 percent
of all prescriptions dispensed in the United States are
generic drugs, they account for only 20 percent of all
expenditures.
(D) In recent years, the intent of the 1984 Act has
been subverted by certain settlement agreements between
brand companies and their potential generic competitors
that make reverse payments, i.e., payments by the brand
company to the generic company.
(E) These settlement agreements have unduly delayed
the marketing of low-cost generic drugs contrary to
free competition and the interests of consumers.
(F) The state of antitrust law relating to such
settlement agreements is unsettled.
(2) Purpose.--The purpose of this section is to provide an
additional means to effectuate the intent of the 1984 Act by
enhancing competition in the pharmaceutical market by stopping
agreements between brand name and generic drug manufacturers
that limit, delay, or otherwise prevent competition from
generic drugs.
(b) In General.--Section 505 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 355) is amended by adding at the end the
following:
``(w) Protecting Consumer Access to Generic Drugs.--
``(1) Unfair and deceptive acts and practices related to
new drug applications.--
``(A) Conduct prohibited.--It shall be unlawful for
any person to directly or indirectly be a party to any
agreement resolving or settling a patent infringement
claim in which--
``(i) an ANDA filer receives anything of
value; and
``(ii) the ANDA filer agrees to limit or
forego research, development, manufacturing,
marketing, or sales, for any period of time, of
the drug that is to be manufactured under the
ANDA involved and is the subject of the patent
infringement claim.
``(B) Exceptions.--Notwithstanding subparagraph
(A)(i), subparagraph (A) does not prohibit a resolution
or settlement of a patent infringement claim in which
the value received by the ANDA filer includes no more
than--
``(i) the right to market the drug that is
to be manufactured under the ANDA involved and
is the subject of the patent infringement
claim, before the expiration of--
``(I) the patent that is the basis
for the patent infringement claim; or
``(II) any other statutory
exclusivity that would prevent the
marketing of such drug; and
``(ii) the waiver of a patent infringement
claim for damages based on prior marketing of
such drug.
``(C) Enforcement.--
``(i) In general.--A violation of
subparagraph (A) shall be treated as an unfair
and deceptive act or practice and an unfair
method of competition in or affecting
interstate commerce prohibited under section 5
of the Federal Trade Commission Act and shall
be enforced by the Federal Trade Commission in
the same manner, by the same means, and with
the same jurisdiction as though all applicable
terms and provisions of the Federal Trade
Commission Act were incorporated into and made
a part of this subsection.
``(ii) Inapplicability.--Subchapter A of
chapter VII shall not apply with respect to
this subsection.
``(D) Definitions.--In this subsection:
``(i) Agreement.--The term `agreement'
means anything that would constitute an
agreement under section 5 of the Federal Trade
Commission Act.
``(ii) Agreement resolving or settling.--
The term `agreement resolving or settling', in
reference to a patent infringement claim,
includes any agreement that is contingent upon,
provides a contingent condition for, or is
otherwise related to the resolution or
settlement of the claim.
``(iii) ANDA.--The term `ANDA' means an
abbreviated new drug application for the
approval of a new drug under section (j).
``(iv) ANDA filer.--The term `ANDA filer'
means a party that has filed an ANDA with the
Food and Drug Administration.
``(v) Patent infringement.--The term
`patent infringement' means infringement of any
patent or of any filed patent application,
extension, reissuance, renewal, division,
continuation, continuation in part,
reexamination, patent term restoration, patent
of addition, or extension thereof.
``(vi) Patent infringement claim.--The term
`patent infringement claim' means any
allegation made to an ANDA filer, whether or
not included in a complaint filed with a court
of law, that its ANDA or drug to be
manufactured under such ANDA may infringe any
patent.
``(2) FTC rulemaking.--The Federal Trade Commission may, by
rule promulgated under section 553 of title 5, United States
Code, exempt certain agreements described in paragraph (1) from
the requirements of this subsection if the Commission finds
such agreements to be in furtherance of market competition and
for the benefit of consumers. Consistent with the authority of
the Commission, such rules may include interpretive rules and
general statements of policy with respect to the practices
prohibited under paragraph (1).''.
(c) Notice and Certification of Agreements.--
(1) Notice of all agreements.--Section 1112(c)(2) of the
Medicare Prescription Drug, Improvement, and Modernization Act
of 2003 (21 U.S.C. 3155 note) is amended by--
(A) striking ``the Commission the'' and inserting
the following: ``the Commission--
``(A) the'';
(B) striking the period at the end and inserting
``; and''; and
(C) adding at the end the following:
``(B) any other agreement the parties enter into
within 30 days of entering into an agreement covered by
subsection (a) or (b).''.
(2) Certification of agreements.--Section 1112 of such Act
is amended by adding at the end the following:
``(d) Certification.--The chief executive officer or the company
official responsible for negotiating any agreement required to be filed
under subsection (a), (b), or (c) shall execute and file with the
Assistant Attorney General and the Commission a certification as
follows: `I declare under penalty of perjury that the following is true
and correct: The materials filed with the Federal Trade Commission and
the Department of Justice under section 1112 of subtitle B of title XI
of the Medicare Prescription Drug, Improvement, and Modernization Act
of 2003, with respect to the agreement referenced in this
certification: (1) represent the complete, final, and exclusive
agreement between the parties; (2) include any ancillary agreements
that are contingent upon, provide a contingent condition for, or are
otherwise related to, the referenced agreement; and (3) include written
descriptions of any oral agreements, representations, commitments, or
promises between the parties that are responsive to subsection (a) or
(b) of such section 1112 and have not been reduced to writing.'.''.
(d) GAO Study.--
(1) Study.--Beginning 2 years after the date of enactment
of this Act, and each year for a period of 4 years thereafter,
the Comptroller General shall conduct a study on the litigation
in United States courts during the period beginning 5 years
prior to the date of enactment of this Act relating to patent
infringement claims involving generic drugs, the number of
patent challenges initiated by manufacturers of generic drugs,
and the number of settlements of such litigation. The
Comptroller General shall transmit to Congress a report of the
findings of such a study and an analysis of the effect of the
amendments made by subsections (b) and (c) on such litigation,
whether such amendments have had an effect on the number and
frequency of claims settled, and whether such amendments
resulted in earlier or delayed entry of generic drugs to
market, including whether any harm or benefit to consumers has
resulted.
(2) Disclosure of agreements.--Notwithstanding any other
law, agreements filed under section 1112 of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003
(21 U.S.C. 355 note), or unaggregated information from such
agreements, shall be disclosed to the Comptroller General for
purposes of the study under paragraph (1) within 30 days of a
request by the Comptroller General.
PART 2--BIOSIMILARS
SEC. 2575. LICENSURE 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).
``(D) Restrictions on biological products
containing dangerous ingredients.--If information in an
application submitted under this subsection, in a
supplement to such an application, or otherwise
available to the Secretary shows that a biological
product--
``(i) is, bears, or contains a select agent
or toxin listed in section 73.3 or 73.4 of
title 42, section 121.3 or 121.4 of title 9, or
section 331.3 of title 7, Code of Federal
Regulations (or any successor regulations); or
``(ii) is, bears, or contains a controlled
substance in schedule I or II of section 202 of
the Controlled Substances Act, as listed in
part 1308 of title 21, Code of Federal
Regulations (or any successor regulations);
the Secretary shall not license the biological product
under this subsection unless the Secretary determines,
after consultation with appropriate national security
and drug enforcement agencies, that there would be no
increased risk to the security or health of the public
from licensing such biological product under this
subsection.
``(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)(5) 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)(5) 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)(5) 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)(5).
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) Pediatric studies.--
``(A) Exclusivity.--If, before or after licensure
of the reference product under subsection (a) of this
section, the Secretary determines that information
relating to the use of such 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 or holder of
the approved application 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
the period referred to in paragraph (7)(A) of this
subsection is deemed to be 12 years and 6 months rather
than 12 years.
``(B) Exception.--The Secretary shall not extend
the period referred to in subparagraph (A) of this
paragraph if the determination under section 505A(d)(3)
of the Federal Food, Drug, and Cosmetic Act is made
later than 9 months prior to the expiration of such
period.
``(C) Application of certain provisions.--The
provisions of subsections (a), (d), (e), (f), (h), (j),
(k), and (l) of section 505A of the Federal Food, Drug,
and Cosmetic Act shall apply with respect to the
extension of a period under subparagraph (A) of this
paragraph 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.
``(9) 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.
``(10) Naming.--The Secretary shall ensure that the
labeling and packaging of each biological product licensed
under this subsection bears a name that uniquely identifies the
biological product and distinguishes it from the reference
product and any other biological products licensed under this
subsection following evaluation against such reference product.
``(l) Patent Notices; Relationship to Final Approval.--
``(1) Definitions.--For the purposes of this subsection,
the term--
``(A) `biosimilar product' means the biological
product that is the subject of the application under
subsection (k);
``(B) `relevant patent' means a patent that--
``(i) expires after the date specified in
subsection (k)(7)(A) that applies to the
reference product; and
``(ii) could reasonably be asserted against
the applicant due to the unauthorized making,
use, sale, or offer for sale within the United
States, or the importation into the United
States of the biosimilar product, or materials
used in the manufacture of the biosimilar
product, or due to a use of the biosimilar
product in a method of treatment that is
indicated in the application;
``(C) `reference product sponsor' means the holder
of an approved application or license for the reference
product; and
``(D) `interested third party' means a person other
than the reference product sponsor that owns a relevant
patent, or has the right to commence or participate in
an action for infringement of a relevant patent.
``(2) Handling of confidential information.--Any entity
receiving confidential information pursuant to this subsection
shall designate one or more individuals to receive such
information. Each individual so designated shall execute an
agreement in accordance with regulations promulgated by the
Secretary. The regulations shall require each such individual
to take reasonable steps to maintain the confidentiality of
information received pursuant to this subsection and use the
information solely for purposes authorized by this subsection.
The obligations imposed on an individual who has received
confidential information pursuant to this subsection shall
continue until the individual returns or destroys the
confidential information, a court imposes a protective order
that governs the use or handling of the confidential
information, or the party providing the confidential
information agrees to other terms or conditions regarding the
handling or use of the confidential information.
``(3) Public notice by secretary.--Within 30 days of
acceptance by the Secretary of an application filed under
subsection (k), the Secretary shall publish a notice
identifying--
``(A) the reference product identified in the
application; and
``(B) the name and address of an agent designated
by the applicant to receive notices pursuant to
paragraph (4)(B).
``(4) Exchanges concerning patents.--
``(A) Exchanges with reference product sponsor.--
``(i) Within 30 days of the date of
acceptance of the application by the Secretary,
the applicant shall provide the reference
product sponsor with a copy of the application
and information concerning the biosimilar
product and its production. This information
shall include a detailed description of the
biosimilar product, its method of manufacture,
and the materials used in the manufacture of
the product.
``(ii) Within 60 days of the date of
receipt of the information required to be
provided under clause (i), the reference
product sponsor shall provide to the applicant
a list of relevant patents owned by the
reference product sponsor, or in respect of
which the reference product sponsor has the
right to commence an action of infringement or
otherwise has an interest in the patent as such
patent concerns the biosimilar product.
``(iii) If the reference product sponsor is
issued or acquires an interest in a relevant
patent after the date on which the reference
product sponsor provides the list required by
clause (ii) to the applicant, the reference
product sponsor shall identify that patent to
the applicant within 30 days of the date of
issue of the patent, or the date of acquisition
of the interest in the patent, as applicable.
``(B) Exchanges with interested third parties.--
``(i) At any time after the date on which
the Secretary publishes a notice for an
application under paragraph (3), any interested
third party may provide notice to the
designated agent of the applicant that the
interested third party owns or has rights under
1 or more patents that may be relevant patents.
The notice shall identify at least 1 patent and
shall designate an individual who has executed
an agreement in accordance with paragraph (2)
to receive confidential information from the
applicant.
``(ii) Within 30 days of the date of
receiving notice pursuant to clause (i), the
applicant shall send to the individual
designated by the interested third party the
information specified in subparagraph (A)(i),
unless the applicant and interested third party
otherwise agree.
``(iii) Within 90 days of the date of
receiving information pursuant to clause (ii),
the interested third party shall provide to the
applicant a list of relevant patents which the
interested third party owns, or in respect of
which the interested third party has the right
to commence or participate in an action for
infringement.
``(iv) If the interested third party is
issued or acquires an interest in a relevant
patent after the date on which the interested
third party provides the list required by
clause (iii), the interested third party shall
identify that patent within 30 days of the date
of issue of the patent, or the date of
acquisition of the interest in the patent, as
applicable.
``(C) Identification of basis for infringement.--
For any patent identified under clause (ii) or (iii) of
subparagraph (A) or under clause (iii) or (iv) of
subparagraph (B), the reference product sponsor or the
interested third party, as applicable--
``(i) shall explain in writing why the
sponsor or the interested third party believes
the relevant patent would be infringed by the
making, use, sale, or offer for sale within the
United States, or importation into the United
States, of the biosimilar product or by a use
of the biosimilar product in treatment that is
indicated in the application;
``(ii) may specify whether the relevant
patent is available for licensing; and
``(iii) shall specify the number and date
of expiration of the relevant patent.
``(D) Certification by applicant concerning
identified relevant patents.--Not later than 45 days
after the date on which a patent is identified under
clause (ii) or (iii) of subparagraph (A) or under
clause (iii) or (iv) of subparagraph (B), the applicant
shall send a written statement regarding each
identified patent to the party that identified the
patent. Such statement shall either--
``(i) state that the applicant will not
commence marketing of the biosimilar product
and has requested the Secretary to not grant
final approval of the application before the
date of expiration of the noticed patent; or
``(ii) provide a detailed written
explanation setting forth the reasons why the
applicant believes--
``(I) the making, use, sale, or
offer for sale within the United
States, or the importation into the
United States, of the biosimilar
product, or the use of the biosimilar
product in a treatment indicated in the
application, would not infringe the
patent; or
``(II) the patent is invalid or
unenforceable.
``(5) Action for infringement involving reference product
sponsor.--If an action for infringement concerning a relevant
patent identified by the reference product sponsor under clause
(ii) or (iii) of paragraph (4)(A), or by an interested third
party under clause (iii) or (iv) of paragraph (4)(B), is
brought within 60 days of the date of receipt of a statement
under paragraph (4)(D)(ii), and the court in which such action
has been commenced determines the patent is infringed prior to
the date applicable under subsection (k)(7)(A) or (k)(8), the
Secretary shall make approval of the application effective on
the day after the date of expiration of the patent that has
been found to be infringed. If more than one such patent is
found to be infringed by the court, the approval of the
application shall be made effective on the day after the date
that the last such patent expires.
``(6) Notification of agreements.--
``(A) Requirements.--
``(i) Agreement between biosimilar product
applicant and reference product sponsor.--If a
biosimilar product applicant under subsection
(k) and the reference product sponsor enter
into an agreement described in subparagraph
(B), the applicant and sponsor shall each file
the agreement in accordance with subparagraph
(C).
``(ii) Agreement between biosimilar product
applicants.--If 2 or more biosimilar product
applicants submit an application under
subsection (k) for biosimilar products with the
same reference product and enter into an
agreement described in subparagraph (B), the
applicants shall each file the agreement in
accordance with subparagraph (C).
``(B) Subject matter of agreement.--An agreement
described in this subparagraph--
``(i) is an agreement between the
biosimilar product applicant under subsection
(k) and the reference product sponsor or
between 2 or more biosimilar product applicants
under subsection (k) regarding the manufacture,
marketing, or sale of--
``(I) the biosimilar product (or
biosimilar products) for which an
application was submitted; or
``(II) the reference product;
``(ii) includes any agreement between the
biosimilar product applicant under subsection
(k) and the reference product sponsor or
between 2 or more biosimilar product applicants
under subsection (k) that is contingent upon,
provides a contingent condition for, or
otherwise relates to an agreement described in
clause (i); and
``(iii) excludes any agreement that solely
concerns--
``(I) purchase orders for raw
material supplies;
``(II) equipment and facility
contracts;
``(III) employment or consulting
contracts; or
``(IV) packaging and labeling
contracts.
``(C) Filing.--
``(i) In general.--The text of an agreement
required to be filed by subparagraph (A) shall
be filed with the Assistant Attorney General
and the Federal Trade Commission not later
than--
``(I) 10 business days after the
date on which the agreement is
executed; and
``(II) prior to the date of the
first commercial marketing of, for
agreements described in subparagraph
(A)(i), the biosimilar product that is
the subject of the application or, for
agreements described in subparagraph
(A)(ii), any biosimilar product that is
the subject of an application described
in such subparagraph.
``(ii) If agreement not reduced to text.--
If an agreement required to be filed by
subparagraph (A) has not been reduced to text,
the persons required to file the agreement
shall each file written descriptions of the
agreement that are sufficient to disclose all
the terms and conditions of the agreement.
``(iii) Certification.--The chief executive
officer or the company official responsible for
negotiating any agreement required to be filed
by subparagraph (A) shall include in any filing
under this paragraph a certification as
follows: `I declare under penalty of perjury
that the following is true and correct: The
materials filed with the Federal Trade
Commission and the Department of Justice under
section 351(l)(6) of the Public Health Service
Act, with respect to the agreement referenced
in this certification: (1) represent the
complete, final, and exclusive agreement
between the parties; (2) include any ancillary
agreements that are contingent upon, provide a
contingent condition for, or are otherwise
related to, the referenced agreement; and (3)
include written descriptions of any oral
agreements, representations, commitments, or
promises between the parties that are
responsive to such section and have not been
reduced to writing.'.
``(D) Disclosure exemption.--Any information or
documentary material filed with the Assistant Attorney
General or the Federal Trade Commission pursuant to
this paragraph shall be exempt from disclosure under
section 552 of title 5, United States Code, and no such
information or documentary material may be made public,
except as may be relevant to any administrative or
judicial action or proceeding. Nothing in this
subparagraph prevents disclosure of information or
documentary material to either body of the Congress or
to any duly authorized committee or subcommittee of the
Congress.
``(E) Enforcement.--
``(i) Civil penalty.--Any person that
violates a provision of this paragraph shall be
liable for a civil penalty of not more than
$11,000 for each day on which the violation
occurs. Such penalty may be recovered in a
civil action--
``(I) brought by the United States;
or
``(II) brought by the Federal Trade
Commission in accordance with the
procedures established in section
16(a)(1) of the Federal Trade
Commission Act.
``(ii) Compliance and equitable relief.--If
any person violates any provision of this
paragraph, the United States district court may
order compliance, and may grant such other
equitable relief as the court in its discretion
determines necessary or appropriate, upon
application of the Assistant Attorney General
or the Federal Trade Commission.
``(F) Rulemaking.--The Federal Trade Commission,
with the concurrence of the Assistant Attorney General
and by rule in accordance with section 553 of title 5,
United States Code, consistent with the purposes of
this paragraph--
``(i) may define the terms used in this
paragraph;
``(ii) may exempt classes of persons or
agreements from the requirements of this
paragraph; and
``(iii) may prescribe such other rules as
may be necessary and appropriate to carry out
the purposes of this paragraph.
``(G) Savings clause.--Any action taken by the
Assistant Attorney General or the Federal Trade
Commission, or any failure of the Assistant Attorney
General or the Commission to take action, under this
paragraph shall not at any time bar any proceeding or
any action with respect to any agreement between a
biosimilar product applicant under subsection (k) and
the reference product sponsor, or any agreement between
biosimilar product applicants under subsection (k),
under any other provision of law, nor shall any filing
under this paragraph constitute or create a presumption
of any violation of any competition laws.''.
(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) 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
Act 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).
SEC. 2576. FEES RELATING TO BIOSIMILAR BIOLOGICAL PRODUCTS.
Subparagraph (B) of section 735(1) of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 379g(1)) is amended by inserting ``, including
licensure of a biological product under section 351(k) of such Act''
before the period at the end.
SEC. 2577. AMENDMENTS TO CERTAIN PATENT PROVISIONS.
(a) Section 271(e)(2) of title 35, United States Code is amended--
(1) in subparagraph (A), by striking ``or'' after
``patent,'';
(2) in subparagraph (B), by adding ``or'' after the comma
at the end;
(3) by inserting the following after subparagraph (B):
``(C) a statement under section 351(l)(4)(D)(ii) of
the Public Health Service Act,''; and
(4) in the matter following subparagraph (C) (as added by
paragraph (3)), by inserting before the period the following:
``, or if the statement described in subparagraph (C) is
provided in connection with an application to obtain a license
to engage in the commercial manufacture, use, or sale of a
biological product claimed in a patent or the use of which is
claimed in a patent before the expiration of such patent''.
(b) Section 271(e)(4) of title 35, United States Code, is amended
by striking ``in paragraph (2)'' in both places it appears and
inserting ``in paragraph (2)(A) or (2)(B)''.
Subtitle D--Community Living Assistance Services and Supports
SEC. 2581. ESTABLISHMENT OF NATIONAL VOLUNTARY INSURANCE PROGRAM FOR
PURCHASING COMMUNITY LIVING ASSISTANCE SERVICES AND
SUPPORT (CLASS PROGRAM).
(a) Establishment of CLASS Program.--The Public Health Service Act
(42 U.S.C. 201 et seq.), as amended by section 2301, 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' has the meaning given the term in section
7702B(c)(2)(B) of the Internal Revenue Code of 1986.
``(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 designated by the Secretary
under section 3205(a)(2)(A)(i).
``(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, for each calendar year
that occurs 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 that 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.
``(12) 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.
``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.--Beginning with the first year of
the CLASS program, and for each year thereafter, 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.
``(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.
``(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.
``(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) Penalty for reenrollment 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 reenrollment 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--
``(A) in the case of the first 5 years in which the
program is in effect under this title, an amount equal
to 3 percent of all premiums paid during each such
year; and
``(B) in the case of subsequent years, an amount
equal to 5 percent of the total amount of all
expenditures (including benefits paid) under this title
with respect to that year.
``(3) No underwriting requirements.--No underwriting (other
than on the basis of age in accordance with paragraph (2))
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.
``SEC. 3204. ENROLLMENT AND DISENROLLMENT REQUIREMENTS.
``(a) Automatic Enrollment.--
``(1) In general.--Subject to paragraph (2), the Secretary
shall establish procedures under which each individual
described in subsection (c) shall be automatically enrolled in
the CLASS program by an employer of such individual under rules
similar to the rules of sections 401(k)(13) and 414(w) 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;
``(C) whose employer does not elect to participate
in the automatic enrollment process established by the
Secretary; or
``(D) who is a spouse described in subsection
(c)(2) of who is not subject to automatic enrollment.
``(3) Administration.--
``(A) In general.--The Secretary shall, by
regulation, establish procedures to--
``(i) ensure that an individual is not
automatically enrolled in the CLASS program by
more than 1 employer; and
``(ii) allow for an individual's employer
to deduct a premium for a spouse described in
subsection (c)(1)(B) who is not subject to
automatic enrollment.
``(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 shall prescribe.
``(c) Individual Described.--For purposes of enrolling in the CLASS
program, an individual described in this paragraph is--
``(1) an individual--
``(A) who has attained age 18;
``(B) who receives wages on which there is imposed
a tax under section 3101(a) or 3201(a) of the Internal
Revenue Code of 1986;
``(C) who is actively employed; and
``(D) who is not--
``(i) 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
``(ii) 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; or
``(2) the spouse of an individual described in paragraph
(1) and who would be an individual so described but for
subparagraph (B) or (C) of that paragraph.
``(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 of such individual
in accordance with such procedures as the Secretary shall
establish for employers who elect to deduct and withhold such
premiums on behalf of enrolled employees.
``(2) Alternative payment mechanism.--The Secretary shall
establish alternative procedures for the payment of monthly
premiums by an individual enrolled in the CLASS program who
does not have an employer who elects to deduct and withhold
premiums in accordance with subparagraph (A).
``(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 this
section. 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 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 Secretary
shall establish, only during an open enrollment period
established by the Secretary 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 during an annual disenrollment period
established by the Secretary and in such form and manner as the
Secretary 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) designate an entity (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 serve as an
Eligibility Assessment System by providing 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 applicant 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
being 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)(2).
``(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
decisionmaking 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 or subsection (c)
or (d) of section 1915 of such Act, 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 or subsection (c) or (d)
of section 1915 of such Act 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, 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 decisionmaking 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, 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.
``(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 Conflicts of Interest.--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.
``(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 projections
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
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 projections 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; and
``(2) the determination of monthly premiums under such
plan.
``(d) Application of FACA.--The Federal Advisory Committee Act,
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. REGULATIONS; ANNUAL REPORT.
``(a) 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.
``(b) 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 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.''.
(b) Conforming Amendments to Medicaid.--For conforming provisions
amending the Medicaid program, see section 1739.
Subtitle E--Miscellaneous
SEC. 2585. STATES FAILING TO ADHERE TO CERTAIN EMPLOYMENT OBLIGATIONS.
A State is eligible for Federal funds under the provisions of the
Public Health Service Act (42 U.S.C. 201 et seq.) only if the State--
(1) agrees to be subject in its capacity as an employer to
each obligation under division A of this Act and the amendments
made by such division applicable to persons in their capacity
as an employer; and
(2) assures that all political subdivisions in the State
will do the same.
SEC. 2586. HEALTH CENTERS UNDER PUBLIC HEALTH SERVICE ACT; LIABILITY
PROTECTIONS FOR VOLUNTEER PRACTITIONERS.
(a) In General.--Section 224 (42 U.S.C. 233) is amended--
(1) in subsection (g)(1)(A)--
(A) in the first sentence, by striking ``or
employee'' and inserting ``employee, or (subject to
subsection (k)(4)) volunteer practitioner''; and
(B) in the second sentence, by inserting ``and
subsection (k)(4)'' after ``subject to paragraph (5)'';
and
(2) in each of subsections (g), (i), (j), (l), and (m), by
striking the term ``employee, or contractor'' each place such
term appears and inserting ``employee, volunteer practitioner,
or contractor'';
(3) in subsection (g)(1)(H), by striking the term
``employee, and contractor'' each place such term appears and
inserting ``employee, volunteer practitioner, and contractor'';
(4) in subsection (l), by striking the term ``employee, or
any contractor'' and inserting ``employee, volunteer
practitioner, or contractor''; and
(5) in subsections (h)(3) and (k), by striking the term
``employees, or contractors'' each place such term appears and
inserting ``employees, volunteer practitioners, or
contractors''.
(b) Applicability; Definition.--Section 224(k) (42 U.S.C. 233(k))
is amended by adding at the end the following paragraph:
``(4)(A) Subsections (g) through (m) apply with respect to
volunteer practitioners beginning with the first fiscal year for which
an appropriations Act provides that amounts in the fund under paragraph
(2) are available with respect to such practitioners.
``(B) For purposes of subsections (g) through (m), the term
`volunteer practitioner' means a practitioner who, with respect to an
entity described in subsection (g)(4), meets the following conditions:
``(i) The practitioner is a licensed physician, a licensed
clinical psychologist, or other licensed or certified health
care practitioner.
``(ii) At the request of such entity, the practitioner
provides services to patients of the entity, at a site at which
the entity operates or at a site designated by the entity. The
weekly number of hours of services provided to the patients by
the practitioner is not a factor with respect to meeting
conditions under this subparagraph.
``(iii) The practitioner does not for the provision of such
services receive any compensation from such patients, from the
entity, or from third-party payors (including reimbursement
under any insurance policy or health plan, or under any Federal
or State health benefits program).''.
SEC. 2587. REPORT TO CONGRESS ON THE CURRENT STATE OF PARASITIC
DISEASES THAT HAVE BEEN OVERLOOKED AMONG THE POOREST
AMERICANS.
Not later than 12 months after the date of the enactment of this
Act, the Secretary of Health and Human Services shall report to
Congress on the epidemiology of, impact of, and appropriate funding
required to address neglected diseases of poverty, including neglected
parasitic diseases identified as Chagas disease, cysticercosis,
toxocariasis, toxoplasmosis, trichomoniasis, the soil-transmitted
helminths, and others. The report should provide the information
necessary to enhance health policy to accurately evaluate and address
the threat of these diseases.
SEC. 2588. OFFICE OF WOMEN'S HEALTH.
(a) Health and Human Services Office on Women's Health.--
(1) Establishment.--Part A of title II (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.''.
(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 (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.''.
(c) Office of Women's Health Research.--Section 486(a) (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) (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 (42 U.S.C. 299c et seq.) is
amended--
(1) by redesignating sections 927 and 928 as sections 928
and 929, respectively;
(2) by inserting after section 926 the following:
``SEC. 927. 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)).''; and
(3) by adding at the end of section 928 (as redesignated by
paragraph (1)) the following:
``(e) Women's Health.--For the purpose of carrying out section 927
regarding women's health, there are authorized to be appropriated such
sums as may be necessary for each of fiscal years 2011 through 2015.''.
(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.''.
(g) Food and Drug Administration Office of Women's Health.--Chapter
IX 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. 911. 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).''.
(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 its powers
or duties transferred unless such termination, reorganization, or
transfer is approved by an Act of Congress.
(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. 2589. LONG-TERM CARE AND FAMILY CAREGIVER SUPPORT.
(a) Amendments to the Older Americans Act of 1965.--
(1) Promotion of direct care workforce.--Section 202(b)(1)
of the Older Americans Act of 1965 (42 U.S.C. 3012(b)(1)) is
amended by inserting before the semicolon the following: ``,
and, in carrying out the purposes of this paragraph, shall make
recommendations to other Federal entities regarding appropriate
and effective means of identifying, promoting, and implementing
investments in the direct care workforce necessary to meet the
growing demand for long-term health services and supports and
of assisting States in developing a comprehensive State
workforce development plan with respect to such workforce,
including assisting efforts to systematically assess, track,
and report on workforce adequacy and capacity''.
(2) Personal care attendant workforce advisory panel.--
Section 202 of such Act (42 U.S.C. 3012) is amended by adding
at the end the following:
``(g)(1) Not later than 90 days after the date of the enactment of
this subsection, the Assistant Secretary shall establish a Personal
Care Attendant Workforce Advisory Panel to examine and formulate
recommendations on--
``(A) working conditions and training for workers providing
long-term services and supports, including home health aides,
certified nurse aides, and personal care attendants; and
``(B) other workforce issues related to such 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) The Panel shall include representatives of--
``(A) relevant home- and community-based service providers,
health care agencies, and facilities (including personal or
home care agencies, home health care agencies, nursing homes,
assisted living facilities, and residential care facilities);
``(B) the disability community, including individuals with
disabilities and family caregivers;
``(C) the nursing community;
``(D) direct care workers (which may include unions and
national organizations);
``(E) older individuals, including senior individuals and
family caregivers;
``(F) State and Federal health care entities; and
``(G) experts in workforce development and adult learning.
``(3) Within one year after the establishment of the Panel, the
Panel shall submit a report to the Assistant Secretary and the Congress
on workforce issues related to providing long-term services and
supports, including information on core competencies for eligible
personal or home care aides necessary to successfully provide long-term
services and supports to eligible consumers, as well as recommended
training curricula and resources.
``(4) Within 180 days after receipt by the Assistant Secretary of
the report under paragraph (3), the Assistant Secretary shall establish
a 3-year demonstration program in 4 States to pilot and evaluate the
effectiveness of the competencies articulated by the Panel and the
training curricula and training methods recommended by the Panel.
``(5) Not later than 1 year after the completion of the
demonstration program under paragraph (4), the Assistant Secretary
shall submit to the Congress a report containing the results of the
evaluations by the Assistant Secretary pursuant to paragraph (4),
together with such recommendations for legislation or administrative
action as the Assistant Secretary determines appropriate.''.
(b) Authorization of Additional Appropriations for the Family
Caregiver Support Program Under the Older Americans Act of 1965.--
Section 303(e)(2) of the Older Americans Act of 1965 (42 U.S.C.
3023(e)(2)) is amended by striking ``, $173,000,000'' and all that
follows through ``2011'', and inserting ``and $250,000,000 for each of
fiscal years 2011, 2012, and 2013''.
SEC. 2590. WEB SITE ON HEALTH CARE LABOR MARKET AND RELATED EDUCATIONAL
AND TRAINING OPPORTUNITIES.
(a) In General.--The Secretary of Labor, in consultation with the
National Center for Health Workforce Analysis, shall establish and
maintain a Web site to serve as a comprehensive source of information,
searchable by workforce region, on the health care labor market and
related educational and training opportunities.
(b) Contents.--The Web site maintained under this section shall
include the following:
(1) Information on the types of jobs that are currently or
are projected to be in high demand in the health care field,
including--
(A) salary information; and
(B) training requirements, such as requirements for
educational credentials, licensure, or certification.
(2) Information on training and educational opportunities
within each region for the type of jobs described in paragraph
(1), including by--
(A) type of provider or program (such as public,
private nonprofit, or private for-profit);
(B) duration;
(C) cost (such as tuition, fees, books, laboratory
expenses, and other mandatory costs);
(D) performance outcomes (such as graduation rates,
job placement, average salary, job retention, and wage
progression);
(E) Federal financial aid participation;
(F) average graduate loan debt;
(G) student loan default rates;
(H) average institutional grant aid provided;
(I) Federal and State accreditation information;
and
(J) other information determined by the Secretary.
(3) A mechanism for searching and comparing training and
educational options for specific health care occupations to
facilitate informed career and education choices.
(4) Financial aid information, including with respect to
loan forgiveness, loan cancellation, loan repayment, stipends,
scholarships, and grants or other assistance authorized by this
Act or other Federal or State programs.
(c) Public Accessibility.--The Web site maintained under this
section shall--
(1) be publicly accessible;
(2) be user friendly and convey information in a manner
that is easily understandable; and
(3) be in English and the second most prevalent language
spoken based on the latest Census information.
SEC. 2591. ONLINE HEALTH WORKFORCE TRAINING PROGRAMS.
Section 171 of the Workforce Investment Act of 1998 (29 U.S.C.
2916) is amended by adding at the end the following:
``(f) Online Health Workforce Training Program.--
``(1) Grant program.--
``(A) In general.--The Secretary in consultation
with the Secretary of Health and Human Services, shall
award National Health Workforce Online Training Grants
on a competitive basis to eligible entities to enable
such entities to carry out training for individuals to
attain or advance in health care occupations. An entity
may leverage such grant with other Federal, State,
local, and private resources, in order to expand the
participation of businesses, employees, and individuals
in such training programs.
``(B) Eligibility.--In order to receive a grant
under the program established under this paragraph--
``(i) an entity shall be an educational
institution, community-based organization,
nonprofit organization, workforce investment
board, or local or county government; and
``(ii) an entity shall provide online
workforce training for individuals seeking to
attain or advance in health care occupations,
including nursing, nursing assistants,
dentistry, pharmacy, health care management and
administration, public health, health
information systems analysis, medical
assistants, and other health care practitioner
and support occupations.
``(C) Priority.--Priority in awarding grants under
this paragraph shall be given to entities that--
``(i) have demonstrated experience in
implementing and operating online worker skills
training and education programs;
``(ii) have demonstrated experience
coordinating activities, where appropriate,
with the workforce investment system; and
``(iii) conduct training for occupations
with national or local shortages.
``(D) Data collection.--Grantees under this
paragraph shall collect and report information on--
``(i) the number of participants;
``(ii) the services received by the
participants;
``(iii) program completion rates;
``(iv) factors determined as significantly
interfering with program participation or
completion;
``(v) the rate of job placement; and
``(vi) other information as determined as
needed by the Secretary.
``(E) Outreach.--Grantees under this paragraph
shall conduct outreach activities to disseminate
information about their program and results to
workforce investment boards, local governments,
educational institutions, and other workforce training
organizations.
``(F) Performance levels.--The Secretary shall
establish indicators of performance that will be used
to evaluate the performance of grantees under this
paragraph in carrying out the activities described in
this paragraph. The Secretary shall negotiate and reach
agreement with each grantee regarding the levels of
performance expected to be achieved by the grantee on
the indicators of performance.
``(G) Authorization of appropriations.--There are
authorized to be appropriated to the Secretary to carry
out this subsection $50,000,000 for fiscal years 2011
through 2020.
``(2) Online health professions training program
clearinghouse.--
``(A) Description of grant.--The Secretary may
award one or more grants to eligible postsecondary
educational institutions to provide the services
described in this paragraph.
``(B) Eligibility.--To be eligible to receive a
grant under this paragraph, a postsecondary educational
institution shall--
``(i) have demonstrated the ability to
disseminate research on best practices for
implementing workforce investment programs; and
``(ii) be a national leader in producing
cutting-edge research on technology related to
workforce investment systems under subtitle B.
``(C) Services.--The postsecondary educational
institution that receives a grant under this paragraph
shall use such grant--
``(i) to provide technical assistance to
entities that receive grants under paragraph
(1);
``(ii) to collect and nationally
disseminate the data gathered by entities that
receive grants under paragraph (1); and
``(iii) to disseminate the best practices
identified by the National Health Workforce
Online Training Grant Program to other
workforce training organizations.
``(D) Authorization of appropriations.--There are
authorized to be appropriated to the Secretary to carry
out this subsection $1,000,000 for fiscal years 2011
through 2020.''.
SEC. 2592. ACCESS 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. STANDARDS FOR ACCESSIBILITY OF MEDICAL DIAGNOSTIC
EQUIPMENT.
``(a) Standards.--Not later than 9 months after the date of
enactment of the Affordable Health Care for America Act, the
Architectural and Transportation Barriers Compliance Board (Access
Board) shall issue guidelines setting forth the minimum technical
criteria for new medical diagnostic equipment to be purchased for use
in (or in conjunction with) physician's offices, clinics, emergency
rooms, hospitals, and other medical settings. The guidelines shall
ensure that such equipment is accessible to, and usable by, individuals
with disabilities, including provisions to ensure independent entry to,
use of, and exit from the equipment by such individuals to the maximum
extent possible.
``(b) Medical Diagnostic Equipment Covered.--The guidelines issued
under subsection (a) for medical diagnostic equipment shall apply to
new purchases of 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 equipment commonly
used for diagnostic or examination purposes by health professionals.
``(c) Regulations.--Not later than 6 months after the date of the
issuance of the guidelines under subsection (a), each appropriate
Federal agency authorized to promulgate regulations under this Act or
under the Americans with Disabilities Act shall--
``(1) prescribe regulations in an accessible format as
necessary to carry out the provisions of such Act and section
504 of this Act that include accessibility standards that are
consistent with the guidelines issued under subsection (a); and
``(2) ensure that health care providers and health care
plans covered by the Affordable Health Care for America Act
meet the requirements of the Americans with Disabilities Act
and section 504, including provisions ensuring that individuals
with disabilities receive equal access to all aspects of the
health care delivery system.
``(d) Review and Amend.--The Architectural and Transportation
Barriers Compliance Board (Access Board) shall periodically review and,
as appropriate, amend the guidelines as prescribed under subsection
(a). Not later than 6 months after the date of the issuance of such
revised guidelines, revised regulations consistent with such guidelines
shall be promulgated in an accessible format by the appropriate Federal
agencies described in subsection (c).''.
DIVISION D--INDIAN HEALTH CARE IMPROVEMENT
SEC. 3001. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This division may be cited as the ``Indian Health
Care Improvement Act Amendments of 2009''.
(b) Table of Contents.--The table of contents of this division is
as follows:
DIVISION D--INDIAN HEALTH CARE IMPROVEMENT
Sec. 3001. Short title; table of contents.
TITLE I--AMENDMENTS TO INDIAN LAWS
Sec. 3101. Indian Health Care Improvement At amended.
Sec. 3102. Soboba sanitation facilities.
Sec. 3103. Native American Health and Wellness Foundation.
Sec. 3104. GAO study and report on payments for contract health
services.
TITLE II--IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER THE SOCIAL
SECURITY ACT
Sec. 3201. Expansion of payments under Medicare, Medicaid, and SCHIP
for all covered services furnished by
Indian Health Programs.
Sec. 3202. Additional provisions to increase outreach to, and
enrollment of, Indians in SCHIP and
Medicaid.
Sec. 3203. Solicitation of proposals for safe harbors under the Social
Security Act for facilities of Indian
Health Programs and urban Indian
organizations.
Sec. 3204. Annual report on Indians served by Social Security Act
health benefit programs.
Sec. 3205. Development of recommendations to improve interstate
coordination of Medicaid and SCHIP coverage
of Indian children and other children who
are outside of their State of residency
because of educational or other needs.
TITLE I--AMENDMENTS TO INDIAN LAWS
SEC. 3101. INDIAN HEALTH CARE IMPROVEMENT AMENDED.
(a) In General.--The Indian Health Care Improvement Act (25 U.S.C.
1601 et seq.) is amended to read as follows:
``SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
``(a) Short Title.--This Act may be cited as the `Indian Health
Care Improvement Act'.
``(b) Table of Contents.--The table of contents for this Act is as
follows:
``Sec. 1. Short title; table of contents.
``Sec. 2. Findings.
``Sec. 3. Declaration of national Indian health policy.
``Sec. 4. Definitions.
``TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT
``Sec. 101. Purpose.
``Sec. 102. Health professions recruitment program for Indians.
``Sec. 103. Health professions preparatory scholarship program for
Indians.
``Sec. 104. Indian health professions scholarships.
``Sec. 105. American Indians Into Psychology Program.
``Sec. 106. Scholarship programs for Indian Tribes.
``Sec. 107. Indian Health Service extern programs.
``Sec. 108. Continuing education allowances.
``Sec. 109. Community Health Representative Program.
``Sec. 110. Indian Health Service Loan Repayment Program.
``Sec. 111. Scholarship and Loan Repayment Recovery Fund.
``Sec. 112. Recruitment activities.
``Sec. 113. Indian recruitment and retention program.
``Sec. 114. Advanced training and research.
``Sec. 115. Quentin N. Burdick American Indians Into Nursing Program.
``Sec. 116. Tribal cultural orientation.
``Sec. 117. INMED Program.
``Sec. 118. Health training programs of community colleges.
``Sec. 119. Retention bonus.
``Sec. 120. Nursing residency program.
``Sec. 121. Community Health Aide Program.
``Sec. 122. Tribal Health Program administration.
``Sec. 123. Health professional chronic shortage demonstration
programs.
``Sec. 124. National Health Service Corps.
``Sec. 125. Substance abuse counselor educational curricula
demonstration programs.
``Sec. 126. Behavioral health training and community education
programs.
``Sec. 127. Exemption from payment of certain fees.
``Sec. 128. Authorization of appropriations.
``TITLE II--HEALTH SERVICES
``Sec. 201. Indian Health Care Improvement Fund.
``Sec. 202. Health promotion and disease prevention services.
``Sec. 203. Diabetes prevention, treatment, and control.
``Sec. 204. Shared services for long-term care.
``Sec. 205. Health services research.
``Sec. 206. Mammography and other cancer screening.
``Sec. 207. Patient travel costs.
``Sec. 208. Epidemiology centers.
``Sec. 209. Comprehensive school health education programs.
``Sec. 210. Indian youth program.
``Sec. 211. Prevention, control, and elimination of communicable and
infectious diseases.
``Sec. 212. Other authority for provision of services.
``Sec. 213. Indian women's health care.
``Sec. 214. Environmental and nuclear health hazards.
``Sec. 215. Arizona as a contract health service delivery area.
``Sec. 216. North Dakota and South Dakota as contract health service
delivery area.
``Sec. 217. California contract health services program.
``Sec. 218. California as a contract health service delivery area.
``Sec. 219. Contract health services for the Trenton Service Area.
``Sec. 220. Programs operated by Indian Tribes and tribal
organizations.
``Sec. 221. Licensing.
``Sec. 222. Notification of provision of emergency contract health
services.
``Sec. 223. Prompt action on payment of claims.
``Sec. 224. Liability for payment.
``Sec. 225. Office of Indian Men's Health.
``Sec. 226. Catastrophic health emergency fund.
``Sec. 227. Authorization of appropriations.
``TITLE III--FACILITIES
``Sec. 301. Consultation; construction and renovation of facilities;
reports.
``Sec. 302. Sanitation facilities.
``Sec. 303. Preference to Indians and Indian firms.
``Sec. 304. Expenditure of non-Service funds for renovation.
``Sec. 305. Funding for the construction, expansion, and modernization
of small ambulatory care facilities.
``Sec. 306. Indian health care delivery demonstration project.
``Sec. 307. Land transfer.
``Sec. 308. Leases, contracts, and other agreements.
``Sec. 309. Study on loans, loan guarantees, and loan repayment.
``Sec. 310. Tribal leasing.
``Sec. 311. Indian Health Service/tribal facilities joint venture
program.
``Sec. 312. Location of facilities.
``Sec. 313. Maintenance and improvement of health care facilities.
``Sec. 314. Tribal management of federally owned quarters.
``Sec. 315. Applicability of Buy American Act requirement.
``Sec. 316. Other funding for facilities.
``Sec. 317. Authorization of appropriations.
``TITLE IV--ACCESS TO HEALTH SERVICES
``Sec. 401. Treatment of payments under Social Security Act health
benefits programs.
``Sec. 402. Grants to and contracts with the Service, Indian Tribes,
Tribal Organizations, and urban Indian
organizations to facilitate outreach,
enrollment, and coverage of Indians under
Social Security Act health benefit
programs.
``Sec. 403. Reimbursement from certain third parties of costs of health
services.
``Sec. 404. Crediting of reimbursements.
``Sec. 405. Purchasing health care coverage.
``Sec. 406. Sharing arrangements with Federal agencies.
``Sec. 407. Eligible indian veteran services.
``Sec. 408. Payor of last resort.
``Sec. 409. Consultation.
``Sec. 410. State Children's Health Insurance Program (SCHIP).
``Sec. 411. Premium and cost sharing protections and eligibility
determinations under Medicaid and SCHIP and
protection of certain Indian property from
Medicaid estate recovery.
``Sec. 412. Treatment under Medicaid and SCHIP managed care.
``Sec. 413. Navajo Nation Medicaid Agency feasibility study.
``Sec. 414. Exception for excepted benefits.
``Sec. 415. Authorization of appropriations.
``TITLE V--HEALTH SERVICES FOR URBAN INDIANS
``Sec. 501. Purpose.
``Sec. 502. Contracts with, and grants to, urban Indian organizations.
``Sec. 503. Contracts and grants for the provision of health care and
referral services.
``Sec. 504. Use of Federal Government Facilities and Sources of Supply.
``Sec. 505. Contracts and grants for the determination of unmet health
care needs.
``Sec. 506. Evaluations; renewals.
``Sec. 507. Other contract and grant requirements.
``Sec. 508. Reports and records.
``Sec. 509. Limitation on contract authority.
``Sec. 510. Facilities.
``Sec. 511. Division of Urban Indian Health.
``Sec. 512. Grants for alcohol and substance abuse-related services.
``Sec. 513. Treatment of certain demonstration projects.
``Sec. 514. Urban NIAAA transferred programs.
``Sec. 515. Conferring with urban Indian organizations.
``Sec. 516. Urban youth treatment center demonstration.
``Sec. 517. Grants for diabetes prevention, treatment, and control.
``Sec. 518. Community health representatives.
``Sec. 519. Effective date.
``Sec. 520. Eligibility for services.
``Sec. 521. Authorization of appropriations.
``Sec. 522. Health information technology.
``TITLE VI--ORGANIZATIONAL IMPROVEMENTS
``Sec. 601. Establishment of the Indian Health Service as an agency of
the Public Health Service.
``Sec. 602. Automated management information system.
``Sec. 603. Authorization of appropriations.
``TITLE VII--BEHAVIORAL HEALTH PROGRAMS
``Sec. 701. Behavioral health prevention and treatment services.
``Sec. 702. Memoranda of agreement with the Department of the Interior.
``Sec. 703. Comprehensive behavioral health prevention and treatment
program.
``Sec. 704. Mental health technician program.
``Sec. 705. Licensing requirement for mental health care workers.
``Sec. 706. Indian women treatment programs.
``Sec. 707. Indian youth program.
``Sec. 708. Indian youth telemental health demonstration project.
``Sec. 709. Inpatient and community-based mental health facilities
design, construction, and staffing.
``Sec. 710. Training and community education.
``Sec. 711. Behavioral health program.
``Sec. 712. Fetal alcohol disorder programs.
``Sec. 713. Child sexual abuse and prevention treatment programs.
``Sec. 714. Domestic and sexual violence prevention and treatment.
``Sec. 715. Behavioral health research.
``Sec. 716. Definitions.
``Sec. 717. Authorization of appropriations.
``TITLE VIII--MISCELLANEOUS
``Sec. 801. Reports.
``Sec. 802. Regulations.
``Sec. 803. Plan of implementation.
``Sec. 804. Limitation on use of funds appropriated to Indian Health
Service.
``Sec. 805. Eligibility of California Indians.
``Sec. 806. Health services for ineligible persons.
``Sec. 807. Reallocation of base resources.
``Sec. 808. Results of demonstration projects.
``Sec. 809. Provision of services in Montana.
``Sec. 810. Moratorium.
``Sec. 811. Severability provisions.
``Sec. 812. Use of patient safety organizations.
``Sec. 813. Confidentiality of medical quality assurance records;
qualified immunity for participants.
``Sec. 814. Claremore Indian Hospital.
``Sec. 815. Sense of Congress regarding law enforcement and
methamphetamine issues in Indian country.
``Sec. 816. Permitting implementation through contracts with Tribal
Health Programs.
``Sec. 817. Authorization of appropriations; availability.
``SEC. 2. FINDINGS.
``Congress makes the following findings:
``(1) Federal health services to maintain and improve the
health of the Indians are consonant with and required by the
Federal Government's historical and unique legal relationship
with, and resulting responsibility to, the American Indian
people.
``(2) A major national goal of the United States is to
provide the resources, processes, and structure that will
enable Indian tribes and tribal members to obtain the quantity
and quality of health care services and opportunities that will
eradicate the health disparities between Indians the general
population.
``(3) A major national goal of the United States is to
provide the quantity and quality of health services which will
permit the health status of Indians to be raised to the highest
possible level and to encourage the maximum participation of
Indians in the planning and management of those services.
``(4) Federal health services to Indians have resulted in a
reduction in the prevalence and incidence of preventable
illnesses among, and unnecessary and premature deaths of,
Indians.
``(5) Despite such services, the unmet health needs of the
American Indian people are severe and the health status of the
Indians is far below that of the general population of the
United States.
``SEC. 3. DECLARATION OF NATIONAL INDIAN HEALTH POLICY.
``Congress declares that it is the policy of this Nation, in
fulfillment of its special trust responsibilities and legal obligations
to Indians--
``(1) to assure the highest possible health status for
Indians and Urban Indians and to provide all resources
necessary to effect that policy;
``(2) to raise the health status of Indians and Urban
Indians to at least the levels set forth in the goals contained
within the Health People 2010 or successor objectives;
``(3) to the greatest extent possible, to allow Indians to
set their own health care priorities and establish goals that
reflect their unmet needs;
``(4) to increase the proportion of all degrees in the
health professions and allied and associated health professions
awarded to Indians so that the proportion of Indian health
professionals in each Service Area is raised to at least the
level of that of the general population;
``(5) to require meaningful consultation with Indian
Tribes, Tribal Organizations, and urban Indian organizations to
implement this Act and the national policy of Indian self-
determination; and
``(6) to provide funding for programs and facilities
operated by Indian Tribes, Tribal Organizations, and Urban
Indian Organizations in amounts that are not less than the
amounts provided to programs and facilities operated directly
by the Service.
``SEC. 4. DEFINITIONS.
``For purposes of this Act:
``(1) The term `accredited and accessible' means on or near
a reservation and accredited by a national or regional
organization with accrediting authority.
``(2) The term `Area Office' means an administrative
entity, including a program office, within the Service through
which services and funds are provided to the Service Units
within a defined geographic area.
``(3) The term `Assistant Secretary' means the Assistant
Secretary of Indian Health.
``(4)(A) The term `behavioral health' means the blending of
substance (including alcohol, drugs, inhalants, and tobacco)
abuse and mental health prevention and treatment, for the
purpose of providing comprehensive services.
``(B) The term `behavioral health' includes the joint
development of substance abuse and mental health treatment
planning and coordinated case management using a
multidisciplinary approach.
``(5) The term `California Indians' means those Indians who
are eligible for health services of the Service pursuant to
section 805.
``(6) The term `community college' means--
``(A) a tribal college or university, or
``(B) a junior or community college.
``(7) The term `contract health service' means health
services provided at the expense of the Service or a Tribal
Health Program by public or private medical providers or
hospitals, other than the Service Unit or the Tribal Health
Program at whose expense the services are provided.
``(8) The term `Department' means, unless otherwise
designated, the Department of Health and Human Services.
``(9) The term `disease prevention' means the reduction,
limitation, and prevention of disease and its complications and
reduction in the consequences of disease, including--
``(A) controlling--
``(i) the development of diabetes;
``(ii) high blood pressure;
``(iii) infectious agents;
``(iv) injuries;
``(v) occupational hazards and
disabilities;
``(vi) sexually transmittable diseases; and
``(vii) toxic agents; and
``(B) providing--
``(i) fluoridation of water; and
``(ii) immunizations.
``(10) The term `health profession' means allopathic
medicine, family medicine, internal medicine, pediatrics,
geriatric medicine, obstetrics and gynecology, podiatric
medicine, nursing, public health nursing, dentistry,
psychiatry, osteopathy, optometry, pharmacy, psychology, public
health, social work, marriage and family therapy, chiropractic
medicine, environmental health and engineering, allied health
professions, naturopathic medicine, and any other health
profession.
``(11) The term `health promotion' means--
``(A) fostering social, economic, environmental,
and personal factors conducive to health, including
raising public awareness about health matters and
enabling the people to cope with health problems by
increasing their knowledge and providing them with
valid information;
``(B) encouraging adequate and appropriate diet,
exercise, and sleep;
``(C) promoting education and work in conformity
with physical and mental capacity;
``(D) making available safe water and sanitary
facilities;
``(E) improving the physical, economic, cultural,
psychological, and social environment;
``(F) promoting culturally competent care; and
``(G) providing adequate and appropriate programs,
which may include--
``(i) abuse prevention (mental and
physical);
``(ii) community health;
``(iii) community safety;
``(iv) consumer health education;
``(v) diet and nutrition;
``(vi) immunization and other prevention of
communicable diseases, including HIV/AIDS;
``(vii) environmental health;
``(viii) exercise and physical fitness;
``(ix) avoidance of fetal alcohol
disorders;
``(x) first aid and CPR education;
``(xi) human growth and development;
``(xii) injury prevention and personal
safety;
``(xiii) behavioral health;
``(xiv) monitoring of disease indicators
between health care provider visits, through
appropriate means, including Internet-based
health care management systems;
``(xv) personal health and wellness
practices;
``(xvi) personal capacity building;
``(xvii) prenatal, pregnancy, and infant
care;
``(xviii) psychological well-being;
``(xix) reproductive health and family
planning;
``(xx) safe and adequate water;
``(xxi) healthy work environments;
``(xxii) elimination, reduction, and
prevention of contaminants that create
unhealthy household conditions (including mold
and other allergens);
``(xxiii) stress control;
``(xxiv) substance abuse;
``(xxv) sanitary facilities;
``(xxvi) sudden infant death syndrome
prevention;
``(xxvii) tobacco use cessation and
reduction;
``(xxviii) violence prevention; and
``(xxix) activities to promote achievement
of any of the objectives described in section
3(2).
``(12) The term `Indian', unless otherwise designated,
means any person who is a member of an Indian Tribe or is
eligible for health services under section 805, except that,
for the purpose of sections 102 and 103, the term also means
any individual who--
``(A)(i) irrespective of whether the individual
lives on or near a reservation, is a member of a tribe,
band, or other organized group of Indians, including
those tribes, bands, or groups terminated since 1940
and those recognized now or in the future by the State
in which they reside; or
``(ii) is a descendant, in the first or second
degree, of any such member;
``(B) is an Eskimo or Aleut or other Alaska Native;
``(C) is considered by the Secretary of the
Interior to be an Indian for any purpose; or
``(D) is determined to be an Indian under
regulations promulgated by the Secretary.
``(13) The term `Indian Health Program' means--
``(A) any health program administered directly by
the Service;
``(B) any Tribal Health Program; or
``(C) any Indian Tribe or Tribal Organization to
which the Secretary provides funding pursuant to
section 23 of the Act of June 25, 1910 (25 U.S.C. 47)
(commonly known as the `Buy Indian Act').
``(14) The term `Indian Tribe' has the meaning given the
term in the Indian Self-Determination and Education Assistance
Act (25 U.S.C. 450 et seq.).
``(15) The term `junior or community college' has the
meaning given the term by section 312(f) of the Higher
Education Act of 1965 (20 U.S.C. 1058(f)).
``(16) The term `reservation' means any federally
recognized Indian Tribe's reservation, Pueblo, or colony,
including former reservations in Oklahoma, Indian allotments,
and Alaska Native Regions established pursuant to the Alaska
Native Claims Settlement Act (43 U.S.C. 1601 et seq.).
``(17) The term `Secretary', unless otherwise designated,
means the Secretary of Health and Human Services.
``(18) The term `Service' means the Indian Health Service.
``(19) The term `Service Area' means the geographical area
served by each Area Office.
``(20) The term `Service Unit' means an administrative
entity of the Service, or a Tribal Health Program through which
services are provided, directly or by contract, to eligible
Indians within a defined geographic area.
``(21) The term `telehealth' has the meaning given the term
in section 330K(a) of the Public Health Service Act (42 U.S.C.
254c-16(a)).
``(22) The term `telemedicine' means a telecommunications
link to an end user through the use of eligible equipment that
electronically links health professionals or patients and
health professionals at separate sites in order to exchange
health care information in audio, video, graphic, or other
format for the purpose of providing improved health care
services.
``(23) The term `tribal college or university' has the
meaning given the term in section 316(b)(3) of the Higher
Education Act (20 U.S.C. 1059c(b)(3)).
``(24) The term `Tribal Health Program' means an Indian
Tribe or Tribal Organization that operates any health program,
service, function, activity, or facility funded, in whole or
part, by the Service through, or provided for in, a contract or
compact with the Service under the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.).
``(25) The term `Tribal Organization' has the meaning given
the term in the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.).
``(26) The term `Urban Center' means any community which
has a sufficient Urban Indian population with unmet health
needs to warrant assistance under title V of this Act, as
determined by the Secretary.
``(27) The term `Urban Indian' means any individual who
resides in an Urban Center and who meets 1 or more of the
following criteria:
``(A) Irrespective of whether the individual lives
on or near a reservation, the individual is a member of
a tribe, band, or other organized group of Indians,
including those tribes, bands, or groups terminated
since 1940 and those tribes, bands, or groups that are
recognized by the States in which they reside, or who
is a descendant in the first or second degree of any
such member.
``(B) The individual is an Eskimo, Aleut, or other
Alaska Native.
``(C) The individual is considered by the Secretary
of the Interior to be an Indian for any purpose.
``(D) The individual is determined to be an Indian
under regulations promulgated by the Secretary.
``(28) The term `urban Indian organization' means a
nonprofit corporate body that (A) is situated in an Urban
Center; (B) is governed by an Urban Indian-controlled board of
directors; (C) provides for the participation of all interested
Indian groups and individuals; and (D) is capable of legally
cooperating with other public and private entities for the
purpose of performing the activities described in section
503(a).
``TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT
``SEC. 101. PURPOSE.
``The purpose of this title is to increase, to the maximum extent
feasible, the number of Indians entering the health professions and
providing health services, and to assure an optimum supply of health
professionals to the Indian Health Programs and urban Indian
organizations involved in the provision of health services to Indians.
``SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM FOR INDIANS.
``(a) In General.--The Secretary, acting through the Service, shall
make grants to public or nonprofit private health or educational
entities, Tribal Health Programs, or urban Indian organizations to
assist such entities in meeting the costs of--
``(1) identifying Indians with a potential for education or
training in the health professions and encouraging and
assisting them--
``(A) to enroll in courses of study in such health
professions; or
``(B) if they are not qualified to enroll in any
such courses of study, to undertake such postsecondary
education or training as may be required to qualify
them for enrollment;
``(2) publicizing existing sources of financial aid
available to Indians enrolled in any course of study referred
to in paragraph (1) or who are undertaking training necessary
to qualify them to enroll in any such course of study; or
``(3) establishing other programs which the Secretary
determines will enhance and facilitate the enrollment of
Indians in, and the subsequent pursuit and completion by them
of, courses of study referred to in paragraph (1).
``(b) Grants.--
``(1) Application.--No grant may be made under this section
unless an application has been submitted to, and approved by,
the Secretary. Such application shall be in such form,
submitted in such manner, and contain such information, as the
Secretary shall by regulation prescribe pursuant to this Act.
The Secretary shall give a preference to applications submitted
by Tribal Health Programs or urban Indian organizations.
``(2) Amount of grants; payment.--The amount of a grant
under this section shall be determined by the Secretary.
Payments pursuant to this section may be made in advance or by
way of reimbursement, and at such intervals and on such
conditions as provided for in regulations issued pursuant to
this Act. To the extent not otherwise prohibited by law, grants
shall be for 3 years, as provided in regulations issued
pursuant to this Act.
``SEC. 103. HEALTH PROFESSIONS PREPARATORY SCHOLARSHIP PROGRAM FOR
INDIANS.
``(a) Scholarships Authorized.--The Secretary, acting through the
Service, shall provide scholarship grants to Indians who--
``(1) have successfully completed their high school
education or high school equivalency; and
``(2) have demonstrated the potential to successfully
complete courses of study in the health professions.
``(b) Purposes.--Scholarship grants provided pursuant to this
section shall be for the following purposes:
``(1) Compensatory preprofessional education of any
recipient, such scholarship not to exceed 2 years on a full-
time basis (or the part-time equivalent thereof, as determined
by the Secretary pursuant to regulations issued under this
Act).
``(2) Pregraduate education of any recipient leading to a
baccalaureate degree in an approved course of study preparatory
to a field of study in a health profession, such scholarship
not to exceed 4 years. An extension of up to 2 years (or the
part-time equivalent thereof, as determined by the Secretary
pursuant to regulations issued pursuant to this Act) may be
approved.
``(c) Other Conditions.--Scholarships under this section--
``(1) may cover costs of tuition, books, transportation,
board, and other necessary related expenses of a recipient
while attending school;
``(2) shall not be denied solely on the basis of the
applicant's scholastic achievement if such applicant has been
admitted to, or maintained good standing at, an accredited
institution; and
``(3) shall not be denied solely by reason of such
applicant's eligibility for assistance or benefits under any
other Federal program.
``SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS.
``(a) In General.--
``(1) Authority.--The Secretary, acting through the
Service, shall make scholarship grants to Indians who are
enrolled full or part time in accredited schools pursuing
courses of study in the health professions. Such scholarships
shall be designated Indian Health Scholarships and shall be
made in accordance with section 338A of the Public Health
Services Act (42 U.S.C. 254l), except as provided in subsection
(b) of this section.
``(2) Determinations by secretary.--The Secretary, acting
through the Service, shall determine--
``(A) who shall receive scholarship grants under
subsection (a); and
``(B) the distribution of the scholarships among
health professions on the basis of the relative needs
of Indians for additional service in the health
professions.
``(3) Certain delegation not allowed.--The administration
of this section shall be a responsibility of the Assistant
Secretary and shall not be delegated in a contract or compact
under the Indian Self-Determination and Education Assistance
Act (25 U.S.C. 450 et seq.).
``(b) Active Duty Service Obligation.--
``(1) Obligation met.--The active duty service obligation
under a written contract with the Secretary under this section
that an Indian has entered into shall, if that individual is a
recipient of an Indian Health Scholarship, be met in full-time
practice equal to 1 year for each school year for which the
participant receives a scholarship award under this part, or 2
years, whichever is greater, by service in 1 or more of the
following:
``(A) In an Indian Health Program.
``(B) In a program assisted under title V of this
Act.
``(C) In the private practice of the applicable
profession if, as determined by the Secretary, in
accordance with guidelines promulgated by the
Secretary, such practice is situated in a physician or
other health professional shortage area and addresses
the health care needs of a substantial number of
Indians.
``(D) In a teaching capacity in a tribal college or
university nursing program (or a related health
profession program) if, as determined by the Secretary,
the health service provided to Indians would not
decrease.
``(2) Obligation deferred.--At the request of any
individual who has entered into a contract referred to in
paragraph (1) and who receives a health professions degree
requiring postgraduate training for licensure or to improve
clinical skills, the Secretary shall defer the active duty
service obligation of that individual under that contract, in
order that such individual may complete any internship,
residency, or other advanced clinical training that is required
for the practice of that health profession, for an appropriate
period (in years, as determined by the Secretary), subject to
the following conditions:
``(A) No period of internship, residency, or other
advanced clinical training shall be counted as
satisfying any period of obligated service under this
subsection.
``(B) The active duty service obligation of that
individual shall commence not later than 90 days after
the completion of that advanced clinical training (or
by a date specified by the Secretary).
``(C) The active duty service obligation will be
served in the health profession of that individual in a
manner consistent with paragraph (1).
``(D) A recipient of a scholarship under this
section may, at the election of the recipient, meet the
active duty service obligation described in paragraph
(1) by service in a program specified under that
paragraph that--
``(i) is located on the reservation of the
Indian Tribe in which the recipient is
enrolled; or
``(ii) serves the Indian Tribe in which the
recipient is enrolled.
``(3) Priority when making assignments.--Subject to
paragraph (2), the Secretary, in making assignments of Indian
Health Scholarship recipients required to meet the active duty
service obligation described in paragraph (1), shall give
priority to assigning individuals to service in those programs
specified in paragraph (1) that have a need for health
professionals to provide health care services as a result of
individuals having breached contracts entered into under this
section.
``(c) Part-time Students.--In the case of an individual receiving a
scholarship under this section who is enrolled part time in an approved
course of study--
``(1) such scholarship shall be for a period of years not
to exceed the part-time equivalent of 4 years, as determined by
the Secretary;
``(2) the period of obligated service described in
subsection (b)(1) shall be equal to the greater of--
``(A) the part-time equivalent of 1 year for each
year for which the individual was provided a
scholarship (as determined by the Secretary); or
``(B) 2 years; and
``(3) the amount of the monthly stipend specified in
section 338A(g)(1)(B) of the Public Health Service Act (42
U.S.C. 254l(g)(1)(B)) shall be reduced pro rata (as determined
by the Secretary) based on the number of hours such student is
enrolled.
``(d) Breach of Contract.--
``(1) Specified breaches.--An individual shall be liable to
the United States for the amount which has been paid to the
individual, or on behalf of the individual, under a contract
entered into with the Secretary under this section on or after
the date of enactment of the Indian Health Care Improvement Act
Amendments of 2009 if that individual--
``(A) fails to maintain an acceptable level of
academic standing in the educational institution in
which he or she is enrolled (such level determined by
the educational institution under regulations of the
Secretary);
``(B) is dismissed from such educational
institution for disciplinary reasons;
``(C) voluntarily terminates the training in such
an educational institution for which he or she is
provided a scholarship under such contract before the
completion of such training; or
``(D) fails to accept payment, or instructs the
educational institution in which he or she is enrolled
not to accept payment, in whole or in part, of a
scholarship under such contract, in lieu of any service
obligation arising under such contract.
``(2) Other breaches.--If for any reason not specified in
paragraph (1) an individual breaches a written contract by
failing either to begin such individual's service obligation
required under such contract or to complete such service
obligation, the United States shall be entitled to recover from
the individual an amount determined in accordance with the
formula specified in subsection (l) of section 110 in the
manner provided for in such subsection.
``(3) Cancellation upon death of recipient.--Upon the death
of an individual who receives an Indian Health Scholarship, any
outstanding obligation of that individual for service or
payment that relates to that scholarship shall be canceled.
``(4) Waivers and suspensions.--The Secretary shall provide
for the partial or total waiver or suspension of any obligation
of service or payment of a recipient of an Indian Health
Scholarship if the Secretary determines that--
``(A) it is not possible for the recipient to meet
that obligation or make that payment;
``(B) requiring that recipient to meet that
obligation or make that payment would result in extreme
hardship to the recipient; or
``(C) the enforcement of the requirement to meet
the obligation or make the payment would be
unconscionable.
``(5) Extreme hardship.--Notwithstanding any other
provision of law, in any case of extreme hardship or for other
good cause shown, the Secretary may waive, in whole or in part,
the right of the United States to recover funds made available
under this section.
``(6) Bankruptcy.--Notwithstanding any other provision of
law, with respect to a recipient of an Indian Health
Scholarship, no obligation for payment may be released by a
discharge in bankruptcy under title 11, United States Code,
unless that discharge is granted after the expiration of the 5-
year period beginning on the initial date on which that payment
is due, and only if the bankruptcy court finds that the
nondischarge of the obligation would be unconscionable.
``SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PROGRAM.
``(a) Grants Authorized.--The Secretary, acting through the
Service, shall make grants of not more than $300,000 to each of 9
colleges and universities for the purpose of developing and maintaining
Indian psychology career recruitment programs as a means of encouraging
Indians to enter the behavioral health field. These programs shall be
located at various locations throughout the country to maximize their
availability to Indian students and new programs shall be established
in different locations from time to time.
``(b) Quentin N. Burdick Program Grant.--The Secretary shall
provide a grant authorized under subsection (a) to develop and maintain
a program at the University of North Dakota to be known as the `Quentin
N. Burdick American Indians Into Psychology Program'. Such program
shall, to the maximum extent feasible, coordinate with the Quentin N.
Burdick Indian Health Programs authorized under section 117(b), the
Quentin N. Burdick American Indians Into Nursing Program authorized
under section 115(e), and existing university research and
communications networks.
``(c) Regulations.--The Secretary shall issue regulations pursuant
to this Act for the competitive awarding of grants provided under this
section.
``(d) Conditions of Grant.--Applicants under this section shall
agree to provide a program which, at a minimum--
``(1) provides outreach and recruitment for health
professions to Indian communities including elementary,
secondary, and accredited and accessible community colleges
that will be served by the program;
``(2) incorporates a program advisory board comprised of
representatives from the tribes and communities that will be
served by the program;
``(3) provides summer enrichment programs to expose Indian
students to the various fields of psychology through research,
clinical, and experimental activities;
``(4) provides stipends to undergraduate and graduate
students to pursue a career in psychology;
``(5) develops affiliation agreements with tribal colleges
and universities, the Service, university affiliated programs,
and other appropriate accredited and accessible entities to
enhance the education of Indian students;
``(6) to the maximum extent feasible, uses existing
university tutoring, counseling, and student support services;
and
``(7) to the maximum extent feasible, employs qualified
Indians in the program.
``(e) Active Duty Service Requirement.--The active duty service
obligation prescribed under section 338C of the Public Health Service
Act (42 U.S.C. 254m) shall be met by each graduate who receives a
stipend described in subsection (d)(4) that is funded under this
section. Such obligation shall be met by service--
``(1) in an Indian Health Program;
``(2) in a program assisted under title V of this Act; or
``(3) in the private practice of psychology if, as
determined by the Secretary, in accordance with guidelines
promulgated by the Secretary, such practice is situated in a
physician or other health professional shortage area and
addresses the health care needs of a substantial number of
Indians.
``(f) Authorization of Appropriations.--There is authorized to be
appropriated such sums as may be necessary to carry out this section.
``SEC. 106. SCHOLARSHIP PROGRAMS FOR INDIAN TRIBES.
``(a) In General.--
``(1) Grants authorized.--The Secretary, acting through the
Service, shall make grants to Tribal Health Programs for the
purpose of providing scholarships for Indians to serve as
health professionals in Indian communities.
``(2) Amount.--Amounts available under paragraph (1) for
any fiscal year shall not exceed 5 percent of the amounts
available for each fiscal year for Indian Health Scholarships
under section 104.
``(3) Application.--An application for a grant under
paragraph (1) shall be in such form and contain such
agreements, assurances, and information as consistent with this
section.
``(b) Requirements.--
``(1) In general.--A Tribal Health Program receiving a
grant under subsection (a) shall provide scholarships to
Indians in accordance with the requirements of this section.
``(2) Costs.--With respect to costs of providing any
scholarship pursuant to subsection (a)--
``(A) 80 percent of the costs of the scholarship
shall be paid from the funds made available pursuant to
subsection (a)(1) provided to the Tribal Health
Program; and
``(B) 20 percent of such costs may be paid from any
other source of funds.
``(c) Course of Study.--A Tribal Health Program shall provide
scholarships under this section only to Indians enrolled or accepted
for enrollment in a course of study (approved by the Secretary) in 1 of
the health professions contemplated by this Act.
``(d) Contract.--
``(1) In general.--In providing scholarships under
subsection (b), the Secretary and the Tribal Health Program
shall enter into a written contract with each recipient of such
scholarship.
``(2) Requirements.--Such contract shall--
``(A) obligate such recipient to provide service in
an Indian Health Program or urban Indian organization,
in the same Service Area where the Tribal Health
Program providing the scholarship is located, for--
``(i) a number of years for which the
scholarship is provided (or the part-time
equivalent thereof, as determined by the
Secretary), or for a period of 2 years,
whichever period is greater; or
``(ii) such greater period of time as the
recipient and the Tribal Health Program may
agree;
``(B) provide that the amount of the scholarship--
``(i) may only be expended for--
``(I) tuition expenses, other
reasonable educational expenses, and
reasonable living expenses incurred in
attendance at the educational
institution; and
``(II) payment to the recipient of
a monthly stipend of not more than the
amount authorized by section
338(g)(1)(B) of the Public Health
Service Act (42 U.S.C. 254m(g)(1)(B)),
with such amount to be reduced pro rata
(as determined by the Secretary) based
on the number of hours such student is
enrolled, and not to exceed, for any
year of attendance for which the
scholarship is provided, the total
amount required for the year for the
purposes authorized in this clause; and
``(ii) may not exceed, for any year of
attendance for which the scholarship is
provided, the total amount required for the
year for the purposes authorized in clause (i);
``(C) require the recipient of such scholarship to
maintain an acceptable level of academic standing as
determined by the educational institution in accordance
with regulations issued pursuant to this Act; and
``(D) require the recipient of such scholarship to
meet the educational and licensure requirements
appropriate to each health profession.
``(3) Service in other service areas.--The contract may
allow the recipient to serve in another Service Area, provided
the Tribal Health Program and Secretary approve and services
are not diminished to Indians in the Service Area where the
Tribal Health Program providing the scholarship is located.
``(e) Breach of Contract.--
``(1) Specific breaches.--An individual who has entered
into a written contract with the Secretary and a Tribal Health
Program under subsection (d) shall be liable to the United
States for the Federal share of the amount which has been paid
to him or her, or on his or her behalf, under the contract if
that individual--
``(A) fails to maintain an acceptable level of
academic standing in the educational institution in
which he or she is enrolled (such level as determined
by the educational institution under regulations of the
Secretary);
``(B) is dismissed from such educational
institution for disciplinary reasons;
``(C) voluntarily terminates the training in such
an educational institution for which he or she is
provided a scholarship under such contract before the
completion of such training; or
``(D) fails to accept payment, or instructs the
educational institution in which he or she is enrolled
not to accept payment, in whole or in part, of a
scholarship under such contract, in lieu of any service
obligation arising under such contract.
``(2) Other breaches.--If for any reason not specified in
paragraph (1), an individual breaches a written contract by
failing to either begin such individual's service obligation
required under such contract or to complete such service
obligation, the United States shall be entitled to recover from
the individual an amount determined in accordance with the
formula specified in subsection (l) of section 110 in the
manner provided for in such subsection.
``(3) Cancellation upon death of recipient.--Upon the death
of an individual who receives an Indian Health Scholarship, any
outstanding obligation of that individual for service or
payment that relates to that scholarship shall be canceled.
``(4) Information.--The Secretary may carry out this
subsection on the basis of information received from Tribal
Health Programs involved or on the basis of information
collected through such other means as the Secretary deems
appropriate.
``(f) Relation to Social Security Act.--The recipient of a
scholarship under this section shall agree, in providing health care
pursuant to the requirements herein--
``(1) not to discriminate against an individual seeking
care on the basis of the ability of the individual to pay for
such care or on the basis that payment for such care will be
made pursuant to a program established in title XVIII of the
Social Security Act or pursuant to the programs established in
title XIX or title XXI of such Act; and
``(2) to accept assignment under section 1842(b)(3)(B)(ii)
of the Social Security Act for all services for which payment
may be made under part B of title XVIII of such Act, and to
enter into an appropriate agreement with the State agency that
administers the State plan for medical assistance under title
XIX, or the State child health plan under title XXI, of such
Act to provide service to individuals entitled to medical
assistance or child health assistance, respectively, under the
plan.
``(g) Continuance of Funding.--The Secretary shall make payments
under this section to a Tribal Health Program for any fiscal year
subsequent to the first fiscal year of such payments unless the
Secretary determines that, for the immediately preceding fiscal year,
the Tribal Health Program has not complied with the requirements of
this section.
``SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS.
``(a) Employment Preference.--Any individual who receives a
scholarship pursuant to section 104 or 106 shall be given preference
for employment in the Service, or may be employed by a Tribal Health
Program or an urban Indian organization, or other agencies of the
Department as available, during any nonacademic period of the year.
``(b) Not Counted Toward Active Duty Service Obligation.--Periods
of employment pursuant to this subsection shall not be counted in
determining fulfillment of the service obligation incurred as a
condition of the scholarship.
``(c) Timing; Length of Employment.--Any individual enrolled in a
program, including a high school program, authorized under section
102(a) may be employed by the Service or by a Tribal Health Program or
an urban Indian organization during any nonacademic period of the year.
Any such employment shall not exceed 120 days during any calendar year.
``(d) Nonapplicability of Competitive Personnel System.--Any
employment pursuant to this section shall be made without regard to any
competitive personnel system or agency personnel limitation and to a
position which will enable the individual so employed to receive
practical experience in the health profession in which he or she is
engaged in study. Any individual so employed shall receive payment for
his or her services comparable to the salary he or she would receive if
he or she were employed in the competitive system. Any individual so
employed shall not be counted against any employment ceiling affecting
the Service or the Department.
``SEC. 108. CONTINUING EDUCATION ALLOWANCES.
``In order to encourage scholarship and stipend recipients under
sections 104, 105, 106, and 115 and health professionals, including
community health representatives and emergency medical technicians, to
join or continue in an Indian Health Program and to provide their
services in the rural and remote areas where a significant portion of
Indians reside, the Secretary, acting through the Service, may--
``(1) provide programs or allowances to transition into an
Indian Health Program, including licensing, board or
certification examination assistance, and technical assistance
in fulfilling service obligations under sections 104, 105, 106,
and 115; and
``(2) provide programs or allowances to health
professionals employed in an Indian Health Program to enable
them for a period of time each year prescribed by regulation of
the Secretary to take leave of their duty stations for
professional consultation, management, leadership, and
refresher training courses.
``SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PROGRAM.
``(a) In General.--Under the authority of the Act of November 2,
1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), the
Secretary, acting through the Service, shall maintain a Community
Health Representative Program under which Indian Health Programs--
``(1) provide for the training of Indians as community
health representatives; and
``(2) use such community health representatives in the
provision of health care, health promotion, and disease
prevention services to Indian communities.
``(b) Duties.--The Community Health Representative Program of the
Service, shall--
``(1) provide a high standard of training for community
health representatives to ensure that the community health
representatives provide quality health care, health promotion,
and disease prevention services to the Indian communities
served by the Program;
``(2) in order to provide such training, develop and
maintain a curriculum that--
``(A) combines education in the theory of health
care with supervised practical experience in the
provision of health care; and
``(B) provides instruction and practical experience
in health promotion and disease prevention activities,
with appropriate consideration given to lifestyle
factors that have an impact on Indian health status,
such as alcoholism, family dysfunction, and poverty;
``(3) maintain a system which identifies the needs of
community health representatives for continuing education in
health care, health promotion, and disease prevention and
develop programs that meet the needs for continuing education;
``(4) maintain a system that provides close supervision of
Community Health Representatives;
``(5) maintain a system under which the work of Community
Health Representatives is reviewed and evaluated; and
``(6) promote traditional health care practices of the
Indian Tribes served consistent with the Service standards for
the provision of health care, health promotion, and disease
prevention.
``SEC. 110. INDIAN HEALTH SERVICE LOAN REPAYMENT PROGRAM.
``(a) Establishment.--The Secretary, acting through the Service,
shall establish and administer a program to be known as the Service
Loan Repayment Program (hereinafter referred to as the `Loan Repayment
Program') in order to ensure an adequate supply of trained health
professionals necessary to maintain accreditation of, and provide
health care services to Indians through, Indian Health Programs and
urban Indian organizations.
``(b) Eligible Individuals.--To be eligible to participate in the
Loan Repayment Program, an individual must--
``(1)(A) be enrolled--
``(i) in a course of study or program in an
accredited educational institution (as determined by
the Secretary under section 338B(b)(1)(c)(i) of the
Public Health Service Act (42 U.S.C. 254l-
1(b)(1)(c)(i))) and be scheduled to complete such
course of study in the same year such individual
applies to participate in such program; or
``(ii) in an approved graduate training program in
a health profession; or
``(B) have--
``(i) a degree in a health profession; and
``(ii) a license to practice a health profession;
``(2)(A) be eligible for, or hold, an appointment as a
commissioned officer in the Regular or Reserve Corps of the
Public Health Service;
``(B) meet the professional standards for civil service
employment in the Service; or
``(C) be employed in an Indian Health Program or urban
Indian organization without a service obligation; and
``(3) submit to the Secretary an application for a contract
described in subsection (e).
``(c) Application.--
``(1) Information to be included with forms.--In
disseminating application forms and contract forms to
individuals desiring to participate in the Loan Repayment
Program, the Secretary shall include with such forms a fair
summary of the rights and liabilities of an individual whose
application is approved (and whose contract is accepted) by the
Secretary, including in the summary a clear explanation of the
damages to which the United States is entitled under subsection
(l) in the case of the individual's breach of contract. The
Secretary shall provide such individuals with sufficient
information regarding the advantages and disadvantages of
service as a commissioned officer in the Regular or Reserve
Corps of the Public Health Service or a civilian employee of
the Service to enable the individual to make a decision on an
informed basis.
``(2) Clear language.--The application form, contract form,
and all other information furnished by the Secretary under this
section shall be written in a manner calculated to be
understood by the average individual applying to participate in
the Loan Repayment Program.
``(3) Timely availability of forms.--The Secretary shall
make such application forms, contract forms, and other
information available to individuals desiring to participate in
the Loan Repayment Program on a date sufficiently early to
ensure that such individuals have adequate time to carefully
review and evaluate such forms and information.
``(d) Priorities.--
``(1) List.--Consistent with subsection (j), the Secretary
shall annually--
``(A) identify the positions in each Indian Health
Program or urban Indian organization for which there is
a need or a vacancy; and
``(B) rank those positions in order of priority.
``(2) Approvals.--Consistent with the priority determined
under paragraph (1), the Secretary, in determining which
applications under the Loan Repayment Program to approve (and
which contracts to accept), shall--
``(A) give first priority to applications made by
individual Indians; and
``(B) after making determinations on all
applications submitted by individual Indians as
required under subparagraph (A), give priority to--
``(i) individuals recruited through the
efforts of an Indian Health Program or urban
Indian organization; and
``(ii) other individuals based on the
priority rankings under paragraph (1).
``(e) Recipient Contracts.--
``(1) Contract required.--An individual becomes a
participant in the Loan Repayment Program only upon the
Secretary and the individual entering into a written contract
described in paragraph (2).
``(2) Contents of contract.--The written contract referred
to in this section between the Secretary and an individual
shall contain--
``(A) an agreement under which--
``(i) subject to subparagraph (C), the
Secretary agrees--
``(I) to pay loans on behalf of the
individual in accordance with the
provisions of this section; and
``(II) to accept (subject to the
availability of appropriated funds for
carrying out this section) the
individual into the Service or place
the individual with a Tribal Health
Program or urban Indian organization as
provided in clause (ii)(III); and
``(ii) subject to subparagraph (C), the
individual agrees--
``(I) to accept loan payments on
behalf of the individual;
``(II) in the case of an individual
described in subsection (b)(1)--
``(aa) to maintain
enrollment in a course of study
or training described in
subsection (b)(1)(A) until the
individual completes the course
of study or training; and
``(bb) while enrolled in
such course of study or
training, to maintain an
acceptable level of academic
standing (as determined under
regulations of the Secretary by
the educational institution
offering such course of study
or training); and
``(III) to serve for a time period
(in this section referred to as the
`period of obligated service') equal to
2 years or such longer period as the
individual may agree to serve in the
full-time clinical practice of such
individual's profession in an Indian
Health Program or urban Indian
organization to which the individual
may be assigned by the Secretary;
``(B) a provision permitting the Secretary to
extend for such longer additional periods, as the
individual may agree to, the period of obligated
service agreed to by the individual under subparagraph
(A)(ii)(III);
``(C) 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 which is conditioned thereon is contingent
upon funds being appropriated for loan repayments under
this section;
``(D) a statement of the damages to which the
United States is entitled under subsection (k) for the
individual's breach of the contract; and
``(E) such other statements of the rights and
liabilities of the Secretary and of the individual, not
inconsistent with this section.
``(f) Deadline for Decision on Application.--The Secretary shall
provide written notice to an individual within 21 days on--
``(1) the Secretary's approving, under subsection (e)(1),
of the individual's participation in the Loan Repayment
Program, including extensions resulting in an aggregate period
of obligated service in excess of 4 years; or
``(2) the Secretary's disapproving an individual's
participation in such Program.
``(g) Payments.--
``(1) In general.--A loan repayment provided for an
individual under a written contract under the Loan Repayment
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--
``(A) tuition expenses;
``(B) all other reasonable educational expenses,
including fees, books, and laboratory expenses,
incurred by the individual; and
``(C) reasonable living expenses as determined by
the Secretary.
``(2) Amount.--For each year of obligated service that an
individual contracts to serve under subsection (e), the
Secretary may pay up to $35,000 or an amount equal to the
amount specified in section 338B(g)(2)(A) of the Public Health
Service Act, whichever is more, on behalf of the individual for
loans described in paragraph (1). In making a determination of
the amount to pay for a year of such service by an individual,
the Secretary shall consider the extent to which each such
determination--
``(A) affects the ability of the Secretary to
maximize the number of contracts that can be provided
under the Loan Repayment Program from the amounts
appropriated for such contracts;
``(B) provides an incentive to serve in Indian
Health Programs and urban Indian organizations with the
greatest shortages of health professionals; and
``(C) provides an incentive with respect to the
health professional involved remaining in an Indian
Health Program or urban Indian organization with such a
health professional shortage, and continuing to provide
primary health services, after the completion of the
period of obligated service under the Loan Repayment
Program.
``(3) Timing.--Any arrangement made by the Secretary for
the making of loan repayments in accordance with this
subsection shall provide that any repayments for a year of
obligated service shall be made no later than the end of the
fiscal year in which the individual completes such year of
service.
``(4) Reimbursements for tax liability.--For the purpose of
providing reimbursements for tax liability resulting from a
payment under paragraph (2) on behalf of an individual, the
Secretary--
``(A) in addition to such payments, may make
payments to the individual in an amount equal to not
less than 20 percent and not more than 39 percent of
the total amount of loan repayments made for the
taxable year involved; and
``(B) may make such additional payments as the
Secretary determines to be appropriate with respect to
such purpose.
``(5) Payment schedule.--The Secretary may enter into an
agreement with the holder of any loan for which payments are
made under the Loan Repayment Program to establish a schedule
for the making of such payments.
``(h) Employment Ceiling.--Notwithstanding any other provision of
law, individuals who have entered into written contracts with the
Secretary under this section shall not be counted against any
employment ceiling affecting the Department while those individuals are
undergoing academic training.
``(i) Recruitment.--The Secretary shall conduct recruiting programs
for the Loan Repayment Program and other manpower programs of the
Service at educational institutions training health professionals or
specialists identified in subsection (a).
``(j) Applicability of Law.--Section 214 of the Public Health
Service Act (42 U.S.C. 215) shall not apply to individuals during their
period of obligated service under the Loan Repayment Program.
``(k) Assignment of Individuals.--The Secretary, in assigning
individuals to serve in Indian Health Programs or urban Indian
organizations pursuant to contracts entered into under this section,
shall--
``(1) ensure that the staffing needs of Tribal Health
Programs and urban Indian organizations receive consideration
on an equal basis with programs that are administered directly
by the Service; and
``(2) give priority to assigning individuals to Indian
Health Programs and urban Indian organizations that have a need
for health professionals to provide health care services as a
result of individuals having breached contracts entered into
under this section.
``(l) Breach of Contract.--
``(1) Specific breaches.--An individual who has entered
into a written contract with the Secretary under this section
and has not received a waiver under subsection (m) shall be
liable, in lieu of any service obligation arising under such
contract, to the United States for the amount which has been
paid on such individual's behalf under the contract if that
individual--
``(A) is enrolled in the final year of a course of
study and--
``(i) fails to maintain an acceptable level
of academic standing in the educational
institution in which he or she is enrolled
(such level determined by the educational
institution under regulations of the
Secretary);
``(ii) voluntarily terminates such
enrollment; or
``(iii) is dismissed from such educational
institution before completion of such course of
study; or
``(B) is enrolled in a graduate training program
and fails to complete such training program.
``(2) Other breaches; formula for amount owed.--If, for any
reason not specified in paragraph (1), an individual breaches
his or her written contract under this section by failing
either to begin, or complete, such individual's period of
obligated service in accordance with subsection (e)(2), the
United States shall be entitled to recover from such individual
an amount to be determined in accordance with the following
formula: A=3Z(t-s/t) in which--
``(A) `A' is the amount the United States is
entitled to recover;
``(B) `Z' is the sum of the amounts paid under this
section to, or on behalf of, the individual and the
interest on such amounts which would be payable if, at
the time the amounts were paid, they were loans bearing
interest at the maximum legal prevailing rate, as
determined by the Secretary of the Treasury;
``(C) `t' is the total number of months in the
individual's period of obligated service; and
``(D) `s' is the number of months of such period
served by such individual in accordance with this
section.
``(3) Time period for repayment.--Any amount of damages
which the United States is entitled to recover under this
subsection shall be paid to the United States within the 1-year
period beginning on the date of the breach or such longer
period beginning on such date as shall be specified by the
Secretary.
``(4) Deductions in medicare payments.--Amounts not paid
within such period shall be subject to collection through
deductions in Medicare payments pursuant to section 1892 of the
Social Security Act.
``(5) Recovery of delinquency.--
``(A) In general.--If damages described in
paragraph (4) are delinquent for 3 months, the
Secretary shall, for the purpose of recovering such
damages--
``(i) use collection agencies contracted
with by the Administrator of General Services;
or
``(ii) enter into contracts for the
recovery of such damages with collection
agencies selected by the Secretary.
``(B) Report.--Each contract for recovering damages
pursuant to this subsection shall provide that the
contractor will, not less than once each 6 months,
submit to the Secretary a status report on the success
of the contractor in collecting such damages. Section
3718 of title 31, United States Code, shall apply to
any such contract to the extent not inconsistent with
this subsection.
``(m) Waiver or Suspension of Obligation.--
``(1) In general.--The Secretary shall by regulation
provide for the partial or total waiver or suspension of any
obligation of service or payment by an individual under the
Loan Repayment Program whenever compliance by the individual is
impossible or would involve extreme hardship to the individual
and if enforcement of such obligation with respect to any
individual would be unconscionable.
``(2) Canceled upon death.--Any obligation of an individual
under the Loan Repayment Program for service or payment of
damages shall be canceled upon the death of the individual.
``(3) Hardship waiver.--The Secretary may waive, in whole
or in part, the rights of the United States to recover amounts
under this section in any case of extreme hardship or other
good cause shown, as determined by the Secretary.
``(4) Bankruptcy.--Any obligation of an individual under
the Loan Repayment Program for payment of damages may be
released by a discharge in bankruptcy under title 11 of the
United States Code only if such discharge is granted after the
expiration of the 5-year period beginning on the first date
that payment of such damages is required, and only if the
bankruptcy court finds that nondischarge of the obligation
would be unconscionable.
``(n) Report.--The Secretary shall submit to the President, for
inclusion in the report required to be submitted to Congress under
section 801, a report concerning the previous fiscal year which sets
forth by Service Area the following:
``(1) A list of the health professional positions
maintained by Indian Health Programs and urban Indian
organizations for which recruitment or retention is difficult.
``(2) The number of Loan Repayment Program applications
filed with respect to each type of health profession.
``(3) The number of contracts described in subsection (e)
that are entered into with respect to each health profession.
``(4) The amount of loan payments made under this section,
in total and by health profession.
``(5) The number of scholarships that are provided under
sections 104 and 106 with respect to each health profession.
``(6) The amount of scholarship grants provided under
sections 104 and 106, in total and by health profession.
``(7) The number of providers of health care that will be
needed by Indian Health Programs and urban Indian
organizations, by location and profession, during the 3 fiscal
years beginning after the date the report is filed.
``(8) The measures the Secretary plans to take to fill the
health professional positions maintained by Indian Health
Programs or urban Indian organizations for which recruitment or
retention is difficult.
``SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOVERY FUND.
``(a) Establishment.--There is established in the Treasury of the
United States a fund to be known as the Indian Health Scholarship and
Loan Repayment Recovery Fund (hereafter in this section referred to as
the `LRRF'). The LRRF shall consist of such amounts as may be collected
from individuals under section 104(d), section 106(e), and section
110(l) for breach of contract, such funds as may be appropriated to the
LRRF, and interest earned on amounts in the LRRF. All amounts
collected, appropriated, or earned relative to the LRRF shall remain
available until expended.
``(b) Use of Funds.--
``(1) By secretary.--Amounts in the LRRF may be expended by
the Secretary, acting through the Service, to make payments to
an Indian Health Program--
``(A) to which a scholarship recipient under
section 104 and 106 or a loan repayment program
participant under section 110 has been assigned to meet
the obligated service requirements pursuant to such
sections; and
``(B) that has a need for a health professional to
provide health care services as a result of such
recipient or participant having breached the contract
entered into under section 104, 106, or 110.
``(2) By tribal health programs.--A Tribal Health Program
receiving payments pursuant to paragraph (1) may expend the
payments to provide scholarships or recruit and employ,
directly or by contract, health professionals to provide health
care services.
``(c) Investment of Funds.--The Secretary of the Treasury shall
invest such amounts of the LRRF as the Secretary of Health and Human
Services determines are not required to meet current withdrawals from
the LRRF. Such investments may be made only in interest bearing
obligations of the United States. For such purpose, such obligations
may be acquired on original issue at the issue price, or by purchase of
outstanding obligations at the market price.
``(d) Sale of Obligations.--Any obligation acquired by the LRRF may
be sold by the Secretary of the Treasury at the market price.
``SEC. 112. RECRUITMENT ACTIVITIES.
``(a) Reimbursement for Travel.--The Secretary, acting through the
Service, may reimburse health professionals seeking positions with
Indian Health Programs or urban Indian organizations, including
individuals considering entering into a contract under section 110 and
their spouses, for actual and reasonable expenses incurred in traveling
to and from their places of residence to an area in which they may be
assigned for the purpose of evaluating such area with respect to such
assignment.
``(b) Recruitment Personnel.--The Secretary, acting through the
Service, shall assign 1 individual in each Area Office to be
responsible on a full-time basis for recruitment activities.
``SEC. 113. INDIAN RECRUITMENT AND RETENTION PROGRAM.
``(a) In General.--The Secretary, acting through the Service, shall
fund, on a competitive basis, innovative demonstration projects for a
period not to exceed 3 years to enable Indian Health Programs and urban
Indian organizations to recruit, place, and retain health professionals
to meet their staffing needs.
``(b) Eligible Entities; Application.--Any Indian Health Program or
Urban Indian organization may submit an application for funding of a
project pursuant to this section.
``SEC. 114. ADVANCED TRAINING AND RESEARCH.
``(a) Demonstration Program.--The Secretary, acting through the
Service, shall establish a demonstration project to enable health
professionals who have worked in an Indian Health Program or urban
Indian organization for a substantial period of time to pursue advanced
training or research areas of study for which the Secretary determines
a need exists.
``(b) Service Obligation.--An individual who participates in a
program under subsection (a), where the educational costs are borne by
the Service, shall incur an obligation to serve in an Indian Health
Program or urban Indian organization for a period of obligated service
equal to at least the period of time during which the individual
participates in such program. In the event that the individual fails to
complete such obligated service, the individual shall be liable to the
United States for the period of service remaining. In such event, with
respect to individuals entering the program after the date of enactment
of the Indian Health Care Improvement Act Amendments of 2009, the
United States shall be entitled to recover from such individual an
amount to be determined in accordance with the formula specified in
subsection (l) of section 110 in the manner provided for in such
subsection.
``(c) Equal Opportunity for Participation.--Health professionals
from Tribal Health Programs and urban Indian organizations shall be
given an equal opportunity to participate in the program under
subsection (a).
``SEC. 115. QUENTIN N. BURDICK AMERICAN INDIANS INTO NURSING PROGRAM.
``(a) Grants Authorized.--For the purpose of increasing the number
of nurses, nurse midwives, and nurse practitioners who deliver health
care services to Indians, the Secretary, acting through the Service,
shall provide grants to the following:
``(1) Public or private schools of nursing.
``(2) Tribal colleges or universities.
``(3) Nurse midwife programs and advanced practice nurse
programs that are provided by any tribal college or university
accredited nursing program, or in the absence of such, any
other public or private institutions.
``(b) Use of Grants.--Grants provided under subsection (a) may be
used for 1 or more of the following:
``(1) To recruit individuals for programs which train
individuals to be nurses, nurse midwives, or advanced practice
nurses.
``(2) To provide scholarships to Indians enrolled in such
programs that may pay the tuition charged for such program and
other expenses incurred in connection with such program,
including books, fees, room and board, and stipends for living
expenses.
``(3) To provide a program that encourages nurses, nurse
midwives, and advanced practice nurses to provide, or continue
to provide, health care services to Indians.
``(4) To provide a program that increases the skills of,
and provides continuing education to, nurses, nurse midwives,
and advanced practice nurses.
``(5) To provide any program that is designed to achieve
the purpose described in subsection (a).
``(c) Applications.--Each application for a grant under subsection
(a) shall include such information as the Secretary may require to
establish the connection between the program of the applicant and a
health care facility that primarily serves Indians.
``(d) Preferences for Grant Recipients.--In providing grants under
subsection (a), the Secretary shall extend a preference to the
following:
``(1) Programs that provide a preference to Indians.
``(2) Programs that train nurse midwives or advanced
practice nurses.
``(3) Programs that are interdisciplinary.
``(4) Programs that are conducted in cooperation with a
program for gifted and talented Indian students.
``(5) Programs conducted by tribal colleges and
universities.
``(e) Quentin N. Burdick Program Grant.--The Secretary shall
provide 1 of the grants authorized under subsection (a) to establish
and maintain a program at the University of North Dakota to be known as
the `Quentin N. Burdick American Indians Into Nursing Program'. Such
program shall, to the maximum extent feasible, coordinate with the
Quentin N. Burdick Indian Health Programs established under section
117(b) and the Quentin N. Burdick American Indians Into Psychology
Program established under section 105(b).
``(f) Active Duty Service Obligation.--The active duty service
obligation prescribed under section 338C of the Public Health Service
Act (42 U.S.C. 254m) shall be met by each individual who receives
training or assistance described in paragraph (1) or (2) of subsection
(b) that is funded by a grant provided under subsection (a). Such
obligation shall be met by service--
``(1) in the Service;
``(2) in a program of an Indian Tribe or Tribal
Organization conducted under the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.) (including
programs under agreements with the Bureau of Indian Affairs);
``(3) in a program assisted under title V of this Act;
``(4) in the private practice of nursing if, as determined
by the Secretary, in accordance with guidelines promulgated by
the Secretary, such practice is situated in a physician or
other health shortage area and addresses the health care needs
of a substantial number of Indians; or
``(5) in a teaching capacity in a tribal college or
university nursing program (or a related health profession
program) if, as determined by the Secretary, health services
provided to Indians would not decrease.
``SEC. 116. TRIBAL CULTURAL ORIENTATION.
``(a) Cultural Education of Employees.--The Secretary, acting
through the Service, shall require that appropriate employees of the
Service who serve Indian Tribes in each Service Area receive
educational instruction in the history and culture of such Indian
Tribes and their relationship to the Service.
``(b) Program.--In carrying out subsection (a), the Secretary shall
establish a program which shall, to the extent feasible--
``(1) be developed in consultation with the affected Indian
Tribes, Tribal Organizations, and urban Indian organizations;
``(2) be carried out through tribal colleges or
universities;
``(3) include instruction in American Indian studies; and
``(4) describe the use and place of traditional health care
practices of the Indian Tribes in the Service Area.
``SEC. 117. INMED PROGRAM.
``(a) Grants Authorized.--The Secretary, acting through the
Service, is authorized to provide grants to colleges and universities
for the purpose of maintaining and expanding the Indian health careers
recruitment program known as the `Indians Into Medicine Program'
(hereinafter in this section referred to as `INMED') as a means of
encouraging Indians to enter the health professions.
``(b) Quentin N. Burdick Grant.--The Secretary shall provide 1 of
the grants authorized under subsection (a) to maintain the INMED
program at the University of North Dakota, to be known as the `Quentin
N. Burdick Indian Health Programs', unless the Secretary makes a
determination, based upon program reviews, that the program is not
meeting the purposes of this section. Such program shall, to the
maximum extent feasible, coordinate with the Quentin N. Burdick
American Indians Into Psychology Program established under section
105(b) and the Quentin N. Burdick American Indians Into Nursing Program
established under section 115.
``(c) Regulations.--The Secretary, pursuant to this Act, shall
develop regulations to govern grants pursuant to this section.
``(d) Requirements.--Applicants for grants provided under this
section shall agree to provide a program which--
``(1) provides outreach and recruitment for health
professions to Indian communities including elementary and
secondary schools and community colleges located on
reservations which will be served by the program;
``(2) incorporates a program advisory board comprised of
representatives from the Indian Tribes and Indian communities
which will be served by the program;
``(3) provides summer preparatory programs for Indian
students who need enrichment in the subjects of math and
science in order to pursue training in the health professions;
``(4) provides tutoring, counseling, and support to
students who are enrolled in a health career program of study
at the respective college or university; and
``(5) to the maximum extent feasible, employs qualified
Indians in the program.
``SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY COLLEGES.
``(a) Grants To Establish Programs.--
``(1) In general.--The Secretary, acting through the
Service, shall award grants to accredited and accessible
community colleges for the purpose of assisting such community
colleges in the establishment of programs which provide
education in a health profession leading to a degree or diploma
in a health profession for individuals who desire to practice
such profession on or near a reservation or in an Indian Health
Program.
``(2) Amount of grants.--The amount of any grant awarded to
a community college under paragraph (1) for the first year in
which such a grant is provided to the community college shall
not exceed $250,000.
``(b) Grants for Maintenance and Recruiting.--
``(1) In general.--The Secretary, acting through the
Service, shall award grants to accredited and accessible
community colleges that have established a program described in
subsection (a)(1) for the purpose of maintaining the program
and recruiting students for the program.
``(2) Requirements.--Grants may only be made under this
section to a community college which--
``(A) is accredited;
``(B) has a relationship with a hospital facility,
Service facility, or hospital that could provide
training of nurses or health professionals;
``(C) has entered into an agreement with an
accredited college or university medical school, the
terms of which--
``(i) provide a program that enhances the
transition and recruitment of students into
advanced baccalaureate or graduate programs
that train health professionals; and
``(ii) stipulate certifications necessary
to approve internship and field placement
opportunities at Indian Health Programs;
``(D) has a qualified staff which has the
appropriate certifications;
``(E) is capable of obtaining State or regional
accreditation of the program described in subsection
(a)(1); and
``(F) agrees to provide for Indian preference for
applicants for programs under this section.
``(c) Technical Assistance.--The Secretary shall encourage
community colleges described in subsection (b)(2) to establish and
maintain programs described in subsection (a)(1) by--
``(1) entering into agreements with such colleges for the
provision of qualified personnel of the Service to teach
courses of study in such programs; and
``(2) providing technical assistance and support to such
colleges.
``(d) Advanced Training.--
``(1) Required.--Any program receiving assistance under
this section that is conducted with respect to a health
profession shall also offer courses of study which provide
advanced training for any health professional who--
``(A) has already received a degree or diploma in
such health profession; and
``(B) provides clinical services on or near a
reservation or for an Indian Health Program.
``(2) May be offered at alternate site.--Such courses of
study may be offered in conjunction with the college or
university with which the community college has entered into
the agreement required under subsection (b)(2)(C).
``(e) Priority.--Where the requirements of subsection (b) are met,
grant award priority shall be provided to tribal colleges and
universities in Service Areas where they exist.
``SEC. 119. RETENTION BONUS.
``(a) Bonus Authorized.--The Secretary may pay a retention bonus to
any health professional employed by, or assigned to, and serving in, an
Indian Health Program or urban Indian organization either as a civilian
employee or as a commissioned officer in the Regular or Reserve Corps
of the Public Health Service who--
``(1) is assigned to, and serving in, a position for which
recruitment or retention of personnel is difficult;
``(2) the Secretary determines is needed by Indian Health
Programs and urban Indian organizations;
``(3) has--
``(A) completed 2 years of employment with an
Indian Health Program or urban Indian organization; or
``(B) completed any service obligations incurred as
a requirement of--
``(i) any Federal scholarship program; or
``(ii) any Federal education loan repayment
program; and
``(4) enters into an agreement with an Indian Health
Program or urban Indian organization for continued employment
for a period of not less than 1 year.
``(b) Rates.--The Secretary may establish rates for the retention
bonus which shall provide for a higher annual rate for multiyear
agreements than for single year agreements referred to in subsection
(a)(4), but in no event shall the annual rate be more than $25,000 per
annum.
``(c) Default of Retention Agreement.--Any health professional
failing to complete the agreed upon term of service, except where such
failure is through no fault of the individual, shall be obligated to
refund to the Government the full amount of the retention bonus for the
period covered by the agreement, plus interest as determined by the
Secretary in accordance with section 110(l)(2)(B).
``(d) Other Retention Bonus.--The Secretary may pay a retention
bonus to any health professional employed by a Tribal Health Program if
such health professional is serving in a position which the Secretary
determines is--
``(1) a position for which recruitment or retention is
difficult; and
``(2) necessary for providing health care services to
Indians.
``SEC. 120. NURSING RESIDENCY PROGRAM.
``(a) Establishment of Program.--The Secretary, acting through the
Service, shall establish a program to enable Indians who are licensed
practical nurses, licensed vocational nurses, and registered nurses who
are working in an Indian Health Program or urban Indian organization,
and have done so for a period of not less than 1 year, to pursue
advanced training. Such program shall include a combination of
education and work study in an Indian Health Program or urban Indian
organization leading to an associate or bachelor's degree (in the case
of a licensed practical nurse or licensed vocational nurse), a
bachelor's degree (in the case of a registered nurse), or advanced
degrees or certifications in nursing and public health.
``(b) Service Obligation.--An individual who participates in a
program under subsection (a), where the educational costs are paid by
the Service, shall incur an obligation to serve in an Indian Health
Program or urban Indian organization for a period of obligated service
equal to 1 year for every year that nonprofessional employee (licensed
practical nurses, licensed vocational nurses, nursing assistants, and
various health care technicians), or 2 years for every year that
professional nurse (associate degree and bachelor-prepared registered
nurses), participates in such program. In the event that the individual
fails to complete such obligated service, the United States shall be
entitled to recover from such individual an amount determined in
accordance with the formula specified subsection (d)(1) of Section 104
for individuals failing to graduate from their degree program and
subsection (l) of Section 110 for individuals failing to start or
complete the obligated service.
``SEC. 121. COMMUNITY HEALTH AIDE PROGRAM.
``(a) General Purposes of Program.--Under the authority of the Act
of November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder
Act'), the Secretary, acting through the Service, shall develop and
operate a Community Health Aide Program in Alaska under which the
Service--
``(1) provides for the training of Alaska Natives as health
aides or community health practitioners;
``(2) uses such aides or practitioners in the provision of
health care, health promotion, and disease prevention services
to Alaska Natives living in villages in rural Alaska; and
``(3) provides for the establishment of teleconferencing
capacity in health clinics located in or near such villages for
use by community health aides or community health
practitioners.
``(b) Specific Program Requirements.--The Secretary, acting through
the Community Health Aide Program of the Service, shall--
``(1) using trainers accredited by the Program, provide a
high standard of training to community health aides and
community health practitioners to ensure that such aides and
practitioners provide quality health care, health promotion,
and disease prevention services to the villages served by the
Program;
``(2) in order to provide such training, develop a
curriculum that--
``(A) combines education in the theory of health
care with supervised practical experience in the
provision of health care;
``(B) provides instruction and practical experience
in the provision of acute care, emergency care, health
promotion, disease prevention, and the efficient and
effective management of clinic pharmacies, supplies,
equipment, and facilities; and
``(C) promotes the achievement of the health status
objectives specified in section 3(2);
``(3) establish and maintain a Community Health Aide
Certification Board to certify as community health aides or
community health practitioners individuals who have
successfully completed the training described in paragraph (1)
or can demonstrate equivalent experience;
``(4) develop and maintain a system which identifies the
needs of community health aides and community health
practitioners for continuing education in the provision of
health care, including the areas described in paragraph (2)(B),
and develop programs that meet the needs for such continuing
education;
``(5) develop and maintain a system that provides close
supervision of community health aides and community health
practitioners;
``(6) develop a system under which the work of community
health aides and community health practitioners is reviewed and
evaluated to assure the provision of quality health care,
health promotion, and disease prevention services; and
``(7) ensure that pulpal therapy (not including pulpotomies
on deciduous teeth) or extraction of adult teeth can be
performed by a dental health aide therapist only after
consultation with a licensed dentist who determines that the
procedure is a medical emergency that cannot be resolved with
palliative treatment, and further that dental health aide
therapists are strictly prohibited from performing all other
oral or jaw surgeries, provided that uncomplicated extractions
shall not be considered oral surgery under this section.
``(c) Program Review.--
``(1) Neutral panel.--
``(A) Establishment.--The Secretary, acting through
the Service, shall establish a neutral panel to carry
out the study under paragraph (2).
``(B) Membership.--Members of the neutral panel
shall be appointed by the Secretary from among
clinicians, economists, community practitioners, oral
epidemiologists, and Alaska Natives.
``(2) Study.--
``(A) In general.--The neutral panel established
under paragraph (1) shall conduct a study of the dental
health aide therapist services provided by the
Community Health Aide Program under this section to
ensure that the quality of care provided through those
services is adequate and appropriate.
``(B) Parameters of study.--The Secretary, in
consultation with interested parties, including
professional dental organizations, shall develop the
parameters of the study.
``(C) Inclusions.--The study shall include a
determination by the neutral panel with respect to--
``(i) the ability of the dental health aide
therapist services under this section to
address the dental care needs of Alaska
Natives;
``(ii) the quality of care provided through
those services, including any training,
improvement, or additional oversight required
to improve the quality of care; and
``(iii) whether safer and less costly
alternatives to the dental health aide
therapist services exist.
``(D) Consultation.--In carrying out the study
under this paragraph, the neutral panel shall consult
with Alaska Tribal Organizations with respect to the
adequacy and accuracy of the study.
``(3) Report.--The neutral panel shall submit to the
Secretary, the Committee on Indian Affairs of the Senate, and
the Committee on Natural Resources of the House of
Representatives a report describing the results of the study
under paragraph (2), including a description of--
``(A) any determination of the neutral panel under
paragraph (2)(C); and
``(B) any comments received from an Alaska Tribal
Organization under paragraph (2)(D).
``(d) Nationalization of Program.--
``(1) In general.--Except as provided in paragraph (2), the
Secretary, acting through the Service, may establish a national
Community Health Aide Program in accordance with the program
under this section, as the Secretary determines to be
appropriate.
``(2) Exception.--The national Community Health Aide
Program under paragraph (1) shall not include dental health
aide therapist services.
``(3) Requirement.--In establishing a national program
under paragraph (1), the Secretary shall not reduce the amount
of funds provided for the Community Health Aide Program
described in subsections (a) and (b).
``SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION.
``The Secretary shall, by contract or otherwise, provide training
for individuals in the administration and planning of Tribal Health
Programs, with priority to Indians.
``SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE DEMONSTRATION
PROGRAMS.
``(a) Demonstration Programs Authorized.--The Secretary, acting
through the Service, may fund demonstration programs for Tribal Health
Programs to address the chronic shortages of health professionals.
``(b) Purposes of Programs.--The purposes of demonstration programs
funded under subsection (a) shall be--
``(1) to provide direct clinical and practical experience
at a Service Unit to health profession students and residents
from medical schools;
``(2) to improve the quality of health care for Indians by
assuring access to qualified health care professionals; and
``(3) to provide academic and scholarly opportunities for
health professionals serving Indians by identifying all
academic and scholarly resources of the region.
``(c) Advisory Board.--The demonstration programs established
pursuant to subsection (a) shall incorporate a program advisory board
composed of representatives from the Indian Tribes and Indian
communities in the area which will be served by the program.
``SEC. 124. NATIONAL HEALTH SERVICE CORPS.
``(a) No Reduction in Services.--The Secretary shall not--
``(1) remove a member of the National Health Service Corps
from an Indian Health Program or urban Indian organization; or
``(2) withdraw funding used to support such member, unless
the Secretary, acting through the Service, has ensured that the
Indians receiving services from such member will experience no
reduction in services.
``(b) Treatment of Indian Health Programs.--At the request of an
Indian Health Program, the services of a member of the National Health
Service Corps assigned to an Indian Health Program may be limited to
the persons who are eligible for services from such Program.
``SEC. 125. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL CURRICULA
DEMONSTRATION PROGRAMS.
``(a) Contracts and Grants.--The Secretary, acting through the
Service, may enter into contracts with, or make grants to, accredited
tribal colleges and universities and eligible accredited and accessible
community colleges to establish demonstration programs to develop
educational curricula for substance abuse counseling.
``(b) Use of Funds.--Funds provided under this section shall be
used only for developing and providing educational curriculum for
substance abuse counseling (including paying salaries for instructors).
Such curricula may be provided through satellite campus programs.
``(c) Time Period of Assistance; Renewal.--A contract entered into
or a grant provided under this section shall be for a period of 3
years. Such contract or grant may be renewed for an additional 2-year
period upon the approval of the Secretary.
``(d) Criteria for Review and Approval of Applications.--Not later
than 180 days after the date of enactment of the Indian Health Care
Improvement Act Amendments of 2009, the Secretary, after consultation
with Indian Tribes and administrators of tribal colleges and
universities and eligible accredited and accessible community colleges,
shall develop and issue criteria for the review and approval of
applications for funding (including applications for renewals of
funding) under this section. Such criteria shall ensure that
demonstration programs established under this section promote the
development of the capacity of such entities to educate substance abuse
counselors.
``(e) Assistance.--The Secretary shall provide such technical and
other assistance as may be necessary to enable grant recipients to
comply with the provisions of this section.
``(f) Report.--Each fiscal year, the Secretary shall submit to the
President, for inclusion in the report which is required to be
submitted under section 801 for that fiscal year, a report on the
findings and conclusions derived from the demonstration programs
conducted under this section during that fiscal year.
``(g) Definition.--For the purposes of this section, the term
`educational curriculum' means 1 or more of the following:
``(1) Classroom education.
``(2) Clinical work experience.
``(3) Continuing education workshops.
``SEC. 126. BEHAVIORAL HEALTH TRAINING AND COMMUNITY EDUCATION
PROGRAMS.
``(a) Study; List.--The Secretary, acting through the Service, and
the Secretary of the Interior, in consultation with Indian Tribes and
Tribal Organizations, shall conduct a study and compile a list of the
types of staff positions specified in subsection (b) whose
qualifications include, or should include, training in the
identification, prevention, education, referral, or treatment of mental
illness, or dysfunctional and self-destructive behavior.
``(b) Positions.--The positions referred to in subsection (a) are--
``(1) staff positions within the Bureau of Indian Affairs,
including existing positions, in the fields of--
``(A) elementary and secondary education;
``(B) social services and family and child welfare;
``(C) law enforcement and judicial services; and
``(D) alcohol and substance abuse;
``(2) staff positions within the Service; and
``(3) staff positions similar to those identified in
paragraphs (1) and (2) established and maintained by Indian
Tribes, Tribal Organizations (without regard to the funding
source), and urban Indian organizations.
``(c) Training Criteria.--
``(1) In general.--The appropriate Secretary shall provide
training criteria appropriate to each type of position
identified in subsection (b)(1) and (b)(2) and ensure that
appropriate training has been, or shall be provided to any
individual in any such position. With respect to any such
individual in a position identified pursuant to subsection
(b)(3), the respective Secretaries shall provide appropriate
training to, or provide funds to, an Indian Tribe, Tribal
Organization, or urban Indian organization for training of
appropriate individuals. In the case of positions funded under
a contract or compact under the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.), the
appropriate Secretary shall ensure that such training costs are
included in the contract or compact, as the Secretary
determines necessary.
``(2) Position specific training criteria.--Position
specific training criteria shall be culturally relevant to
Indians and Indian Tribes and shall ensure that appropriate
information regarding traditional health care practices is
provided.
``(d) Community Education on Mental Illness.--The Service shall
develop and implement, on request of an Indian Tribe, Tribal
Organization, or urban Indian organization, or assist the Indian Tribe,
Tribal Organization, or urban Indian organization to develop and
implement, a program of community education on mental illness. In
carrying out this subsection, the Service shall, upon request of an
Indian Tribe, Tribal Organization, or urban Indian organization,
provide technical assistance to the Indian Tribe, Tribal Organization,
or urban Indian organization to obtain and develop community
educational materials on the identification, prevention, referral, and
treatment of mental illness and dysfunctional and self-destructive
behavior.
``(e) Plan.--Not later than 90 days after the date of enactment of
the Indian Health Care Improvement Act Amendments of 2009, the
Secretary shall develop a plan under which the Service will increase
the health care staff providing behavioral health services by at least
500 positions within 5 years after the date of enactment of this
section, with at least 200 of such positions devoted to child,
adolescent, and family services. The plan developed under this
subsection shall be implemented under the Act of November 2, 1921 (25
U.S.C. 13) (commonly known as the `Snyder Act').
``SEC. 127. EXEMPTION FROM PAYMENT OF CERTAIN FEES.
``Employees of a Tribal Health Program or an Urban Indian
Organization shall be exempt from payment of licensing, registration,
and other fees imposed by a Federal agency to the same extent that
Commissioned Corps Officers or other employees of the Indian Health
Service are exempt from such fees.
``SEC. 128. AUTHORIZATION OF APPROPRIATIONS.
``There are authorized to be appropriated such sums as may be
necessary to carry out this title.
``TITLE II--HEALTH SERVICES
``SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND.
``(a) Use of Funds.--The Secretary, acting through the Service, is
authorized to expend funds, directly or under the authority of the
Indian Self-Determination and Education Assistance Act (25 U.S.C. 450
et seq.), which are appropriated under the authority of this section,
for the purposes of--
``(1) eliminating the deficiencies in health status and
health resources of all Indian Tribes;
``(2) eliminating backlogs in the provision of health care
services to Indians;
``(3) meeting the health needs of Indians in an efficient
and equitable manner, including the use of telehealth and
telemedicine when appropriate;
``(4) eliminating inequities in funding for both direct
care and contract health service programs; and
``(5) augmenting the ability of the Service to meet the
following health service responsibilities with respect to those
Indian Tribes with the highest levels of health status
deficiencies and resource deficiencies:
``(A) Clinical care, including inpatient care,
outpatient care (including audiology, clinical eye, and
vision care), primary care, secondary and tertiary
care, and long-term care.
``(B) Preventive health, including mammography and
other cancer screening in accordance with section 207.
``(C) Dental care.
``(D) Mental health, including community mental
health services, inpatient mental health services,
dormitory mental health services, therapeutic and
residential treatment centers, and training of
traditional health care practitioners.
``(E) Emergency medical services.
``(F) Treatment and control of, and rehabilitative
care related to, alcoholism and drug abuse (including
fetal alcohol syndrome) among Indians.
``(G) Injury prevention programs, including data
collection and evaluation, demonstration projects,
training, and capacity building.
``(H) Home health care.
``(I) Community health representatives.
``(J) Maintenance and improvement.
``(b) No Offset or Limitation.--Any funds appropriated under the
authority of this section shall not be used to offset or limit any
other appropriations made to the Service under this Act or the Act of
November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'),
or any other provision of law.
``(c) Allocation; Use.--
``(1) In general.--Funds appropriated under the authority
of this section shall be allocated to Service Units, Indian
Tribes, or Tribal Organizations. The funds allocated to each
Indian Tribe, Tribal Organization, or Service Unit under this
paragraph shall be used by the Indian Tribe, Tribal
Organization, or Service Unit under this paragraph to improve
the health status and reduce the resource deficiency of each
Indian Tribe served by such Service Unit, Indian Tribe, or
Tribal Organization.
``(2) Apportionment of allocated funds.--The apportionment
of funds allocated to a Service Unit, Indian Tribe, or Tribal
Organization under paragraph (1) among the health service
responsibilities described in subsection (a)(5) shall be
determined by the Service in consultation with, and with the
active participation of, the affected Indian Tribes and Tribal
Organizations.
``(d) Provisions Relating to Health Status and Resource
Deficiencies.--For the purposes of this section, the following
definitions apply:
``(1) Definition.--The term `health status and resource
deficiency' means the extent to which--
``(A) the health status objectives set forth in
section 3(2) are not being achieved; and
``(B) the Indian Tribe or Tribal Organization does
not have available to it the health resources it needs,
taking into account the actual cost of providing health
care services given local geographic, climatic, rural,
or other circumstances.
``(2) Available resources.--The health resources available
to an Indian Tribe or Tribal Organization include health
resources provided by the Service as well as health resources
used by the Indian Tribe or Tribal Organization, including
services and financing systems provided by any Federal
programs, private insurance, and programs of State or local
governments.
``(3) Process for review of determinations.--The Secretary
shall establish procedures which allow any Indian Tribe or
Tribal Organization to petition the Secretary for a review of
any determination of the extent of the health status and
resource deficiency of such Indian Tribe or Tribal
Organization.
``(e) Eligibility for Funds.--Tribal Health Programs shall be
eligible for funds appropriated under the authority of this section on
an equal basis with programs that are administered directly by the
Service.
``(f) Report.--By no later than the date that is 3 years after the
date of enactment of the Indian Health Care Improvement Act Amendments
of 2009, the Secretary shall submit to Congress the current health
status and resource deficiency report of the Service for each Service
Unit, including newly recognized or acknowledged Indian Tribes. Such
report shall set out--
``(1) the methodology then in use by the Service for
determining Tribal health status and resource deficiencies, as
well as the most recent application of that methodology;
``(2) the extent of the health status and resource
deficiency of each Indian Tribe served by the Service or a
Tribal Health Program;
``(3) the amount of funds necessary to eliminate the health
status and resource deficiencies of all Indian Tribes served by
the Service or a Tribal Health Program; and
``(4) an estimate of--
``(A) the amount of health service funds
appropriated under the authority of this Act, or any
other Act, including the amount of any funds
transferred to the Service for the preceding fiscal
year which is allocated to each Service Unit, Indian
Tribe, or Tribal Organization;
``(B) the number of Indians eligible for health
services in each Service Unit or Indian Tribe or Tribal
Organization; and
``(C) the number of Indians using the Service
resources made available to each Service Unit, Indian
Tribe or Tribal Organization, and, to the extent
available, information on the waiting lists and number
of Indians turned away for services due to lack of
resources.
``(g) Inclusion in Base Budget.--Funds appropriated under this
section for any fiscal year shall be included in the base budget of the
Service for the purpose of determining appropriations under this
section in subsequent fiscal years.
``(h) Clarification.--Nothing in this section is intended to
diminish the primary responsibility of the Service to eliminate
existing backlogs in unmet health care needs, nor are the provisions of
this section intended to discourage the Service from undertaking
additional efforts to achieve equity among Indian Tribes and Tribal
Organizations.
``(i) Funding Designation.--Any funds appropriated under the
authority of this section shall be designated as the `Indian Health
Care Improvement Fund'.
``SEC. 202. HEALTH PROMOTION AND DISEASE PREVENTION SERVICES.
``(a) Findings.--Congress finds that health promotion and disease
prevention activities--
``(1) improve the health and well-being of Indians; and
``(2) reduce the expenses for health care of Indians.
``(b) Provision of Services.--The Secretary, acting through the
Service, shall provide health promotion and disease prevention services
to Indians to achieve the health status objectives set forth in section
3(2).
``(c) Evaluation.--The Secretary, after obtaining input from the
affected Tribal Health Programs, shall submit to the President for
inclusion in the report which is required to be submitted to Congress
under section 801 an evaluation of--
``(1) the health promotion and disease prevention needs of
Indians;
``(2) the health promotion and disease prevention
activities which would best meet such needs;
``(3) the internal capacity of the Service and Tribal
Health Programs to meet such needs; and
``(4) the resources which would be required to enable the
Service and Tribal Health Programs to undertake the health
promotion and disease prevention activities necessary to meet
such needs.
``SEC. 203. DIABETES PREVENTION, TREATMENT, AND CONTROL.
``(a) Determinations Regarding Diabetes.--The Secretary, acting
through the Service, and in consultation with Indian Tribes and Tribal
Organizations, shall determine--
``(1) by Indian Tribe and by Service Unit, the incidence
of, and the types of complications resulting from, diabetes
among Indians; and
``(2) based on the determinations made pursuant to
paragraph (1), the measures (including patient education and
effective ongoing monitoring of disease indicators) each
Service Unit should take to reduce the incidence of, and
prevent, treat, and control the complications resulting from,
diabetes among Indian Tribes within that Service Unit.
``(b) Diabetes Screening.--To the extent medically indicated and
with informed consent, the Secretary shall screen each Indian who
receives services from the Service for diabetes and for conditions
which indicate a high risk that the individual will become diabetic and
establish a cost-effective approach to ensure ongoing monitoring of
disease indicators. Such screening and monitoring may be conducted by a
Tribal Health Program and may be conducted through appropriate
Internet-based health care management programs.
``(c) Diabetes Projects.--The Secretary shall continue to maintain
each model diabetes project in existence on the date of enactment of
the Indian Health Care Improvement Act Amendments of 2009.
``(d) Dialysis Programs.--The Secretary is authorized to provide,
through the Service, Indian Tribes, and Tribal Organizations, dialysis
programs, including the purchase of dialysis equipment and the
provision of necessary staffing.
``(e) Other Duties of the Secretary.--
``(1) In general.--The Secretary shall, to the extent
funding is available--
``(A) in each Area Office, consult with Indian
Tribes and Tribal Organizations regarding programs for
the prevention, treatment, and control of diabetes;
``(B) establish in each Area Office a registry of
patients with diabetes to track the incidence of
diabetes and the complications from diabetes in that
area; and
``(C) ensure that data collected in each Area
Office regarding diabetes and related complications
among Indians are disseminated to all other Area
Offices, subject to applicable patient privacy laws.
``(2) Diabetes control officers.--
``(A) In general.--The Secretary may establish and
maintain in each Area Office a position of diabetes
control officer to coordinate and manage any activity
of that Area Office relating to the prevention,
treatment, or control of diabetes to assist the
Secretary in carrying out a program under this section
or section 330C of the Public Health Service Act (42
U.S.C. 254c-3).
``(B) Certain activities.--Any activity carried out
by a diabetes control officer under subparagraph (A)
that is the subject of a contract or compact under the
Indian Self-Determination and Education Assistance Act
(25 U.S.C. 450 et seq.), and any funds made available
to carry out such an activity, shall not be divisible
for purposes of that Act.
``SEC. 204. SHARED SERVICES FOR LONG-TERM CARE.
``(a) Long-term Care.--Notwithstanding any other provision of law,
the Secretary, acting through the Service, is authorized to provide
directly, or enter into contracts or compacts under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et seq.) with
Indian Tribes or Tribal Organizations for, the delivery of long-term
care (including health care services associated with long-term care)
provided in a facility to Indians. Such agreements shall provide for
the sharing of staff or other services between the Service or a Tribal
Health Program and a long-term care or related facility owned and
operated (directly or through a contract or compact under the Indian
Self-Determination and Education Assistance Act (25 U.S.C. 450 et
seq.)) by such Indian Tribe or Tribal Organization.
``(b) Contents of Agreements.--An agreement entered into pursuant
to subsection (a)--
``(1) may, at the request of the Indian Tribe or Tribal
Organization, delegate to such Indian Tribe or Tribal
Organization such powers of supervision and control over
Service employees as the Secretary deems necessary to carry out
the purposes of this section;
``(2) shall provide that expenses (including salaries)
relating to services that are shared between the Service and
the Tribal Health Program be allocated proportionately between
the Service and the Indian Tribe or Tribal Organization; and
``(3) may authorize such Indian Tribe or Tribal
Organization to construct, renovate, or expand a long-term care
or other similar facility (including the construction of a
facility attached to a Service facility).
``(c) Minimum Requirement.--Any nursing facility provided for under
this section shall meet the requirements for nursing facilities under
section 1919 of the Social Security Act.
``(d) Other Assistance.--The Secretary shall provide such technical
and other assistance as may be necessary to enable applicants to comply
with the provisions of this section.
``(e) Use of Existing or Underused Facilities.--The Secretary shall
encourage the use of existing facilities that are underused or allow
the use of swing beds for long-term or similar care.
``SEC. 205. HEALTH SERVICES RESEARCH.
``(a) In General.--The Secretary, acting through the Service, shall
make funding available for research to further the performance of the
health service responsibilities of Indian Health Programs.
``(b) Coordination of Resources and Activities.--The Secretary
shall also, to the maximum extent practicable, coordinate departmental
research resources and activities to address relevant Indian Health
Program research needs.
``(c) Availability.--Tribal Health Programs shall be given an equal
opportunity to compete for, and receive, research funds under this
section.
``(d) Use of Funds.--This funding may be used for both clinical and
nonclinical research.
``(e) Evaluation and Dissemination.--The Secretary shall
periodically--
``(1) evaluate the impact of research conducted under this
section; and
``(2) disseminate to Tribal Health Programs information
regarding that research as the Secretary determines to be
appropriate.
``SEC. 206. MAMMOGRAPHY AND OTHER CANCER SCREENING.
``The Secretary, acting through the Service, shall provide for
screening as follows:
``(1) Screening mammography (as defined in section 1861(jj)
of the Social Security Act) for Indian women at a frequency
appropriate to such women under accepted and appropriate
national standards, and under such terms and conditions as are
consistent with standards established by the Secretary to
ensure the safety and accuracy of screening mammography under
part B of title XVIII of such Act.
``(2) Other cancer screening that receives an A or B rating
as recommended by the United States Preventive Services Task
Force established under section 915(a)(1) of the Public Health
Service Act (42 U.S.C. 299b-4(a)(1)). The Secretary shall
ensure that screening provided for under this paragraph
complies with the recommendations of the Task Force with
respect to--
``(A) frequency;
``(B) the population to be served;
``(C) the procedure or technology to be used;
``(D) evidence of effectiveness; and
``(E) other matters that the Secretary determines
appropriate.
``SEC. 207. PATIENT TRAVEL COSTS.
``(a) Definition of Qualified Escort.--In this section, the term
`qualified escort' means--
``(1) an adult escort (including a parent, guardian, or
other family member) who is required because of the physical or
mental condition, or age, of the applicable patient;
``(2) a health professional for the purpose of providing
necessary medical care during travel by the applicable patient;
or
``(3) other escorts, as the Secretary or applicable Indian
Health Program determines to be appropriate.
``(b) Provision of Funds.--The Secretary, acting through the
Service, is authorized to provide funds for the following patient
travel costs, including qualified escorts, associated with receiving
health care services provided (either through direct or contract care
or through a contract or compact under the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.)) under this Act--
``(1) emergency air transportation and non-emergency air
transportation where ground transportation is infeasible;
``(2) transportation by private vehicle (where no other
means of transportation is available), specially equipped
vehicle, and ambulance; and
``(3) transportation by such other means as may be
available and required when air or motor vehicle transportation
is not available.
``SEC. 208. EPIDEMIOLOGY CENTERS.
``(a) Establishment of Centers.--The Secretary shall establish an
epidemiology center in each Service Area to carry out the functions
described in subsection (b). Any new center established after the date
of enactment of the Indian Health Care Improvement Act Amendments of
2008 may be operated under a grant authorized by subsection (d), but
funding under such a grant shall not be divisible.
``(b) Functions of Centers.--In consultation with and upon the
request of Indian Tribes, Tribal Organizations, and Urban Indian
communities, each Service Area epidemiology center established under
this section shall, with respect to such Service Area--
``(1) collect data relating to, and monitor progress made
toward meeting, each of the health status objectives of the
Service, the Indian Tribes, Tribal Organizations, and Urban
Indian communities in the Service Area;
``(2) evaluate existing delivery systems, data systems, and
other systems that impact the improvement of Indian health;
``(3) assist Indian Tribes, Tribal Organizations, and Urban
Indian Organizations in identifying their highest priority
health status objectives and the services needed to achieve
such objectives, based on epidemiological data;
``(4) make recommendations for the targeting of services
needed by the populations served;
``(5) make recommendations to improve health care delivery
systems for Indians and Urban Indians;
``(6) provide requested technical assistance to Indian
Tribes, Tribal Organizations, and Urban Indian Organizations in
the development of local health service priorities and
incidence and prevalence rates of disease and other illness in
the community; and
``(7) provide disease surveillance and assist Indian
Tribes, Tribal Organizations, and Urban Indian communities to
promote public health.
``(c) Technical Assistance.--The Director of the Centers for
Disease Control and Prevention shall provide technical assistance to
the centers in carrying out the requirements of this section.
``(d) Grants for Studies.--
``(1) In general.--The Secretary may make grants to Indian
Tribes, Tribal Organizations, Indian organizations, and
eligible intertribal consortia to conduct epidemiological
studies of Indian communities.
``(2) Eligible intertribal consortia.--An intertribal
consortium or Indian organization is eligible to receive a
grant under this subsection if--
``(A) the intertribal consortium is incorporated
for the primary purpose of improving Indian health; and
``(B) the intertribal consortium is representative
of the Indian Tribes or urban Indian communities in
which the intertribal consortium is located.
``(3) Applications.--An application for a grant under this
subsection shall be submitted in such manner and at such time
as the Secretary shall prescribe.
``(4) Requirements.--An applicant for a grant under this
subsection shall--
``(A) demonstrate the technical, administrative,
and financial expertise necessary to carry out the
functions described in paragraph (5);
``(B) consult and cooperate with providers of
related health and social services in order to avoid
duplication of existing services; and
``(C) demonstrate cooperation from Indian Tribes or
Urban Indian Organizations in the area to be served.
``(5) Use of funds.--A grant awarded under paragraph (1)
may be used--
``(A) to carry out the functions described in
subsection (b);
``(B) to provide information to and consult with
tribal leaders, urban Indian community leaders, and
related health staff on health care and health service
management issues; and
``(C) in collaboration with Indian Tribes, Tribal
Organizations, and urban Indian communities, to provide
the Service with information regarding ways to improve
the health status of Indians.
``(e) Access to Information.--
``(1) An epidemiology center operated by a grantee pursuant
to a grant awarded under subsection (d) shall be treated as a
public health authority for purposes of the Health Insurance
Portability and Accountability Act of 1996, as such entities
are defined in part 164.501 of title 45, Code of Federal
Regulations.
``(2) The Secretary shall grant to such epidemiology center
access to use of the data, data sets, monitoring systems,
delivery systems, and other protected health information in the
possession of the Secretary.
``(3) The activities of such an epidemiology center shall
be for the purposes of research and for preventing and
controlling disease, injury, or disability for purposes of the
Health Insurance Portability and Accountability Act of 1996
(Public Law 104-191; 110 Stat. 2033), as such activities are
described in part 164.512 of title 45, Code of Federal
Regulations (or a successor regulation).
``(f) Funds Not Divisible.--An epidemiology center established
under this section shall be subject to the provisions of the Indian
Self-Determination and Education Assistance Act (25 U.S.C. 450 et
seq.), but the funds for such center shall not be divisible.
``SEC. 209. COMPREHENSIVE SCHOOL HEALTH EDUCATION PROGRAMS.
``(a) Funding for Development of Programs.--In addition to carrying
out any other program for health promotion or disease prevention, the
Secretary, acting through the Service, is authorized to award grants to
Indian Tribes and Tribal Organizations to develop comprehensive school
health education programs for children from pre-school through grade 12
in schools for the benefit of Indian children.
``(b) Use of Grant Funds.--A grant awarded under this section may
be used for purposes which may include, but are not limited to, the
following:
``(1) Developing health education materials both for
regular school programs and afterschool programs.
``(2) Training teachers in comprehensive school health
education materials.
``(3) Integrating school-based, community-based, and other
public and private health promotion efforts.
``(4) Encouraging healthy, tobacco-free school
environments.
``(5) Coordinating school-based health programs with
existing services and programs available in the community.
``(6) Developing school programs on nutrition education,
personal health, oral health, and fitness.
``(7) Developing behavioral health wellness programs.
``(8) Developing chronic disease prevention programs.
``(9) Developing substance abuse prevention programs.
``(10) Developing injury prevention and safety education
programs.
``(11) Developing activities for the prevention and control
of communicable diseases.
``(12) Developing community and environmental health
education programs that include traditional health care
practitioners.
``(13) Violence prevention.
``(14) Such other health issues as are appropriate.
``(c) Technical Assistance.--Upon request, the Secretary, acting
through the Service, shall provide technical assistance to Indian
Tribes and Tribal Organizations in the development of comprehensive
health education plans and the dissemination of comprehensive health
education materials and information on existing health programs and
resources.
``(d) Criteria for Review and Approval of Applications.--The
Secretary, acting through the Service, and in consultation with Indian
Tribes and Tribal Organizations, shall establish criteria for the
review and approval of applications for grants awarded under this
section.
``(e) Development of Program for BIA-funded Schools.--
``(1) In general.--The Secretary of the Interior, acting
through the Bureau of Indian Affairs and in cooperation with
the Secretary, acting through the Service, shall develop a
comprehensive school health education program for children from
preschool through grade 12 in schools for which support is
provided by the Bureau of Indian Affairs.
``(2) Requirements for programs.--Such programs shall
include--
``(A) school programs on nutrition education,
personal health, oral health, and fitness;
``(B) behavioral health wellness programs;
``(C) chronic disease prevention programs;
``(D) substance abuse prevention programs;
``(E) injury prevention and safety education
programs; and
``(F) activities for the prevention and control of
communicable diseases.
``(3) Duties of the secretary.--The Secretary of the
Interior shall--
``(A) provide training to teachers in comprehensive
school health education materials;
``(B) ensure the integration and coordination of
school-based programs with existing services and health
programs available in the community; and
``(C) encourage healthy, tobacco-free school
environments.
``SEC. 210. INDIAN YOUTH PROGRAM.
``(a) Program Authorized.--The Secretary, acting through the
Service, is authorized to establish and administer a program to provide
grants to Indian Tribes, Tribal Organizations, and urban Indian
organizations for innovative mental and physical disease prevention and
health promotion and treatment programs for Indian and urban Indian
preadolescent and adolescent youths.
``(b) Use of Funds.--
``(1) Allowable uses.--Funds made available under this
section may be used to--
``(A) develop prevention and treatment programs for
Indian youth which promote mental and physical health
and incorporate cultural values, community and family
involvement, and traditional health care practitioners;
and
``(B) develop and provide community training and
education.
``(2) Prohibited use.--Funds made available under this
section may not be used to provide services described in
section 707(c).
``(c) Duties of the Secretary.--The Secretary shall--
``(1) disseminate to Indian Tribes, Tribal Organizations,
and urban Indian organizations information regarding models for
the delivery of comprehensive health care services to Indian
and urban Indian adolescents;
``(2) encourage the implementation of such models; and
``(3) at the request of an Indian Tribe, Tribal
Organization, or urban Indian organization, provide technical
assistance in the implementation of such models.
``(d) Criteria for Review and Approval of Applications.--The
Secretary, in consultation with Indian Tribes, Tribal Organizations,
and urban Indian organizations, shall establish criteria for the review
and approval of applications or proposals under this section.
``SEC. 211. PREVENTION, CONTROL, AND ELIMINATION OF COMMUNICABLE AND
INFECTIOUS DISEASES.
``(a) Grants Authorized.--The Secretary, acting through the
Service, and after consultation with the Centers for Disease Control
and Prevention, may make grants available to Indian Tribes, Tribal
Organizations, and urban Indian organizations for the following:
``(1) Projects for the prevention, control, and elimination
of communicable and infectious diseases, including
tuberculosis, hepatitis, HIV, respiratory syncytial virus,
hanta virus, sexually transmitted diseases, and H. Pylori.
``(2) Public information and education programs for the
prevention, control, and elimination of communicable and
infectious diseases.
``(3) Education, training, and clinical skills improvement
activities in the prevention, control, and elimination of
communicable and infectious diseases for health professionals,
including allied health professionals.
``(4) Demonstration projects for the screening, treatment,
and prevention of hepatitis C virus (HCV).
``(b) Application Required.--The Secretary may provide funding
under subsection (a) only if an application or proposal for funding is
submitted to the Secretary.
``(c) Coordination With Health Agencies.--Indian Tribes, Tribal
Organizations, and urban Indian organizations receiving funding under
this section are encouraged to coordinate their activities with the
Centers for Disease Control and Prevention and State and local health
agencies.
``(d) Technical Assistance; Report.--In carrying out this section,
the Secretary--
``(1) may, at the request of an Indian Tribe, Tribal
Organization, or urban Indian organization, provide technical
assistance; and
``(2) shall prepare and submit a report to Congress
biennially on the use of funds under this section and on the
progress made toward the prevention, control, and elimination
of communicable and infectious diseases among Indians and Urban
Indians.
``SEC. 212. OTHER AUTHORITY FOR PROVISION OF SERVICES.
``(a) Funding Authorized.--The Secretary may provide funding under
this Act to meet the objectives set forth in section 3 of this Act
through health care-related services and programs of the Service,
Indian Tribes, and Tribal Organizations not otherwise described in this
Act for the following services:
``(1) Hospice care.
``(2) Assisted living services.
``(3) Long-term care services.
``(4) Home- and community-based services.
``(b) Eligibility.--The following individuals shall be eligible to
receive long-term care under this section:
``(1) Individuals who are unable to perform a certain
number of activities of daily living without assistance.
``(2) Individuals with a mental impairment, such as
dementia, Alzheimer's disease, or another disabling mental
illness, who may be able to perform activities of daily living
under supervision.
``(3) Such other individuals as an applicable Indian Health
Program determines to be appropriate.
``(c) Definitions.--For the purposes of this section, the following
definitions shall apply:
``(1) The term `assisted living services' means any service
provided by an assisted living facility (as defined in section
232(b) of the National Housing Act (12 U.S.C. 1715w(b))),
except that such an assisted living facility--
``(A) shall not be required to obtain a license;
but
``(B) shall meet all applicable standards for
licensure.
``(2) The term `home- and community-based services' means 1
or more of the services specified in paragraphs (1) through (9)
of section 1929(a) of the Social Security Act (42 U.S.C.
1396t(a)) (whether provided by the Service or by an Indian
Tribe or Tribal Organization pursuant to the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.)) that are or will be provided in accordance with
applicable standards.
``(3) The term `hospice care' means the items and services
specified in subparagraphs (A) through (H) of section
1861(dd)(1) of the Social Security Act (42 U.S.C.
1395x(dd)(1)), and such other services which an Indian Tribe or
Tribal Organization determines are necessary and appropriate to
provide in furtherance of this care.
``(4) The term `long-term care services' has the meaning
given the term `qualified long-term care services' in section
7702B(c) of the Internal Revenue Code of 1986.
``(d) Authorization of Convenient Care Services.--The Secretary,
acting through the Service, Indian Tribes, and Tribal Organizations,
may also provide funding under this Act to meet the objectives set
forth in section 3 of this Act for convenient care services programs
pursuant to section 306(c)(2)(A).
``SEC. 213. INDIAN WOMEN'S HEALTH CARE.
``The Secretary, acting through the Service and Indian Tribes,
Tribal Organizations, and Urban Indian Organizations, shall monitor and
improve the quality of health care for Indian women of all ages through
the planning and delivery of programs administered by the Service, in
order to improve and enhance the treatment models of care for Indian
women.
``SEC. 214. ENVIRONMENTAL AND NUCLEAR HEALTH HAZARDS.
``(a) Studies and Monitoring.--The Secretary and the Service shall
conduct, in conjunction with other appropriate Federal agencies and in
consultation with concerned Indian Tribes and Tribal Organizations,
studies and ongoing monitoring programs to determine trends in the
health hazards to Indian miners and to Indians on or near reservations
and Indian communities as a result of environmental hazards which may
result in chronic or life threatening health problems, such as nuclear
resource development, petroleum contamination, and contamination of
water source and of the food chain. Such studies shall include--
``(1) an evaluation of the nature and extent of health
problems caused by environmental hazards currently exhibited
among Indians and the causes of such health problems;
``(2) an analysis of the potential effect of ongoing and
future environmental resource development on or near
reservations and Indian communities, including the cumulative
effect over time on health;
``(3) an evaluation of the types and nature of activities,
practices, and conditions causing or affecting such health
problems, including uranium mining and milling, uranium mine
tailing deposits, nuclear power plant operation and
construction, and nuclear waste disposal; oil and gas
production or transportation on or near reservations or Indian
communities; and other development that could affect the health
of Indians and their water supply and food chain;
``(4) a summary of any findings and recommendations
provided in Federal and State studies, reports, investigations,
and inspections during the 5 years prior to the date of
enactment of the Indian Health Care Improvement Act Amendments
of 2009 that directly or indirectly relate to the activities,
practices, and conditions affecting the health or safety of
such Indians; and
``(5) the efforts that have been made by Federal and State
agencies and resource and economic development companies to
effectively carry out an education program for such Indians
regarding the health and safety hazards of such development.
``(b) Health Care Plans.--Upon completion of such studies, the
Secretary and the Service shall take into account the results of such
studies and develop health care plans to address the health problems
studied under subsection (a). The plans shall include--
``(1) methods for diagnosing and treating Indians currently
exhibiting such health problems;
``(2) preventive care and testing for Indians who may be
exposed to such health hazards, including the monitoring of the
health of individuals who have or may have been exposed to
excessive amounts of radiation or affected by other activities
that have had or could have a serious impact upon the health of
such individuals; and
``(3) a program of education for Indians who, by reason of
their work or geographic proximity to such nuclear or other
development activities, may experience health problems.
``(c) Submission of Report and Plan to Congress.--The Secretary and
the Service shall submit to Congress the study prepared under
subsection (a) no later than 18 months after the date of enactment of
the Indian Health Care Improvement Act Amendments of 2009. The health
care plan prepared under subsection (b) shall be submitted in a report
no later than 1 year after the study prepared under subsection (a) is
submitted to Congress. Such report shall include recommended activities
for the implementation of the plan, as well as an evaluation of any
activities previously undertaken by the Service to address such health
problems.
``(d) Intergovernmental Task Force.--
``(1) Establishment; members.--There is established an
Intergovernmental Task Force to be composed of the following
individuals (or their designees):
``(A) The Secretary of Energy.
``(B) The Secretary of the Environmental Protection
Agency.
``(C) The Director of the Bureau of Mines.
``(D) The Assistant Secretary for Occupational
Safety and Health.
``(E) The Secretary of the Interior.
``(F) The Secretary of Health and Human Services.
``(G) The Director of the Indian Health Service.
``(2) Duties.--The Task Force shall--
``(A) identify existing and potential operations
related to nuclear resource development or other
environmental hazards that affect or may affect the
health of Indians on or near a reservation or in an
Indian community; and
``(B) enter into activities to correct existing
health hazards and ensure that current and future
health problems resulting from nuclear resource or
other development activities are minimized or reduced.
``(3) Chairman; meetings.--The Secretary of Health and
Human Services shall be the Chairman of the Task Force. The
Task Force shall meet at least twice each year.
``(e) Health Services to Certain Employees.--In the case of any
Indian who--
``(1) as a result of employment in or near a uranium mine
or mill or near any other environmental hazard, suffers from a
work-related illness or condition;
``(2) is eligible to receive diagnosis and treatment
services from an Indian Health Program; and
``(3) by reason of such Indian's employment, is entitled to
medical care at the expense of such mine or mill operator or
entity responsible for the environmental hazard, the Indian
Health Program shall, at the request of such Indian, render
appropriate medical care to such Indian for such illness or
condition and may be reimbursed for any medical care so
rendered to which such Indian is entitled at the expense of
such operator or entity from such operator or entity. Nothing
in this subsection shall affect the rights of such Indian to
recover damages other than such amounts paid to the Indian
Health Program from the employer for providing medical care for
such illness or condition.
``SEC. 215. ARIZONA AS A CONTRACT HEALTH SERVICE DELIVERY AREA.
``(a) In General.--For fiscal years beginning with the fiscal year
ending September 30, 1983, and ending with the fiscal year ending
September 30, 2025, the State of Arizona shall be designated as a
contract health service delivery area by the Service for the purpose of
providing contract health care services to members of federally
recognized Indian Tribes of Arizona.
``(b) Maintenance of Services.--The Service shall not curtail any
health care services provided to Indians residing on reservations in
the State of Arizona if such curtailment is due to the provision of
contract services in such State pursuant to the designation of such
State as a contract health service delivery area pursuant to subsection
(a).
``SEC. 216. NORTH DAKOTA AND SOUTH DAKOTA AS CONTRACT HEALTH SERVICE
DELIVERY AREA.
``(a) In General.--Beginning in fiscal year 2003, the States of
North Dakota and South Dakota shall be designated as a contract health
service delivery area by the Service for the purpose of providing
contract health care services to members of federally recognized Indian
Tribes of North Dakota and South Dakota.
``(b) Limitation.--The Service shall not curtail any health care
services provided to Indians residing on any reservation, or in any
county that has a common boundary with any reservation, in the State of
North Dakota or South Dakota if such curtailment is due to the
provision of contract services in such States pursuant to the
designation of such States as a contract health service delivery area
pursuant to subsection (a).
``SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PROGRAM.
``(a) Funding Authorized.--The Secretary is authorized to fund a
program using the California Rural Indian Health Board (hereafter in
this section referred to as the `CRIHB') as a contract care
intermediary to improve the accessibility of health services to
California Indians.
``(b) Reimbursement Contract.--The Secretary shall enter into an
agreement with the CRIHB to reimburse the CRIHB for costs (including
reasonable administrative costs) incurred pursuant to this section, in
providing medical treatment under contract to California Indians
described in section 805(a) throughout the California contract health
services delivery area described in section 219 with respect to high
cost contract care cases.
``(c) Administrative Expenses.--Not more than 5 percent of the
amounts provided to the CRIHB under this section for any fiscal year
may be for reimbursement for administrative expenses incurred by the
CRIHB during such fiscal year.
``(d) Limitation on Payment.--No payment may be made for treatment
provided hereunder to the extent payment may be made for such treatment
under the Indian Catastrophic Health Emergency Fund described in
section 202 or from amounts appropriated or otherwise made available to
the California contract health service delivery area for a fiscal year.
``(e) Advisory Board.--There is established an advisory board which
shall advise the CRIHB in carrying out this section. The advisory board
shall be composed of representatives, selected by the CRIHB, from not
less than 8 Tribal Health Programs serving California Indians covered
under this section at least \1/2\ of whom of whom are not affiliated
with the CRIHB.
``SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE DELIVERY AREA.
``The State of California, excluding the counties of Alameda,
Contra Costa, Los Angeles, Marin, Orange, Sacramento, San Francisco,
San Mateo, Santa Clara, Kern, Merced, Monterey, Napa, San Benito, San
Joaquin, San Luis Obispo, Santa Cruz, Solano, Stanislaus, and Ventura,
shall be designated as a contract health service delivery area by the
Service for the purpose of providing contract health services to
California Indians. However, any of the counties listed herein may only
be included in the contract health services delivery area if funding is
specifically provided by the Service for such services in those
counties.
``SEC. 219. CONTRACT HEALTH SERVICES FOR THE TRENTON SERVICE AREA.
``(a) Authorization for Services.--The Secretary, acting through
the Service, is directed to provide contract health services to members
of the Turtle Mountain Band of Chippewa Indians that reside in the
Trenton Service Area of Divide, McKenzie, and Williams counties in the
State of North Dakota and the adjoining counties of Richland,
Roosevelt, and Sheridan in the State of Montana.
``(b) No Expansion of Eligibility.--Nothing in this section may be
construed as expanding the eligibility of members of the Turtle
Mountain Band of Chippewa Indians for health services provided by the
Service beyond the scope of eligibility for such health services that
applied on May 1, 1986.
``SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND TRIBAL
ORGANIZATIONS.
``The Service shall provide funds for health care programs,
functions, services, activities, information technology, and facilities
operated by Tribal Health Programs on the same basis as such funds are
provided to programs, functions, services, activities, information
technology, and facilities operated directly by the Service.
``SEC. 221. LICENSING.
``Licensed health care professionals employed by a Tribal Health
Program shall, if licensed in any State, be exempt from the licensing
requirements of the State in which the Tribal Health Program performs
the services described in its contract or compact under the Indian
Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.)
while performing such services.
``SEC. 222. NOTIFICATION OF PROVISION OF EMERGENCY CONTRACT HEALTH
SERVICES.
``With respect to an elderly Indian or an Indian with a disability
receiving emergency medical care or services from a non-Service
provider or in a non-Service facility under the authority of this Act,
the time limitation (as a condition of payment) for notifying the
Service of such treatment or admission shall be 30 days.
``SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS.
``(a) Deadline for Response.--The Service shall respond to a
notification of a claim by a provider of a contract care service with
either an individual purchase order or a denial of the claim within 5
working days after the receipt of such notification.
``(b) Effect of Untimely Response.--If the Service fails to respond
to a notification of a claim in accordance with subsection (a), the
Service shall accept as valid the claim submitted by the provider of a
contract care service.
``(c) Deadline for Payment of Valid Claim.--The Service shall pay a
valid contract care service claim within 30 days after the completion
of the claim.
``SEC. 224. LIABILITY FOR PAYMENT.
``(a) No Patient Liability.--A patient who receives contract health
care services that are authorized by the Service shall not be liable
for the payment of any charges or costs associated with the provision
of such services.
``(b) Notification.--The Secretary shall notify a contract care
provider and any patient who receives contract health care services
authorized by the Service that such patient is not liable for the
payment of any charges or costs associated with the provision of such
services not later than 5 business days after receipt of a notification
of a claim by a provider of contract care services.
``(c) No Recourse.--Following receipt of the notice provided under
subsection (b), or, if a claim has been deemed accepted under section
224(b), the provider shall have no further recourse against the patient
who received the services.
``SEC. 225. OFFICE OF INDIAN MEN'S HEALTH.
``(a) Establishment.--The Secretary may establish within the
Service an office to be known as the `Office of Indian Men's Health'
(referred to in this section as the `Office').
``(b) Director.--
``(1) In general.--The Office shall be headed by a
director, to be appointed by the Secretary.
``(2) Duties.--The director shall coordinate and promote
the status of the health of Indian men in the United States.
``(c) Report.--Not later than 2 years after the date of enactment
of the Indian Health Care Improvement Act Amendments of 2009, the
Secretary, acting through the director of the Office, shall submit to
Congress a report describing--
``(1) any activity carried out by the director as of the
date on which the report is prepared; and
``(2) any finding of the director with respect to the
health of Indian men.
``SEC. 226. CATASTROPHIC HEALTH EMERGENCY FUND.
``(a) Establishment.--There is established an Indian Catastrophic
Health Emergency Fund (hereafter in this section referred to as the
`CHEF') consisting of--
``(1) the amounts deposited under subsection (f); and
``(2) the amounts appropriated to CHEF under this section.
``(b) Administration.--CHEF shall be administered by the Secretary,
acting through the headquarters of the Service, solely for the purpose
of meeting the extraordinary medical costs associated with the
treatment of victims of disasters or catastrophic illnesses who are
within the responsibility of the Service.
``(c) Conditions on Use of Fund.--No part of CHEF or its
administration shall be subject to contract or grant under any law,
including the Indian Self-Determination and Education Assistance Act
(25 U.S.C. 450 et seq.), nor shall CHEF funds be allocated,
apportioned, or delegated on an Area Office, Service Unit, or other
similar basis.
``(d) Regulations.--The Secretary shall promulgate regulations
consistent with the provisions of this section to--
``(1) establish a definition of disasters and catastrophic
illnesses for which the cost of the treatment provided under
contract would qualify for payment from CHEF;
``(2) provide that a Service Unit shall not be eligible for
reimbursement for the cost of treatment from CHEF until its
cost of treating any victim of such catastrophic illness or
disaster has reached a certain threshold cost which the
Secretary shall establish at--
``(A) the 2000 level of $19,000; and
``(B) for any subsequent year, not less than the
threshold cost of the previous year increased by the
percentage increase in the medical care expenditure
category of the consumer price index for all urban
consumers (United States city average) for the 12-month
period ending with December of the previous year;
``(3) establish a procedure for the reimbursement of the
portion of the costs that exceeds such threshold cost incurred
by--
``(A) Service Units; or
``(B) whenever otherwise authorized by the Service,
non-Service facilities or providers;
``(4) establish a procedure for payment from CHEF in cases
in which the exigencies of the medical circumstances warrant
treatment prior to the authorization of such treatment by the
Service; and
``(5) establish a procedure that will ensure that no
payment shall be made from CHEF to any provider of treatment to
the extent that such provider is eligible to receive payment
for the treatment from any other Federal, State, local, or
private source of reimbursement for which the patient is
eligible.
``(e) No Offset or Limitation.--Amounts appropriated to CHEF under
this section shall not be used to offset or limit appropriations made
to the Service under the authority of the Act of November 2, 1921 (25
U.S.C. 13) (commonly known as the `Snyder Act'), or any other law.
``(f) Deposit of Reimbursement Funds.--There shall be deposited
into CHEF all reimbursements to which the Service is entitled from any
Federal, State, local, or private source (including third party
insurance) by reason of treatment rendered to any victim of a disaster
or catastrophic illness the cost of which was paid from CHEF.
``SEC. 227. AUTHORIZATION OF APPROPRIATIONS.
``There are authorized to be appropriated such sums as may be
necessary to carry out this title.
``TITLE III--FACILITIES
``SEC. 301. CONSULTATION; CONSTRUCTION AND RENOVATION OF FACILITIES;
REPORTS.
``(a) Prerequisites for Expenditure of Funds.--Prior to the
expenditure of, or the making of any binding commitment to expend, any
funds appropriated for the planning, design, construction, or
renovation of facilities pursuant to the Act of November 2, 1921 (25
U.S.C. 13) (commonly known as the `Snyder Act'), the Secretary, acting
through the Service, shall--
``(1) consult with any Indian Tribe that would be
significantly affected by such expenditure for the purpose of
determining and, whenever practicable, honoring tribal
preferences concerning size, location, type, and other
characteristics of any facility on which such expenditure is to
be made; and
``(2) ensure, whenever practicable and applicable, that
such facility meets the construction standards of any
accrediting body recognized by the Secretary for the purposes
of the Medicare, Medicaid, and SCHIP programs under titles
XVIII, XIX, and XXI of the Social Security Act by not later
than 1 year after the date on which the construction or
renovation of such facility is completed.
``(b) Closures.--
``(1) Evaluation required.--Notwithstanding any other
provision of law, no facility operated by the Service may be
closed if the Secretary has not submitted to Congress, not less
than 1 year and not more than 2 years before the date of the
proposed closure, an evaluation, completed not more than 2
years before such submission, of the impact of the proposed
closure that specifies, in addition to other considerations--
``(A) the accessibility of alternative health care
resources for the population served by such facility;
``(B) the cost-effectiveness of such closure;
``(C) the quality of health care to be provided to
the population served by such facility after such
closure;
``(D) the availability of contract health care
funds to maintain existing levels of service;
``(E) the views of the Indian Tribes served by such
facility concerning such closure;
``(F) the level of use of such facility by all
eligible Indians; and
``(G) the distance between such facility and the
nearest operating Service hospital.
``(2) Exception for certain temporary closures.--Paragraph
(1) shall not apply to any temporary closure of a facility or
any portion of a facility if such closure is necessary for
medical, environmental, or construction safety reasons.
``(c) Health Care Facility Priority System.--
``(1) In general.--
``(A) Priority system.--The Secretary, acting
through the Service, shall maintain a health care
facility priority system, which--
``(i) shall be developed in consultation
with Indian Tribes and Tribal Organizations;
``(ii) shall give Indian Tribes' needs the
highest priority;
``(iii)(I) may include the lists required
in paragraph (2)(B)(ii); and
``(II) shall include the methodology
required in paragraph (2)(B)(v); and
``(III) may include such other facilities,
and such renovation or expansion needs of any
health care facility, as the Service, Indian
Tribes, and Tribal Organizations may identify;
and
``(iv) shall provide an opportunity for the
nomination of planning, design, and
construction projects by the Service, Indian
Tribes, and Tribal Organizations for
consideration under the priority system at
least once every 3 years, or more frequently as
the Secretary determines to be appropriate.
``(B) Needs of facilities under isdeaa
agreements.--The Secretary shall ensure that the
planning, design, construction, renovation, and
expansion needs of Service and non-Service facilities
operated under contracts or compacts in accordance with
the Indian Self-Determination and Education Assistance
Act (25 U.S.C. 450 et seq.) are fully and equitably
integrated into the health care facility priority
system.
``(C) Criteria for evaluating needs.--For purposes
of this subsection, the Secretary, in evaluating the
needs of facilities operated under a contract or
compact under the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.), shall
use the criteria used by the Secretary in evaluating
the needs of facilities operated directly by the
Service.
``(D) Priority of certain projects protected.--The
priority of any project established under the
construction priority system in effect on the date of
enactment of the Indian Health Care Improvement Act
Amendments of 2009 shall not be affected by any change
in the construction priority system taking place after
that date if the project--
``(i) was identified in the fiscal year
2008 Service budget justification as--
``(I) 1 of the 10 top-priority
inpatient projects;
``(II) 1 of the 10 top-priority
outpatient projects;
``(III) 1 of the 10 top-priority
staff quarters developments; or
``(IV) 1 of the 10 top-priority
Youth Regional Treatment Centers;
``(ii) had completed both Phase I and Phase
II of the construction priority system in
effect on the date of enactment of such Act; or
``(iii) is not included in clause (i) or
(ii) and is selected, as determined by the
Secretary--
``(I) on the initiative of the
Secretary; or
``(II) pursuant to a request of an
Indian Tribe or Tribal Organization.
``(2) Report; contents.--
``(A) Initial comprehensive report.--
``(i) Definitions.--In this subparagraph:
``(I) Facilities appropriation
advisory board.--The term `Facilities
Appropriation Advisory Board' means the
advisory board, comprised of 12 members
representing Indian tribes and 2
members representing the Service,
established at the discretion of the
Assistant Secretary--
``(aa) to provide advice
and recommendations for
policies and procedures of the
programs funded pursuant to
facilities appropriations; and
``(bb) to address other
facilities issues.
``(II) Facilities needs assessment
workgroup.--The term `Facilities Needs
Assessment Workgroup' means the
workgroup established at the discretion
of the Assistant Secretary--
``(aa) to review the health
care facilities construction
priority system; and
``(bb) to make
recommendations to the
Facilities Appropriation
Advisory Board for revising the
priority system.
``(ii) Initial report.--
``(I) In general.--Not later than 1
year after the date of enactment of the
Indian Health Care Improvement Act
Amendments of 2009, the Secretary shall
submit to the Committee on Indian
Affairs of the Senate and the Committee
on Natural Resources of the House of
Representatives a report that describes
the comprehensive, national, ranked
list of all health care facilities
needs for the Service, Indian Tribes,
and Tribal Organizations (including
inpatient health care facilities,
outpatient health care facilities,
specialized health care facilities
(such as for long-term care and alcohol
and drug abuse treatment), wellness
centers, staff quarters and hostels
associated with health care facilities,
and the renovation and expansion needs,
if any, of such facilities) developed
by the Service, Indian Tribes, and
Tribal Organizations for the Facilities
Needs Assessment Workgroup and the
Facilities Appropriation Advisory
Board.
``(II) Inclusions.--The initial
report shall include--
``(aa) the methodology and
criteria used by the Service in
determining the needs and
establishing the ranking of the
facilities needs; and
``(bb) such other
information as the Secretary
determines to be appropriate.
``(iii) Updates of report.--Beginning in
calendar year 2011, the Secretary shall--
``(I) update the report under
clause (ii) not less frequently that
once every 5 years; and
``(II) include the updated report
in the appropriate annual report under
subparagraph (B) for submission to
Congress under section 801.
``(B) Annual reports.--The Secretary shall submit
to the President, for inclusion in the report required
to be transmitted to Congress under section 801, a
report which sets forth the following:
``(i) A description of the health care
facility priority system of the Service
established under paragraph (1).
``(ii) Health care facilities lists, which
may include--
``(I) the 10 top-priority inpatient
health care facilities;
``(II) the 10 top-priority
outpatient health care facilities;
``(III) the 10 top-priority
specialized health care facilities
(such as long-term care and alcohol and
drug abuse treatment);
``(IV) the 10 top-priority staff
quarters developments associated with
health care facilities; and
``(V) the 10 top-priority hostels
associated with health care facilities.
``(iii) The justification for such order of
priority.
``(iv) The projected cost of such projects.
``(v) The methodology adopted by the
Service in establishing priorities under its
health care facility priority system.
``(3) Requirements for preparation of reports.--In
preparing the report required under paragraph (2), the
Secretary shall--
``(A) consult with and obtain information on all
health care facilities needs from Indian Tribes, Tribal
Organizations, and urban Indian organizations; and
``(B) review the total unmet needs of all Indian
Tribes, Tribal Organizations, and urban Indian
organizations for health care facilities (including
hostels and staff quarters), including needs for
renovation and expansion of existing facilities.
``(d) Review of Methodology Used for Health Facilities Construction
Priority System.--
``(1) In general.--Not later than 1 year after the
establishment of the priority system under subsection
(c)(1)(A), the Comptroller General of the United States shall
prepare and finalize a report reviewing the methodologies
applied, and the processes followed, by the Service in making
each assessment of needs for the list under subsection
(c)(2)(A)(ii) and developing the priority system under
subsection (c)(1), including a review of--
``(A) the recommendations of the Facilities
Appropriation Advisory Board and the Facilities Needs
Assessment Workgroup (as those terms are defined in
subsection (c)(2)(A)(i)); and
``(B) the relevant criteria used in ranking or
prioritizing facilities other than hospitals or
clinics.
``(2) Submission to congress.--The Comptroller General of
the United States shall submit the report under paragraph (1)
to--
``(A) the Committees on Indian Affairs and
Appropriations of the Senate;
``(B) the Committees on Natural Resources and
Appropriations of the House of Representatives; and
``(C) the Secretary.
``(e) Funding Condition.--All funds appropriated under the Act of
November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'),
for the planning, design, construction, or renovation of health
facilities for the benefit of 1 or more Indian Tribes shall be subject
to the provisions of the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.).
``(f) Development of Innovative Approaches.--The Secretary shall
consult and cooperate with Indian Tribes, Tribal Organizations, and
urban Indian organizations in developing innovative approaches to
address all or part of the total unmet need for construction of health
facilities, including those provided for in other sections of this
title and other approaches.
``SEC. 302. SANITATION FACILITIES.
``(a) Findings.--Congress finds the following:
``(1) The provision of sanitation facilities is primarily a
health consideration and function.
``(2) Indian people suffer an inordinately high incidence
of disease, injury, and illness directly attributable to the
absence or inadequacy of sanitation facilities.
``(3) The long-term cost to the United States of treating
and curing such disease, injury, and illness is substantially
greater than the short-term cost of providing sanitation
facilities and other preventive health measures.
``(4) Many Indian homes and Indian communities still lack
sanitation facilities.
``(5) It is in the interest of the United States, and it is
the policy of the United States, that all Indian communities
and Indian homes, new and existing, be provided with sanitation
facilities.
``(b) Facilities and Services.--In furtherance of the findings made
in subsection (a), Congress reaffirms the primary responsibility and
authority of the Service to provide the necessary sanitation facilities
and services as provided in section 7 of the Act of August 5, 1954 (42
U.S.C. 2004a). Under such authority, the Secretary, acting through the
Service, is authorized to provide the following:
``(1) Financial and technical assistance to Indian Tribes,
Tribal Organizations, and Indian communities in the
establishment, training, and equipping of utility organizations
to operate and maintain sanitation facilities, including the
provision of existing plans, standard details, and
specifications available in the Department, to be used at the
option of the Indian Tribe, Tribal Organization, or Indian
community.
``(2) Ongoing technical assistance and training to Indian
Tribes, Tribal Organizations, and Indian communities in the
management of utility organizations which operate and maintain
sanitation facilities.
``(3) Priority funding for operation and maintenance
assistance for, and emergency repairs to, sanitation facilities
operated by an Indian Tribe, Tribal Organization or Indian
community when necessary to avoid an imminent health threat or
to protect the investment in sanitation facilities and the
investment in the health benefits gained through the provision
of sanitation facilities.
``(c) Funding.--Notwithstanding any other provision of law--
``(1) the Secretary of Housing and Urban Development is
authorized to transfer funds appropriated under the Native
American Housing Assistance and Self-Determination Act of 1996
(25 U.S.C. 4101 et seq.) to the Secretary of Health and Human
Services;
``(2) the Secretary of Health and Human Services is
authorized to accept and use such funds for the purpose of
providing sanitation facilities and services for Indians under
section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a);
``(3) unless specifically authorized when funds are
appropriated, the Secretary shall not use funds appropriated
under section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a),
to provide sanitation facilities to new homes constructed using
funds provided by the Department of Housing and Urban
Development;
``(4) the Secretary of Health and Human Services is
authorized to accept from any source, including Federal and
State agencies, funds for the purpose of providing sanitation
facilities and services and place these funds into contracts or
compacts under the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.);
``(5) except as otherwise prohibited by this section, the
Secretary may use funds appropriated under the authority of
section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a), to
fund up to 100 percent of the amount of an Indian Tribe's loan
obtained under any Federal program for new projects to
construct eligible sanitation facilities to serve Indian homes;
``(6) except as otherwise prohibited by this section, the
Secretary may use funds appropriated under the authority of
section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a), to
meet matching or cost participation requirements under other
Federal and non-Federal programs for new projects to construct
eligible sanitation facilities;
``(7) all Federal agencies are authorized to transfer to
the Secretary funds identified, granted, loaned, or
appropriated whereby the Department's applicable policies,
rules, and regulations shall apply in the implementation of
such projects;
``(8) the Secretary of Health and Human Services shall
enter into interagency agreements with Federal and State
agencies for the purpose of providing financial assistance for
sanitation facilities and services under this Act;
``(9) the Secretary of Health and Human Services shall, by
regulation, establish standards applicable to the planning,
design, and construction of sanitation facilities funded under
this Act; and
``(10) the Secretary of Health and Human Services is
authorized to accept payments for goods and services furnished
by the Service from appropriate public authorities, nonprofit
organizations or agencies, or Indian Tribes, as contributions
by that authority, organization, agency, or tribe to agreements
made under section 7 of the Act of August 5, 1954 (42 U.S.C.
2004a), and such payments shall be credited to the same or
subsequent appropriation account as funds appropriated under
the authority of section 7 of the Act of August 5, 1954 (42
U.S.C. 2004a).
``(d) Certain Capabilities Not Prerequisite.--The financial and
technical capability of an Indian Tribe, Tribal Organization, or Indian
community to safely operate, manage, and maintain a sanitation facility
shall not be a prerequisite to the provision or construction of
sanitation facilities by the Secretary.
``(e) Financial Assistance.--The Secretary is authorized to provide
financial assistance to Indian Tribes, Tribal Organizations, and Indian
communities in an amount equal to the Federal share of the costs of
operating, managing, and maintaining the facilities provided under the
plan described in subsection (h)(1)(F).
``(f) Operation, Management, and Maintenance of Facilities.--The
Indian Tribe has the primary responsibility to establish, collect, and
use reasonable user fees, or otherwise set aside funding, for the
purpose of operating, managing, and maintaining sanitation facilities.
If a sanitation facility serving a community that is operated by an
Indian Tribe or Tribal Organization is threatened with imminent failure
and such operator lacks capacity to maintain the integrity or the
health benefits of the sanitation facility, then the Secretary is
authorized to assist the Indian Tribe, Tribal Organization, or Indian
community in the resolution of the problem on a short-term basis
through cooperation with the emergency coordinator or by providing
operation, management, and maintenance service.
``(g) ISDEAA Program Funded on Equal Basis.--Tribal Health Programs
shall be eligible (on an equal basis with programs that are
administered directly by the Service) for--
``(1) any funds appropriated pursuant to this section; and
``(2) any funds appropriated for the purpose of providing
sanitation facilities.
``(h) Report.--
``(1) Required; contents.--The Secretary, in consultation
with the Secretary of Housing and Urban Development, Indian
Tribes, Tribal Organizations, and tribally designated housing
entities (as defined in section 4 of the Native American
Housing Assistance and Self-Determination Act of 1996 (25
U.S.C. 4103)) shall submit to the President, for inclusion in
the report required to be transmitted to Congress under section
801, a report which sets forth--
``(A) the current Indian sanitation facility
priority system of the Service;
``(B) the methodology for determining sanitation
deficiencies and needs;
``(C) the criteria on which the deficiencies and
needs will be evaluated;
``(D) the level of initial and final sanitation
deficiency for each type of sanitation facility for
each project of each Indian Tribe or Indian community;
``(E) the amount and most effective use of funds,
derived from whatever source, necessary to accommodate
the sanitation facilities needs of new homes assisted
with funds under the Native American Housing Assistance
and Self-Determination Act (25 U.S.C. 4101 et seq.),
and to reduce the identified sanitation deficiency
levels of all Indian Tribes and Indian communities to
level I sanitation deficiency as defined in paragraph
(3)(A); and
``(F) a 10-year plan to provide sanitation
facilities to serve existing Indian homes and Indian
communities and new and renovated Indian homes.
``(2) Uniform methodology.--The methodology used by the
Secretary in determining, preparing cost estimates for, and
reporting sanitation deficiencies for purposes of paragraph (1)
shall be applied uniformly to all Indian Tribes and Indian
communities.
``(3) Sanitation deficiency levels.--For purposes of this
subsection, the sanitation deficiency levels for an individual,
Indian Tribe, or Indian community sanitation facility to serve
Indian homes are determined as follows:
``(A) A level I deficiency exists if a sanitation
facility serving an individual, Indian Tribe, or Indian
community--
``(i) complies with all applicable water
supply, pollution control, and solid waste
disposal laws; and
``(ii) deficiencies relate to routine
replacement, repair, or maintenance needs.
``(B) A level II deficiency exists if a sanitation
facility serving an individual, Indian Tribe, or Indian
community substantially or recently complied with all
applicable water supply, pollution control, and solid
waste laws and any deficiencies relate to--
``(i) small or minor capital improvements
needed to bring the facility back into
compliance;
``(ii) capital improvements that are
necessary to enlarge or improve the facilities
in order to meet the current needs for domestic
sanitation facilities; or
``(iii) the lack of equipment or training
by an Indian Tribe, Tribal Organization, or an
Indian community to properly operate and
maintain the sanitation facilities.
``(C) A level III deficiency exists if a sanitation
facility serving an individual, Indian Tribe or Indian
community meets 1 or more of the following conditions--
``(i) water or sewer service in the home is
provided by a haul system with holding tanks
and interior plumbing;
``(ii) major significant interruptions to
water supply or sewage disposal occur
frequently, requiring major capital
improvements to correct the deficiencies; or
``(iii) there is no access to or no
approved or permitted solid waste facility
available.
``(D) A level IV deficiency exists--
``(i) if a sanitation facility for an
individual home, an Indian Tribe, or an Indian
community exists but--
``(I) lacks--
``(aa) a safe water supply
system; or
``(bb) a waste disposal
system;
``(II) contains no piped water or
sewer facilities; or
``(III) has become inoperable due
to a major component failure; or
``(ii) if only a washeteria or central
facility exists in the community.
``(E) A level V deficiency exists in the absence of
a sanitation facility, where individual homes do not
have access to safe drinking water or adequate
wastewater (including sewage) disposal.
``(i) Definitions.--For purposes of this section, the following
terms apply:
``(1) Indian community.--The term `Indian community' means
a geographic area, a significant proportion of whose
inhabitants are Indians and which is served by or capable of
being served by a facility described in this section.
``(2) Sanitation facilities.--The terms `sanitation
facility' and `sanitation facilities' mean safe and adequate
water supply systems, sanitary sewage disposal systems, and
sanitary solid waste systems (and all related equipment and
support infrastructure).
``SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS.
``(a) Buy Indian Act.--The Secretary, acting through the Service,
may use the negotiating authority of section 23 of the Act of June 25,
1910 (25 U.S.C. 47, commonly known as the `Buy Indian Act'), to give
preference to any Indian or any enterprise, partnership, corporation,
or other type of business organization owned and controlled by an
Indian or Indians including former or currently federally recognized
Indian Tribes in the State of New York (hereinafter referred to as an
`Indian firm') in the construction and renovation of Service facilities
pursuant to section 301 and in the construction of sanitation
facilities pursuant to section 302. Such preference may be accorded by
the Secretary unless the Secretary finds, pursuant to regulations, that
the project or function to be contracted for will not be satisfactory
or such project or function cannot be properly completed or maintained
under the proposed contract. The Secretary, in arriving at such a
finding, shall consider whether the Indian or Indian firm will be
deficient with respect to--
``(1) ownership and control by Indians;
``(2) equipment;
``(3) bookkeeping and accounting procedures;
``(4) substantive knowledge of the project or function to
be contracted for;
``(5) adequately trained personnel; or
``(6) other necessary components of contract performance.
``(b) Pay Rates.--For the purposes of implementing the provisions
of this title, the Secretary shall assure that the rates of pay for
personnel engaged in the construction or renovation of facilities
constructed or renovated in whole or in part by funds made available
pursuant to this title are not less than the prevailing local wage
rates for similar work as determined in accordance with the Act of
March 3, 1931 (40 U.S.C. 276a-276a-5, known as the Davis-Bacon Act).
``(c) Labor Standards.--For the purposes of implementing the
provisions of this title, contracts for the construction or renovation
of health care facilities, staff quarters, and sanitation facilities,
and related support infrastructure, funded in whole or in part with
funds made available pursuant to this title, shall contain a provision
requiring compliance with subchapter IV of chapter 31 of title 40,
United States Code (commonly known as the `Davis-Bacon Act').
``SEC. 304. EXPENDITURE OF NON-SERVICE FUNDS FOR RENOVATION.
``(a) In General.--Notwithstanding any other provision of law, if
the requirements of subsection (c) are met, the Secretary, acting
through the Service, is authorized to accept any major expansion,
renovation, or modernization by any Indian Tribe or Tribal Organization
of any Service facility or of any other Indian health facility operated
pursuant to a contract or compact under the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.), including--
``(1) any plans or designs for such expansion, renovation,
or modernization; and
``(2) any expansion, renovation, or modernization for which
funds appropriated under any Federal law were lawfully
expended.
``(b) Priority List.--
``(1) In general.--The Secretary shall maintain a separate
priority list to address the needs for increased operating
expenses, personnel, or equipment for such facilities. The
methodology for establishing priorities shall be developed
through regulations. The list of priority facilities will be
revised annually in consultation with Indian Tribes and Tribal
Organizations.
``(2) Report.--The Secretary shall submit to the President,
for inclusion in the report required to be transmitted to
Congress under section 801, the priority list maintained
pursuant to paragraph (1).
``(c) Requirements.--The requirements of this subsection are met
with respect to any expansion, renovation, or modernization if--
``(1) the Indian Tribe or Tribal Organization--
``(A) provides notice to the Secretary of its
intent to expand, renovate, or modernize; and
``(B) applies to the Secretary to be placed on a
separate priority list to address the needs of such new
facilities for increased operating expenses, personnel,
or equipment; and
``(2) the expansion, renovation, or modernization--
``(A) is approved by the appropriate area director
of the Service for Federal facilities; and
``(B) is administered by the Indian Tribe or Tribal
Organization in accordance with any applicable
regulations prescribed by the Secretary with respect to
construction or renovation of Service facilities.
``(d) Additional Requirement for Expansion.--In addition to the
requirements under subsection (c), for any expansion, the Indian Tribe
or Tribal Organization shall provide to the Secretary additional
information pursuant to regulations, including additional staffing,
equipment, and other costs associated with the expansion.
``(e) Closure or Conversion of Facilities.--If any Service facility
which has been expanded, renovated, or modernized by an Indian Tribe or
Tribal Organization under this section ceases to be used as a Service
facility during the 20-year period beginning on the date such
expansion, renovation, or modernization is completed, such Indian Tribe
or Tribal Organization shall be entitled to recover from the United
States an amount which bears the same ratio to the value of such
facility at the time of such cessation as the value of such expansion,
renovation, or modernization (less the total amount of any funds
provided specifically for such facility under any Federal program that
were expended for such expansion, renovation, or modernization) bore to
the value of such facility at the time of the completion of such
expansion, renovation, or modernization.
``SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, AND MODERNIZATION
OF SMALL AMBULATORY CARE FACILITIES.
``(a) Grants.--
``(1) In general.--The Secretary, acting through the
Service, shall make grants to Indian Tribes and Tribal
Organizations for the construction, expansion, or modernization
of facilities for the provision of ambulatory care services to
eligible Indians (and noneligible persons pursuant to
subsections (b)(2) and (c)(1)(C)). A grant made under this
section may cover up to 100 percent of the costs of such
construction, expansion, or modernization. For the purposes of
this section, the term `construction' includes the replacement
of an existing facility.
``(2) Grant agreement required.--A grant under paragraph
(1) may only be made available to a Tribal Health Program
operating an Indian health facility (other than a facility
owned or constructed by the Service, including a facility
originally owned or constructed by the Service and transferred
to an Indian Tribe or Tribal Organization).
``(b) Use of Grant Funds.--
``(1) Allowable uses.--A grant awarded under this section
may be used for the construction, expansion, or modernization
(including the planning and design of such construction,
expansion, or modernization) of an ambulatory care facility--
``(A) located apart from a hospital;
``(B) not funded under section 301 or section 306;
and
``(C) which, upon completion of such construction
or modernization will--
``(i) have a total capacity appropriate to
its projected service population;
``(ii) provide annually no fewer than 150
patient visits by eligible Indians and other
users who are eligible for services in such
facility in accordance with section 806(c)(2);
and
``(iii) provide ambulatory care in a
Service Area (specified in the contract or
compact under the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et
seq.)) with a population of no fewer than 1,500
eligible Indians and other users who are
eligible for services in such facility in
accordance with section 806(c)(2).
``(2) Additional allowable use.--The Secretary may also
reserve a portion of the funding provided under this section
and use those reserved funds to reduce an outstanding debt
incurred by Indian Tribes or Tribal Organizations for the
construction, expansion, or modernization of an ambulatory care
facility that meets the requirements under paragraph (1). The
provisions of this section shall apply, except that such
applications for funding under this paragraph shall be
considered separately from applications for funding under
paragraph (1).
``(3) Use only for certain portion of costs.--A grant
provided under this section may be used only for the cost of
that portion of a construction, expansion, or modernization
project that benefits the Service population identified above
in subsection (b)(1)(C) (ii) and (iii). The requirements of
clauses (ii) and (iii) of paragraph (1)(C) shall not apply to
an Indian Tribe or Tribal Organization applying for a grant
under this section for a health care facility located or to be
constructed on an island or when such facility is not located
on a road system providing direct access to an inpatient
hospital where care is available to the Service population.
``(c) Grants.--
``(1) Application.--No grant may be made under this section
unless an application or proposal for the grant has been
approved by the Secretary in accordance with applicable
regulations and has set forth reasonable assurance by the
applicant that, at all times after the construction, expansion,
or modernization of a facility carried out using a grant
received under this section--
``(A) adequate financial support will be available
for the provision of services at such facility;
``(B) such facility will be available to eligible
Indians without regard to ability to pay or source of
payment; and
``(C) such facility will, as feasible without
diminishing the quality or quantity of services
provided to eligible Indians, serve noneligible persons
on a cost basis.
``(2) Priority.--In awarding grants under this section, the
Secretary shall give priority to Indian Tribes and Tribal
Organizations that demonstrate--
``(A) a need for increased ambulatory care
services; and
``(B) insufficient capacity to deliver such
services.
``(3) Peer review panels.--The Secretary may provide for
the establishment of peer review panels, as necessary, to
review and evaluate applications and proposals and to advise
the Secretary regarding such applications using the criteria
developed pursuant to subsection (a)(1).
``(d) Reversion of Facilities.--If any facility (or portion
thereof) with respect to which funds have been paid under this section,
ceases, at any time after completion of the construction, expansion, or
modernization carried out with such funds, to be used for the purposes
of providing health care services to eligible Indians, all of the
right, title, and interest in and to such facility (or portion thereof)
shall transfer to the United States unless otherwise negotiated by the
Service and the Indian Tribe or Tribal Organization.
``(e) Funding Nonrecurring.--Funding provided under this section
shall be nonrecurring and shall not be available for inclusion in any
individual Indian Tribe's tribal share for an award under the Indian
Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.)
or for reallocation or redesign thereunder.
``SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRATION PROJECT.
``(a) Health Care Demonstration Projects.--The Secretary, acting
through the Service, is authorized to make grants to, and enter into
construction contracts or construction project agreements with, Indian
Tribes or Tribal Organizations under the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.) for the purpose of
carrying out a health care delivery demonstration project to test
alternative means of delivering health care and services to Indians
through facilities.
``(b) Use of Funds.--The Secretary, in approving projects pursuant
to this section, may authorize such contracts for the construction and
renovation of hospitals, health centers, health stations, and other
facilities to deliver health care services and is authorized to--
``(1) waive any leasing prohibition;
``(2) permit carryover of funds appropriated for the
provision of health care services;
``(3) permit the use of other available funds;
``(4) permit the use of funds or property donated from any
source for project purposes;
``(5) provide for the reversion of donated real or personal
property to the donor; and
``(6) permit the use of Service funds to match other funds,
including Federal funds.
``(c) Regulations.--The Secretary shall develop and promulgate
regulations, not later than 1 year after the date of enactment of the
Indian Health Care Improvement Act Amendments of 2009, for the review
and approval of applications submitted under this section.
``(d) Criteria.--The Secretary may approve projects that meet the
following criteria:
``(1) There is a need for a new facility or program or the
reorientation of an existing facility or program.
``(2) A significant number of Indians, including those with
low health status, will be served by the project.
``(3) The project has the potential to deliver services in
an efficient and effective manner.
``(4) The project is economically viable.
``(5) The Indian Tribe or Tribal Organization has the
administrative and financial capability to administer the
project.
``(6) The project is integrated with providers of related
health and social services and is coordinated with, and avoids
duplication of, existing services.
``(e) Peer Review Panels.--The Secretary may provide for the
establishment of peer review panels, as necessary, to review and
evaluate applications using the criteria developed pursuant to
subsection (d).
``(f) Priority.--The Secretary shall give priority to applications
for demonstration projects in each of the following Service Units to
the extent that such applications are timely filed and meet the
criteria specified in subsection (d):
``(1) Cass Lake, Minnesota.
``(2) Mescalero, New Mexico.
``(3) Owyhee, Nevada.
``(4) Schurz, Nevada.
``(5) Ft. Yuma, California.
``(g) Technical Assistance.--The Secretary shall provide such
technical and other assistance as may be necessary to enable applicants
to comply with the provisions of this section.
``(h) Service to Ineligible Persons.--Subject to section 806, the
authority to provide services to persons otherwise ineligible for the
health care benefits of the Service and the authority to extend
hospital privileges in Service facilities to non-Service health
practitioners as provided in section 806 may be included, subject to
the terms of such section, in any demonstration project approved
pursuant to this section.
``(i) Equitable Treatment.--For purposes of subsection (d)(1), the
Secretary shall, in evaluating facilities operated under any contract
or compact under the Indian Self-Determination and Education Assistance
Act (25 U.S.C. 450 et seq.), use the same criteria that the Secretary
uses in evaluating facilities operated directly by the Service.
``(j) Equitable Integration of Facilities.--The Secretary shall
ensure that the planning, design, construction, renovation, and
expansion needs of Service and non-Service facilities which are the
subject of a contract or compact under the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.) for health
services are fully and equitably integrated into the implementation of
the health care delivery demonstration projects under this section.
``SEC. 307. LAND TRANSFER.
``Notwithstanding any other provision of law, the Bureau of Indian
Affairs and all other agencies and departments of the United States are
authorized to transfer, at no cost, land and improvements to the
Service for the provision of health care services. The Secretary is
authorized to accept such land and improvements for such purposes.
``SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS.
``The Secretary, acting through the Service, may enter into leases,
contracts, and other agreements with Indian Tribes and Tribal
Organizations which hold (1) title to, (2) a leasehold interest in, or
(3) a beneficial interest in (when title is held by the United States
in trust for the benefit of an Indian Tribe) facilities used or to be
used for the administration and delivery of health services by an
Indian Health Program. Such leases, contracts, or agreements may
include provisions for construction or renovation and provide for
compensation to the Indian Tribe or Tribal Organization of rental and
other costs consistent with section 105(l) of the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450j(l)) and
regulations thereunder.
``SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND LOAN REPAYMENT.
``(a) In General.--The Secretary, in consultation with the
Secretary of the Treasury, Indian Tribes, and Tribal Organizations,
shall carry out a study to determine the feasibility of establishing a
loan fund to provide to Indian Tribes and Tribal Organizations direct
loans or guarantees for loans for the construction of health care
facilities, including--
``(1) inpatient facilities;
``(2) outpatient facilities;
``(3) staff quarters;
``(4) hostels; and
``(5) specialized care facilities, such as behavioral
health and elder care facilities.
``(b) Determinations.--In carrying out the study under subsection
(a), the Secretary shall determine--
``(1) the maximum principal amount of a loan or loan
guarantee that should be offered to a recipient from the loan
fund;
``(2) the percentage of eligible costs, not to exceed 100
percent, that may be covered by a loan or loan guarantee from
the loan fund (including costs relating to planning, design,
financing, site land development, construction, rehabilitation,
renovation, conversion, improvements, medical equipment and
furnishings, and other facility-related costs and capital
purchase (but excluding staffing));
``(3) the cumulative total of the principal of direct loans
and loan guarantees, respectively, that may be outstanding at
any 1 time;
``(4) the maximum term of a loan or loan guarantee that may
be made for a facility from the loan fund;
``(5) the maximum percentage of funds from the loan fund
that should be allocated for payment of costs associated with
planning and applying for a loan or loan guarantee;
``(6) whether acceptance by the Secretary of an assignment
of the revenue of an Indian Tribe or Tribal Organization as
security for any direct loan or loan guarantee from the loan
fund would be appropriate;
``(7) whether, in the planning and design of health
facilities under this section, users eligible under section
806(c) may be included in any projection of patient population;
``(8) whether funds of the Service provided through loans
or loan guarantees from the loan fund should be eligible for
use in matching other Federal funds under other programs;
``(9) the appropriateness of, and best methods for,
coordinating the loan fund with the health care priority system
of the Service under section 301; and
``(10) any legislative or regulatory changes required to
implement recommendations of the Secretary based on results of
the study.
``(c) Report.--Not later than September 30, 2010, the Secretary
shall submit to the Committee on Indian Affairs of the Senate and the
Committee on Natural Resources and the Committee on Energy and Commerce
of the House of Representatives a report that describes--
``(1) the manner of consultation made as required by
subsection (a); and
``(2) the results of the study, including any
recommendations of the Secretary based on results of the study.
``SEC. 310. TRIBAL LEASING.
``A Tribal Health Program may lease permanent structures for the
purpose of providing health care services without obtaining advance
approval in appropriation Acts.
``SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES JOINT VENTURE
PROGRAM.
``(a) In General.--The Secretary, acting through the Service, shall
make arrangements with Indian Tribes and Tribal Organizations to
establish joint venture demonstration projects under which an Indian
Tribe or Tribal Organization shall expend tribal, private, or other
available funds, for the acquisition or construction of a health
facility for a minimum of 10 years, under a no-cost lease, in exchange
for agreement by the Service to provide the equipment, supplies, and
staffing for the operation and maintenance of such a health facility.
An Indian Tribe or Tribal Organization may use tribal funds, private
sector, or other available resources, including loan guarantees, to
fulfill its commitment under a joint venture entered into under this
subsection. An Indian Tribe or Tribal Organization shall be eligible to
establish a joint venture project if, when it submits a letter of
intent, it--
``(1) has begun but not completed the process of
acquisition or construction of a health facility to be used in
the joint venture project;
``(2) has not begun the process of acquisition or
construction of a health facility for use in the joint venture
project; or
``(3) in its application for a joint venture agreement,
agrees--
``(A) to construct a facility for the joint venture
which complies with the size and space criteria
established by the Service; or
``(B) if the facility it proposes for the joint
venture is already in existence or under construction,
that only the portion of such facility which complies
with the size and space criteria of the Service will be
eligible for the joint venture agreement.
``(b) Requirements.--The Secretary shall make such an arrangement
with an Indian Tribe or Tribal Organization only if--
``(1) the Secretary first determines that the Indian Tribe
or Tribal Organization has the administrative and financial
capabilities necessary to complete the timely acquisition or
construction of the relevant health facility; and
``(2) the Indian Tribe or Tribal Organization meets the
need criteria determined using the criteria developed under the
health care facility priority system under section 301, unless
the Secretary determines, pursuant to regulations, that other
criteria will result in a more cost-effective and efficient
method of facilitating and completing construction of health
care facilities.
``(c) Continued Operation.--The Secretary shall negotiate an
agreement with the Indian Tribe or Tribal Organization regarding the
continued operation of the facility at the end of the initial 10 year
no-cost lease period.
``(d) Breach of Agreement.--An Indian Tribe or Tribal Organization
that has entered into a written agreement with the Secretary under this
section, and that breaches or terminates without cause such agreement,
shall be liable to the United States for the amount that has been paid
to the Indian Tribe or Tribal Organization, or paid to a third party on
the Indian Tribe's or Tribal Organization's behalf, under the
agreement. The Secretary has the right to recover tangible property
(including supplies) and equipment, less depreciation, and any funds
expended for operations and maintenance under this section. The
preceding sentence does not apply to any funds expended for the
delivery of health care services, personnel, or staffing.
``(e) Recovery for Nonuse.--An Indian Tribe or Tribal Organization
that has entered into a written agreement with the Secretary under this
subsection shall be entitled to recover from the United States an
amount that is proportional to the value of such facility if, at any
time within the 10-year term of the agreement, the Service ceases to
use the facility or otherwise breaches the agreement.
``(f) Definition.--For the purposes of this section, the term
`health facility' or `health facilities' includes quarters needed to
provide housing for staff of the relevant Tribal Health Program.
``SEC. 312. LOCATION OF FACILITIES.
``(a) In General.--In all matters involving the reorganization or
development of Service facilities or in the establishment of related
employment projects to address unemployment conditions in economically
depressed areas, the Bureau of Indian Affairs and the Service shall
give priority to locating such facilities and projects on Indian lands,
or lands in Alaska owned by any Alaska Native village, or village or
regional corporation under the Alaska Native Claims Settlement Act (43
U.S.C. 1601 et seq.), or any land allotted to any Alaska Native, if
requested by the Indian owner and the Indian Tribe with jurisdiction
over such lands or other lands owned or leased by the Indian Tribe or
Tribal Organization. Top priority shall be given to Indian land owned
by 1 or more Indian Tribes.
``(b) Definition.--For purposes of this section, the term `Indian
lands' means--
``(1) all lands within the exterior boundaries of any
reservation; and
``(2) any lands title to which is held in trust by the
United States for the benefit of any Indian Tribe or individual
Indian or held by any Indian Tribe or individual Indian subject
to restriction by the United States against alienation.
``SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH CARE FACILITIES.
``(a) Report.--The Secretary shall submit to the President, for
inclusion in the report required to be transmitted to Congress under
section 801, a report which identifies the backlog of maintenance and
repair work required at both Service and tribal health care facilities,
including new health care facilities expected to be in operation in the
next fiscal year. The report shall also identify the need for
renovation and expansion of existing facilities to support the growth
of health care programs.
``(b) Maintenance of Newly Constructed Space.--The Secretary,
acting through the Service, is authorized to expend maintenance and
improvement funds to support maintenance of newly constructed space
only if such space falls within the approved supportable space
allocation for the Indian Tribe or Tribal Organization. Supportable
space allocation shall be defined through the health care facility
priority system under section 301(c).
``(c) Replacement Facilities.--In addition to using maintenance and
improvement funds for renovation, modernization, and expansion of
facilities, an Indian Tribe or Tribal Organization may use maintenance
and improvement funds for construction of a replacement facility if the
costs of renovation of such facility would exceed a maximum renovation
cost threshold. The Secretary shall consult with Indian Tribes and
Tribal Organizations in determining the maximum renovation cost
threshold.
``SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY OWNED QUARTERS.
``(a) Rental Rates.--
``(1) Establishment.--Notwithstanding any other provision
of law, a Tribal Health Program which operates a hospital or
other health facility and the federally owned quarters
associated therewith pursuant to a contract or compact under
the Indian Self-Determination and Education Assistance Act (25
U.S.C. 450 et seq.) shall have the authority to establish the
rental rates charged to the occupants of such quarters by
providing notice to the Secretary of its election to exercise
such authority.
``(2) Objectives.--In establishing rental rates pursuant to
authority of this subsection, a Tribal Health Program shall
endeavor to achieve the following objectives:
``(A) To base such rental rates on the reasonable
value of the quarters to the occupants thereof.
``(B) To generate sufficient funds to prudently
provide for the operation and maintenance of the
quarters, and subject to the discretion of the Tribal
Health Program, to supply reserve funds for capital
repairs and replacement of the quarters.
``(3) Equitable funding.--Any quarters whose rental rates
are established by a Tribal Health Program pursuant to this
subsection shall remain eligible for quarters improvement and
repair funds to the same extent as all federally owned quarters
used to house personnel in Services-supported programs.
``(4) Notice of rate change.--A Tribal Health Program which
exercises the authority provided under this subsection shall
provide occupants with no less than 60 days notice of any
change in rental rates.
``(b) Direct Collection of Rent.--
``(1) In general.--Notwithstanding any other provision of
law, and subject to paragraph (2), a Tribal Health Program
shall have the authority to collect rents directly from Federal
employees who occupy such quarters in accordance with the
following:
``(A) The Tribal Health Program shall notify the
Secretary and the subject Federal employees of its
election to exercise its authority to collect rents
directly from such Federal employees.
``(B) Upon receipt of a notice described in
subparagraph (A), the Federal employees shall pay rents
for occupancy of such quarters directly to the Tribal
Health Program and the Secretary shall have no further
authority to collect rents from such employees through
payroll deduction or otherwise.
``(C) Such rent payments shall be retained by the
Tribal Health Program and shall not be made payable to
or otherwise be deposited with the United States.
``(D) Such rent payments shall be deposited into a
separate account which shall be used by the Tribal
Health Program for the maintenance (including capital
repairs and replacement) and operation of the quarters
and facilities as the Tribal Health Program shall
determine.
``(2) Retrocession of authority.--If a Tribal Health
Program which has made an election under paragraph (1) requests
retrocession of its authority to directly collect rents from
Federal employees occupying federally owned quarters, such
retrocession shall become effective on the earlier of--
``(A) the first day of the month that begins no
less than 180 days after the Tribal Health Program
notifies the Secretary of its desire to retrocede; or
``(B) such other date as may be mutually agreed by
the Secretary and the Tribal Health Program.
``(c) Rates in Alaska.--To the extent that a Tribal Health Program,
pursuant to authority granted in subsection (a), establishes rental
rates for federally owned quarters provided to a Federal employee in
Alaska, such rents may be based on the cost of comparable private
rental housing in the nearest established community with a year-round
population of 1,500 or more individuals.
``SEC. 315. APPLICABILITY OF BUY AMERICAN ACT REQUIREMENT.
``(a) Applicability.--The Secretary shall ensure that the
requirements of the Buy American Act apply to all procurements made
with funds provided pursuant to section 317. Indian Tribes and Tribal
Organizations shall be exempt from these requirements.
``(b) Effect of Violation.--If it has been finally determined by a
court or Federal agency that any person intentionally affixed a label
bearing a `Made in America' inscription or any inscription with the
same meaning, to any product sold in or shipped to the United States
that is not made in the United States, such person shall be ineligible
to receive any contract or subcontract made with funds provided
pursuant to section 317, pursuant to the debarment, suspension, and
ineligibility procedures described in sections 9.400 through 9.409 of
title 48, Code of Federal Regulations.
``(c) Definitions.--For purposes of this section, the term `Buy
American Act' means title III of the Act entitled `An Act making
appropriations for the Treasury and Post Office Departments for the
fiscal year ending June 30, 1934, and for other purposes', approved
March 3, 1933 (41 U.S.C. 10a et seq.).
``SEC. 316. OTHER FUNDING FOR FACILITIES.
``(a) Authority To Accept Funds.--The Secretary is authorized to
accept from any source, including Federal and State agencies, funds
that are available for the construction of health care facilities and
use such funds to plan, design, and construct health care facilities
for Indians and to place such funds into a contract or compact under
the Indian Self-Determination and Education Assistance Act (25 U.S.C.
450 et seq.). Receipt of such funds shall have no effect on the
priorities established pursuant to section 301.
``(b) Interagency Agreements.--The Secretary is authorized to enter
into interagency agreements with other Federal agencies or State
agencies and other entities and to accept funds from such Federal or
State agencies or other sources to provide for the planning, design,
and construction of health care facilities to be administered by Indian
Health Programs in order to carry out the purposes of this Act and the
purposes for which the funds were appropriated or for which the funds
were otherwise provided.
``(c) Transferred Funds.--Any Federal agency to which funds for the
construction of health care facilities are appropriated is authorized
to transfer such funds to the Secretary for the construction of health
care facilities to carry out the purposes of this Act as well as the
purposes for which such funds are appropriated to such other Federal
agency.
``(d) Establishment of Standards.--The Secretary, through the
Service, shall establish standards by regulation for the planning,
design, and construction of health care facilities serving Indians
under this Act.
``SEC. 317. AUTHORIZATION OF APPROPRIATIONS.
``There are authorized to be appropriated such sums as may be
necessary to carry out this title.
``TITLE IV--ACCESS TO HEALTH SERVICES
``SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SECURITY ACT HEALTH
BENEFITS PROGRAMS.
``(a) Disregard of Medicare, Medicaid, and SCHIP Payments in
Determining Appropriations.--Any payments received by an Indian Health
Program or by an urban Indian organization under title XVIII, XIX, or
XXI of the Social Security Act for services provided to Indians
eligible for benefits under such respective titles shall not be
considered in determining appropriations for the provision of health
care and services to Indians.
``(b) Nonpreferential Treatment.--Nothing in this Act authorizes
the Secretary to provide services to an Indian with coverage under
title XVIII, XIX, or XXI of the Social Security Act in preference to an
Indian without such coverage.
``(c) Use of Funds.--
``(1) Special fund.--
``(A) 100 percent pass-through of payments due to
facilities.--Notwithstanding any other provision of
law, but subject to paragraph (2), payments to which a
facility of the Service is entitled by reason of a
provision of title XVIII or XIX of the Social Security
Act shall be placed in a special fund to be held by the
Secretary. In making payments from such fund, the
Secretary shall ensure that each Service Unit of the
Service receives 100 percent of the amount to which the
facilities of the Service, for which such Service Unit
makes collections, are entitled by reason of a
provision of either such title.
``(B) Use of funds.--Amounts received by a facility
of the Service under subparagraph (A) by reason of a
provision of title XVIII or XIX of the Social Security
Act shall first be used (to such extent or in such
amounts as are provided in appropriation Acts) for the
purpose of making any improvements in the programs of
the Service operated by or through such facility which
may be necessary to achieve or maintain compliance with
the applicable conditions and requirements of such
respective title. Any amounts so received that are in
excess of the amount necessary to achieve or maintain
such conditions and requirements shall, subject to
consultation with the Indian Tribes being served by the
Service Unit, be used for increasing the facility's
capacity to provide, or improving the quality or
accessibility of, services.
``(2) Direct payment option.--Paragraph (1) shall not apply
to a Tribal Health Program upon the election of such Program
under subsection (d) to receive payments directly. No payment
may be made out of the special fund described in such paragraph
with respect to reimbursement made for services provided by
such Program during the period of such election.
``(d) Direct Billing.--
``(1) In general.--Subject to complying with the
requirements of paragraph (2), a Tribal Health Program may
elect to directly bill for, and receive payment for, health
care items and services provided by such Program for which
payment is made under title XVIII, XIX, or XXI of the Social
Security Act.
``(2) Direct reimbursement.--
``(A) Use of funds.--Each Tribal Health Program
making the election described in paragraph (1) with
respect to a program under title XVIII, XIX, or XXI of
the Social Security Act shall be reimbursed directly by
that program for items and services furnished without
regard to subsection (c)(1), but all amounts so
reimbursed shall be used by the Tribal Health Program
for the same purposes with respect to such Program for
which payment under subparagraph (A) of subsection
(c)(1) to a facility of the Service may be used
pursuant to subparagraph (B) of such subsection with
respect to the Service.
``(B) Audits.--The amounts paid to a Tribal Health
Program making the election described in paragraph (1)
with respect to a program under title XVIII, XIX, or
XXI of the Social Security Act shall be subject to all
auditing requirements applicable to the program under
such title, as well as all auditing requirements
applicable to programs administered by an Indian Health
Program. Nothing in the preceding sentence shall be
construed as limiting the application of auditing
requirements applicable to amounts paid under title
XVIII, XIX, or XXI of the Social Security Act.
``(C) Identification of source of payments.--Any
Tribal Health Program that receives reimbursements or
payments under title XVIII, XIX, or XXI of the Social
Security Act shall provide to the Service a list of
each provider enrollment number (or other identifier)
under which such Program receives such reimbursements
or payments.
``(3) Examination and implementation of changes.--
``(A) In general.--The Secretary, acting through
the Service and with the assistance of the
Administrator of the Centers for Medicare & Medicaid
Services, shall examine on an ongoing basis and
implement any administrative changes that may be
necessary to facilitate direct billing and
reimbursement under the program established under this
subsection, including any agreements with States that
may be necessary to provide for direct billing under a
program under title XIX or XXI of the Social Security
Act.
``(B) Coordination of information.--The Service
shall provide the Administrator of the Centers for
Medicare & Medicaid Services with copies of the lists
submitted to the Service under paragraph (2)(C),
enrollment data regarding patients served by the
Service (and by Tribal Health Programs, to the extent
such data is available to the Service), and such other
information as the Administrator may require for
purposes of administering title XVIII, XIX, or XXI of
the Social Security Act.
``(4) Withdrawal from program.--A Tribal Health Program
that bills directly under the program established under this
subsection may withdraw from participation in the same manner
and under the same conditions that an Indian Tribe or Tribal
Organization may retrocede a contracted program to the
Secretary under the authority of the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.). All cost
accounting and billing authority under the program established
under this subsection shall be returned to the Secretary upon
the Secretary's acceptance of the withdrawal of participation
in this program.
``(5) Termination for failure to comply with
requirements.--The Secretary may terminate the participation of
a Tribal Health Program or in the direct billing program
established under this subsection if the Secretary determines
that the Program has failed to comply with the requirements of
paragraph (2). The Secretary shall provide a Tribal Health
Program with notice of a determination that the Program has
failed to comply with any such requirement and a reasonable
opportunity to correct such noncompliance prior to terminating
the Program's participation in the direct billing program
established under this subsection.
``(e) Related Provisions Under the Social Security Act.--For
provisions related to subsections (c) and (d), see sections 1880, 1911,
and 2107(e)(1)(D) of the Social Security Act.
``SEC. 402. GRANTS TO AND CONTRACTS WITH THE SERVICE, INDIAN TRIBES,
TRIBAL ORGANIZATIONS, AND URBAN INDIAN ORGANIZATIONS TO
FACILITATE OUTREACH, ENROLLMENT, AND COVERAGE OF INDIANS
UNDER SOCIAL SECURITY ACT HEALTH BENEFIT PROGRAMS.
``(a) Indian Tribes and Tribal Organizations.--The Secretary,
acting through the Service, shall make grants to or enter into
contracts with Indian Tribes and Tribal Organizations to assist such
Tribes and Tribal Organizations in establishing and administering
programs on or near reservations, trust lands, and Alaska Native
Villages, including programs to provide outreach and enrollment through
video, electronic delivery methods, or telecommunication devices that
allow real-time or time-delayed communication between individual
Indians and the benefit program, to assist individual Indians--
``(1) to enroll for benefits under a program established
under title XVIII, XIX, or XXI of the Social Security Act; and
``(2) with respect to such programs for which the charging
of premiums and cost sharing is not prohibited under such
programs, to pay premiums or cost sharing for coverage for such
benefits, which may be based on financial need (as determined
by the Indian Tribe or Tribes or Tribal Organizations being
served based on a schedule of income levels developed or
implemented by such Tribe, Tribes, or Tribal Organizations).
``(b) Conditions.--The Secretary, acting through the Service, shall
place conditions as deemed necessary to effect the purpose of this
section in any grant or contract which the Secretary makes with any
Indian Tribe or Tribal Organization pursuant to this section. Such
conditions shall include requirements that the Indian Tribe or Tribal
Organization successfully undertake--
``(1) to determine the population of Indians eligible for
the benefits described in subsection (a);
``(2) to educate Indians with respect to the benefits
available under the respective programs;
``(3) to provide transportation for such individual Indians
to the appropriate offices for enrollment or applications for
such benefits; and
``(4) to develop and implement methods of improving the
participation of Indians in receiving benefits under such
programs.
``(c) Application to Urban Indian Organizations.--
``(1) In general.--The provisions of subsection (a) shall
apply with respect to grants and other funding to urban Indian
organizations with respect to populations served by such
organizations in the same manner they apply to grants and
contracts with Indian Tribes and Tribal Organizations with
respect to programs on or near reservations.
``(2) Requirements.--The Secretary shall include in the
grants or contracts made or provided under paragraph (1)
requirements that are--
``(A) consistent with the requirements imposed by
the Secretary under subsection (b);
``(B) appropriate to urban Indian organizations and
urban Indians; and
``(C) necessary to effect the purposes of this
section.
``(d) Facilitating Cooperation in Enrollment and Retention.--The
Secretary, acting through the Centers for Medicare & Medicaid Services,
shall consult with States, the Service, Indian Tribes, Tribal
Organizations, and urban Indian organizations to develop and
disseminate best practices with respect to facilitating agreements
between the States and Indian Tribes, Tribal Organizations, and urban
Indian organizations relating to enrollment and retention of Indians in
programs established under titles XVIII, XIX, and XXI of the Social
Security Act.
``(e) Agreements To Improve Enrollment of Indians Under Social
Security Act Health Benefits Programs.--For provisions relating to
agreements between the Secretary and the Service, Indian Tribes, Tribal
Organizations, and urban Indian organizations for the collection,
preparation, and submission of applications by Indians for assistance
under the Medicaid and children's health insurance programs established
under titles XIX and XXI of the Social Security Act, and benefits under
the Medicare program established under title XVIII of such Act, see
subsections (a) and (b) of section 1139 of the Social Security Act.
``(f) Definitions.--In this section:
``(1) Premium.--The term `premium' includes any enrollment
fee or similar charge.
``(2) Cost sharing.--The term `cost sharing' includes any
deduction, deductible, copayment, coinsurance, or similar
charge.
``(3) Benefits.--The term `benefits' means, with respect
to--
``(A) title XVIII of the Social Security Act,
benefits under such title;
``(B) title XIX of such Act, medical assistance
under such title; and
``(C) title XXI of such Act, assistance under such
title.
``SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PARTIES OF COSTS OF HEALTH
SERVICES.
``(a) Right of Recovery.--Except as provided in subsection (f), the
United States, an Indian Tribe, or Tribal Organization shall have the
right to recover from an insurance company, health maintenance
organization, employee benefit plan, third-party tortfeasor, or any
other responsible or liable third party (including a political
subdivision or local governmental entity of a State) the reasonable
charges incurred by the Secretary, an Indian Tribe, or Tribal
Organization, or, if higher, the highest amount the third party would
pay for care and services furnished by providers other than
governmental entities, in providing health services through the
Service, an Indian Tribe, or Tribal Organization to any individual to
the same extent that such individual, or any nongovernmental provider
of such services, would be eligible to receive damages, reimbursement,
or indemnification for such charges if--
``(1) such services had been provided by a nongovernmental
provider; and
``(2) such individual had been required to pay such charges
or expenses and did pay such charges or expenses.
``(b) Limitations on Recoveries From States.--Subsection (a) shall
provide a right of recovery against any State, only if the injury,
illness, or disability for which health services were provided is
covered under--
``(1) workers' compensation laws; or
``(2) a no-fault automobile accident insurance plan or
program.
``(c) Nonapplication of Other Laws.--No law of any State, or of any
political subdivision of a State and no provision of any contract,
insurance or health maintenance organization policy, employee benefit
plan, self-insurance plan, managed care plan, or other health care plan
or program entered into or renewed after the date of the enactment of
the Indian Health Care Amendments of 1988, shall prevent or hinder the
right of recovery of the United States, an Indian Tribe, or Tribal
Organization under subsection (a).
``(d) No Effect on Private Rights of Action.--No action taken by
the United States, an Indian Tribe, or Tribal Organization to enforce
the right of recovery provided under this section shall operate to deny
to the injured person the recovery for that portion of the person's
damage not covered hereunder.
``(e) Enforcement.--
``(1) In general.--The United States, an Indian Tribe, or
Tribal Organization may enforce the right of recovery provided
under subsection (a) by--
``(A) intervening or joining in any civil action or
proceeding brought--
``(i) by the individual for whom health
services were provided by the Secretary, an
Indian Tribe, or Tribal Organization; or
``(ii) by any representative or heirs of
such individual, or
``(B) instituting a civil action, including a civil
action for injunctive relief and other relief and
including, with respect to a political subdivision or
local governmental entity of a State, such an action
against an official thereof.
``(2) Notice.--All reasonable efforts shall be made to
provide notice of action instituted under paragraph (1)(B) to
the individual to whom health services were provided, either
before or during the pendency of such action.
``(3) Recovery from tortfeasors.--
``(A) In general.--In any case in which an Indian
Tribe or Tribal Organization that is authorized or
required under a compact or contract issued pursuant to
the Indian Self-Determination and Education Assistance
Act (25 U.S.C. 450 et seq.) to furnish or pay for
health services to a person who is injured or suffers a
disease on or after the date of enactment of the Indian
Health Care Improvement Act Amendments of 2009 under
circumstances that establish grounds for a claim of
liability against the tortfeasor with respect to the
injury or disease, the Indian Tribe or Tribal
Organization shall have a right to recover from the
tortfeasor (or an insurer of the tortfeasor) the
reasonable value of the health services so furnished,
paid for, or to be paid for, in accordance with the
Federal Medical Care Recovery Act (42 U.S.C. 2651 et
seq.), to the same extent and under the same
circumstances as the United States may recover under
that Act.
``(B) Treatment.--The right of an Indian Tribe or
Tribal Organization to recover under subparagraph (A)
shall be independent of the rights of the injured or
diseased person served by the Indian Tribe or Tribal
Organization.
``(f) Limitation.--Absent specific written authorization by the
governing body of an Indian Tribe for the period of such authorization
(which may not be for a period of more than 1 year and which may be
revoked at any time upon written notice by the governing body to the
Service), the United States shall not have a right of recovery under
this section if the injury, illness, or disability for which health
services were provided is covered under a self-insurance plan funded by
an Indian Tribe, Tribal Organization, or urban Indian organization.
Where such authorization is provided, the Service may receive and
expend such amounts for the provision of additional health services
consistent with such authorization.
``(g) Costs and Attorneys' Fees.--In any action brought to enforce
the provisions of this section, a prevailing plaintiff shall be awarded
its reasonable attorneys' fees and costs of litigation.
``(h) Nonapplication of Claims Filing Requirements.--An insurance
company, health maintenance organization, self-insurance plan, managed
care plan, or other health care plan or program (under the Social
Security Act or otherwise) may not deny a claim for benefits submitted
by the Service or by an Indian Tribe or Tribal Organization based on
the format in which the claim is submitted if such format complies with
the format required for submission of claims under title XVIII of the
Social Security Act or recognized under section 1175 of such Act.
``(i) Application to Urban Indian Organizations.--The previous
provisions of this section shall apply to urban Indian organizations
with respect to populations served by such Organizations in the same
manner they apply to Indian Tribes and Tribal Organizations with
respect to populations served by such Indian Tribes and Tribal
Organizations.
``(j) Statute of Limitations.--The provisions of section 2415 of
title 28, United States Code, shall apply to all actions commenced
under this section, and the references therein to the United States are
deemed to include Indian Tribes, Tribal Organizations, and urban Indian
organizations.
``(k) Savings.--Nothing in this section shall be construed to limit
any right of recovery available to the United States, an Indian Tribe,
or Tribal Organization under the provisions of any applicable, Federal,
State, or Tribal law, including medical lien laws.
``SEC. 404. CREDITING OF REIMBURSEMENTS.
``(a) Retention of Amounts for Use by Program.--Except as provided
in section 202(f) (relating to the Catastrophic Health Emergency Fund)
and section 806 (relating to health services for ineligible persons),
all reimbursements received or recovered, including under section 806,
by reason of the provision of health services by the Service, by an
Indian Tribe or Tribal Organization, or by an urban Indian
organization, shall be credited to the Service, such Indian Tribe or
Tribal Organization, or such urban Indian organization, respectively,
and may be used as provided in section 401. In the case of such a
service provided by or through a Service Unit, such amounts shall be
credited to such unit and used for such purposes.
``(b) No Offset of Amounts.--The Service may not offset or limit
any amount obligated to any Service Unit or entity receiving funding
from the Service because of the receipt of reimbursements under
subsection (a).
``SEC. 405. PURCHASING HEALTH CARE COVERAGE.
``(a) Purchasing Coverage.--
``(1) In general.--Insofar as amounts are made available
under law (including a provision of the Social Security Act,
the Indian Self-Determination and Education Assistance Act (25
U.S.C. 450 et seq.), or other law, other than under section
402) to Indian Tribes, Tribal Organizations, and urban Indian
organizations for health benefits for Service beneficiaries,
Indian Tribes, Tribal Organizations, and urban Indian
organizations may use such amounts to purchase health benefits
coverage that qualifies as creditable coverage under section
2701(c)(1) of the Public Health Service Act for such
beneficiaries, including, subject to paragraph (2), through--
``(A) a tribally owned and operated health care
plan;
``(B) a State or locally authorized or licensed
health care plan;
``(C) a health insurance provider or managed care
organization; or
``(D) a self-insured plan.
``(2) Exception.--The coverage provided under paragraph (1)
may not include coverage consisting of--
``(A) benefits provided under a health flexible
spending arrangement (as defined in section 106(c)(2)
of the Internal Revenue Code of 1986); or
``(B) a high deductible health plan (as defined in
section 223(c)(2) of such Code), without regard to
whether the plan is purchased in conjunction with a
health savings account (as defined under section 223(d)
of such Code).
``(3) Permitting purchase of coverage based on financial
need.--The purchase of coverage by an Indian Tribe, Tribal
Organization, or urban Indian organization under this
subsection may be based on the financial needs of beneficiaries
(as determined by the Indian Tribe or Tribes being served based
on a schedule of income levels developed or implemented by such
Indian Tribe or Tribes).
``(b) Expenses for Self-insured Plan.--In the case of a self-
insured plan under subsection (a)(4), the amounts may be used for
expenses of operating the plan, including administration and insurance
to limit the financial risks to the entity offering the plan.
``(c) Construction.--Nothing in this section shall be construed as
affecting the use of any amounts not referred to in subsection (a).
``SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGENCIES.
``(a) Authority.--
``(1) In general.--The Secretary may enter into (or expand)
arrangements for the sharing of medical facilities and services
between the Service, Indian Tribes, and Tribal Organizations
and the Department of Veterans Affairs and the Department of
Defense.
``(2) Consultation by secretary required.--The Secretary
may not finalize any arrangement between the Service and a
Department described in paragraph (1) without first consulting
with the Indian Tribes which will be significantly affected by
the arrangement.
``(b) Limitations.--The Secretary shall not take any action under
this section or under subchapter IV of chapter 81 of title 38, United
States Code, which would impair--
``(1) the priority access of any Indian to health care
services provided through the Service and the eligibility of
any Indian to receive health services through the Service;
``(2) the quality of health care services provided to any
Indian through the Service;
``(3) the priority access of any veteran to health care
services provided by the Department of Veterans Affairs;
``(4) the quality of health care services provided by the
Department of Veterans Affairs or the Department of Defense; or
``(5) the eligibility of any Indian who is a veteran to
receive health services through the Department of Veterans
Affairs.
``(c) Reimbursement.--The Service, Indian Tribe, or Tribal
Organization shall be reimbursed by the Department of Veterans Affairs
or the Department of Defense (as the case may be) where services are
provided through the Service, an Indian Tribe, or a Tribal Organization
to beneficiaries eligible for services from either such Department,
notwithstanding any other provision of law.
``(d) Construction.--Nothing in this section may be construed as
creating any right of a non-Indian veteran to obtain health services
from the Service.
``SEC. 407. ELIGIBLE INDIAN VETERAN SERVICES.
``(a) Findings; Purpose.--
``(1) Findings.--Congress finds that--
``(A) collaborations between the Secretary and the
Secretary of Veterans Affairs regarding the treatment
of Indian veterans at facilities of the Service should
be encouraged to the maximum extent practicable; and
``(B) increased enrollment for services of the
Department of Veterans Affairs by veterans who are
members of Indian tribes should be encouraged to the
maximum extent practicable.
``(2) Purpose.--The purpose of this section is to reaffirm
the goals stated in the document entitled `Memorandum of
Understanding Between the VA/Veterans Health Administration And
HHS/Indian Health Service' and dated February 25, 2003
(relating to cooperation and resource sharing between the
Veterans Health Administration and Service).
``(b) Definitions.--In this section:
``(1) Eligible indian veteran.--The term `eligible Indian
veteran' means an Indian or Alaska Native veteran who receives
any medical service that is--
``(A) authorized under the laws administered by the
Secretary of Veterans Affairs; and
``(B) administered at a facility of the Service
(including a facility operated by an Indian tribe or
tribal organization through a contract or compact with
the Service under the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.))
pursuant to a local memorandum of understanding.
``(2) Local memorandum of understanding.--The term `local
memorandum of understanding' means a memorandum of
understanding between the Secretary (or a designee, including
the director of any Area Office of the Service) and the
Secretary of Veterans Affairs (or a designee) to implement the
document entitled `Memorandum of Understanding Between the VA/
Veterans Health Administration And HHS/Indian Health Service'
and dated February 25, 2003 (relating to cooperation and
resource sharing between the Veterans Health Administration and
Indian Health Service).
``(c) Eligible Indian Veterans' Expenses.--
``(1) In general.--Notwithstanding any other provision of
law, the Secretary shall provide for veteran-related expenses
incurred by eligible Indian veterans as described in subsection
(b)(1)(B).
``(2) Method of payment.--The Secretary shall establish
such guidelines as the Secretary determines to be appropriate
regarding the method of payments to the Secretary of Veterans
Affairs under paragraph (1).
``(d) Tribal Approval of Memoranda.--In negotiating a local
memorandum of understanding with the Secretary of Veterans Affairs
regarding the provision of services to eligible Indian veterans, the
Secretary shall consult with each Indian tribe that would be affected
by the local memorandum of understanding.
``(e) Funding.--
``(1) Treatment.--Expenses incurred by the Secretary in
carrying out subsection (c)(1) shall not be considered to be
Contract Health Service expenses.
``(2) Use of funds.--Of funds made available to the
Secretary in appropriations Acts for the Service (excluding
funds made available for facilities, Contract Health Services,
or contract support costs), the Secretary shall use such sums
as are necessary to carry out this section.
``SEC. 408. PAYOR OF LAST RESORT.
``Indian Health Programs and health care programs operated by Urban
Indian Organizations shall be the payor of last resort for services
provided to persons eligible for services from Indian Health Programs
and Urban Indian Organizations, notwithstanding any Federal, State, or
local law to the contrary.
``SEC. 409. CONSULTATION.
``For provisions related to consultation with representatives of
Indian Health Programs and urban Indian organizations with respect to
the health care programs established under titles XVIII, XIX, and XXI
of the Social Security Act, see section 1139(d) of the Social Security
Act (42 U.S.C. 1320b-9(d)).
``SEC. 410. STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP).
``For provisions relating to--
``(1) outreach to families of Indian children likely to be
eligible for child health assistance under the State children's
health insurance program established under title XXI of the
Social Security Act, see sections 2105(c)(2)(C) and 1139(a) of
such Act (42 U.S.C. 1397ee(c)(2), 1320b-9); and
``(2) ensuring that child health assistance is provided
under such program to targeted low-income children who are
Indians and that payments are made under such program to Indian
Health Programs and urban Indian organizations operating in the
State that provide such assistance, see sections 2102(b)(3)(D)
and 2105(c)(6)(B) of such Act (42 U.S.C. 1397bb(b)(3)(D),
1397ee(c)(6)(B)).
``SEC. 411. PREMIUM AND COST SHARING PROTECTIONS AND ELIGIBILITY
DETERMINATIONS UNDER MEDICAID AND SCHIP AND PROTECTION OF
CERTAIN INDIAN PROPERTY FROM MEDICAID ESTATE RECOVERY.
``For provisions relating to--
``(1) premiums or cost sharing protections for Indians
furnished items or services directly by Indian Health Programs
or through referral under the contract health service under the
Medicaid program established under title XIX of the Social
Security Act, see sections 1916(j) and 1916A(a)(1) of the
Social Security Act (42 U.S.C. 1396o(j), 1396o-1(a)(1));
``(2) rules regarding the treatment of certain property for
purposes of determining eligibility under such programs, see
sections 1902(e)(13) and 2107(e)(1)(B) of such Act (42 U.S.C.
1396a(e)(13), 1397gg(e)(1)(B)); and
``(3) the protection of certain property from estate
recovery provisions under the Medicaid program, see section
1917(b)(3)(B) of such Act (42 U.S.C. 1396p(b)(3)(B)).
``SEC. 412. TREATMENT UNDER MEDICAID AND SCHIP MANAGED CARE.
``For provisions relating to the treatment of Indians enrolled in a
managed care entity under the Medicaid program under title XIX of the
Social Security Act and Indian Health Programs and urban Indian
organizations that are providers of items or services to such Indian
enrollees, see sections 1932(h) and 2107(e)(1)(H) of the Social
Security Act (42 U.S.C. 1396u-2(h), 1397gg(e)(1)(H)).
``SEC. 413. NAVAJO NATION MEDICAID AGENCY FEASIBILITY STUDY.
``(a) Study.--The Secretary shall conduct a study to determine the
feasibility of treating the Navajo Nation as a State for the purposes
of title XIX of the Social Security Act, to provide services to Indians
living within the boundaries of the Navajo Nation through an entity
established having the same authority and performing the same functions
as single-State Medicaid agencies responsible for the administration of
the State plan under title XIX of the Social Security Act.
``(b) Considerations.--In conducting the study, the Secretary shall
consider the feasibility of--
``(1) assigning and paying all expenditures for the
provision of services and related administration funds, under
title XIX of the Social Security Act, to Indians living within
the boundaries of the Navajo Nation that are currently paid to
or would otherwise be paid to the State of Arizona, New Mexico,
or Utah;
``(2) providing assistance to the Navajo Nation in the
development and implementation of such entity for the
administration, eligibility, payment, and delivery of medical
assistance under title XIX of the Social Security Act;
``(3) providing an appropriate level of matching funds for
Federal medical assistance with respect to amounts such entity
expends for medical assistance for services and related
administrative costs; and
``(4) authorizing the Secretary, at the option of the
Navajo Nation, to treat the Navajo Nation as a State for the
purposes of title XIX of the Social Security Act (relating to
the State children's health insurance program) under terms
equivalent to those described in paragraphs (2) through (4).
``(c) Report.--Not later than 3 years after the date of enactment
of the Indian Health Care Improvement Act Amendments of 2009, the
Secretary shall submit to the Committee on Indian Affairs and Committee
on Finance of the Senate and the Committee on Natural Resources and
Committee on Energy and Commerce of the House of Representatives a
report that includes--
``(1) the results of the study under this section;
``(2) a summary of any consultation that occurred between
the Secretary and the Navajo Nation, other Indian Tribes, the
States of Arizona, New Mexico, and Utah, counties which include
Navajo Lands, and other interested parties, in conducting this
study;
``(3) projected costs or savings associated with
establishment of such entity, and any estimated impact on
services provided as described in this section in relation to
probable costs or savings; and
``(4) legislative actions that would be required to
authorize the establishment of such entity if such entity is
determined by the Secretary to be feasible.
``SEC. 414. EXCEPTION FOR EXCEPTED BENEFITS.
``The previous provisions of this title shall not apply to the
provision of excepted benefits described in paragraph (1)(A) or (3) of
section 2791(c) of the Public Health Service Act (42 U.S.C. 300gg-
91(c)).
``SEC. 415. AUTHORIZATION OF APPROPRIATIONS.
``There are authorized to be appropriated such sums as may be
necessary to carry out this title.
``TITLE V--HEALTH SERVICES FOR URBAN INDIANS
``SEC. 501. PURPOSE.
``The purpose of this title is to establish and maintain programs
in Urban Centers to make health services more accessible and available
to Urban Indians.
``SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN INDIAN ORGANIZATIONS.
``Under authority of the Act of November 2, 1921 (25 U.S.C. 13)
(commonly known as the `Snyder Act'), the Secretary, acting through the
Service, shall enter into contracts with, or make grants to, urban
Indian organizations to assist such organizations in the establishment
and administration, within Urban Centers, of programs which meet the
requirements set forth in this title. Subject to section 506, the
Secretary, acting through the Service, shall include such conditions as
the Secretary considers necessary to effect the purpose of this title
in any contract into which the Secretary enters with, or in any grant
the Secretary makes to, any urban Indian organization pursuant to this
title.
``SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION OF HEALTH CARE AND
REFERRAL SERVICES.
``(a) Requirements for Grants and Contracts.--Under authority of
the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the
`Snyder Act'), the Secretary, acting through the Service, shall enter
into contracts with, and make grants to, urban Indian organizations for
the provision of health care and referral services for Urban Indians.
Any such contract or grant shall include requirements that the urban
Indian organization successfully undertake to--
``(1) estimate the population of Urban Indians residing in
the Urban Center or centers that the organization proposes to
serve who are or could be recipients of health care or referral
services;
``(2) estimate the current health status of Urban Indians
residing in such Urban Center or centers;
``(3) estimate the current health care needs of Urban
Indians residing in such Urban Center or centers;
``(4) provide basic health education, including health
promotion and disease prevention education, to Urban Indians;
``(5) make recommendations to the Secretary and Federal,
State, local, and other resource agencies on methods of
improving health service programs to meet the needs of Urban
Indians; and
``(6) where necessary, provide, or enter into contracts for
the provision of, health care services for Urban Indians.
``(b) Criteria.--The Secretary, acting through the Service, shall,
by regulation, prescribe the criteria for selecting urban Indian
organizations to enter into contracts or receive grants under this
section. Such criteria shall, among other factors, include--
``(1) the extent of unmet health care needs of Urban
Indians in the Urban Center or centers involved;
``(2) the size of the urban Indian population in the Urban
Center or centers involved;
``(3) the extent, if any, to which the activities set forth
in subsection (a) would duplicate any project funded under this
title, or under any current public health service project
funded in a manner other than pursuant to this title;
``(4) the capability of an urban Indian organization to
perform the activities set forth in subsection (a) and to enter
into a contract with the Secretary or to meet the requirements
for receiving a grant under this section;
``(5) the satisfactory performance and successful
completion by an urban Indian organization of other contracts
with the Secretary under this title;
``(6) the appropriateness and likely effectiveness of
conducting the activities set forth in subsection (a) in an
Urban Center or centers; and
``(7) the extent of existing or likely future participation
in the activities set forth in subsection (a) by appropriate
health and health-related Federal, State, local, and other
agencies.
``(c) Access to Health Promotion and Disease Prevention Programs.--
The Secretary, acting through the Service, shall facilitate access to
or provide health promotion and disease prevention services for Urban
Indians through grants made to urban Indian organizations administering
contracts entered into or receiving grants under subsection (a).
``(d) Immunization Services.--
``(1) Access or services provided.--The Secretary, acting
through the Service, shall facilitate access to, or provide,
immunization services for Urban Indians through grants made to
urban Indian organizations administering contracts entered into
or receiving grants under this section.
``(2) Definition.--For purposes of this subsection, the
term `immunization services' means services to provide without
charge immunizations against vaccine-preventable diseases.
``(e) Behavioral Health Services.--
``(1) Access or services provided.--The Secretary, acting
through the Service, shall facilitate access to, or provide,
behavioral health services for Urban Indians through grants
made to urban Indian organizations administering contracts
entered into or receiving grants under subsection (a).
``(2) Assessment required.--Except as provided by paragraph
(3)(A), a grant may not be made under this subsection to an
urban Indian organization until that organization has prepared,
and the Service has approved, an assessment of the following:
``(A) The behavioral health needs of the urban
Indian population concerned.
``(B) The behavioral health services and other
related resources available to that population.
``(C) The barriers to obtaining those services and
resources.
``(D) The needs that are unmet by such services and
resources.
``(3) Purposes of grants.--Grants may be made under this
subsection for the following:
``(A) To prepare assessments required under
paragraph (2).
``(B) To provide outreach, educational, and
referral services to Urban Indians regarding the
availability of direct behavioral health services, to
educate Urban Indians about behavioral health issues
and services, and effect coordination with existing
behavioral health providers in order to improve
services to Urban Indians.
``(C) To provide outpatient behavioral health
services to Urban Indians, including the identification
and assessment of illness, therapeutic treatments, case
management, support groups, family treatment, and other
treatment.
``(D) To develop innovative behavioral health
service delivery models which incorporate Indian
cultural support systems and resources.
``(f) Prevention of Child Abuse.--
``(1) Access or services provided.--The Secretary, acting
through the Service, shall facilitate access to or provide
services for Urban Indians through grants to urban Indian
organizations administering contracts entered into or receiving
grants under subsection (a) to prevent and treat child abuse
(including sexual abuse) among Urban Indians.
``(2) Evaluation required.--Except as provided by paragraph
(3)(A), a grant may not be made under this subsection to an
urban Indian organization until that organization has prepared,
and the Service has approved, an assessment that documents the
prevalence of child abuse in the urban Indian population
concerned and specifies the services and programs (which may
not duplicate existing services and programs) for which the
grant is requested.
``(3) Purposes of grants.--Grants may be made under this
subsection for the following:
``(A) To prepare assessments required under
paragraph (2).
``(B) For the development of prevention, training,
and education programs for Urban Indians, including
child education, parent education, provider training on
identification and intervention, education on reporting
requirements, prevention campaigns, and establishing
service networks of all those involved in Indian child
protection.
``(C) To provide direct outpatient treatment
services (including individual treatment, family
treatment, group therapy, and support groups) to Urban
Indians who are child victims of abuse (including
sexual abuse) or adult survivors of child sexual abuse,
to the families of such child victims, and to urban
Indian perpetrators of child abuse (including sexual
abuse).
``(4) Considerations when making grants.--In making grants
to carry out this subsection, the Secretary shall take into
consideration--
``(A) the support for the urban Indian organization
demonstrated by the child protection authorities in the
area, including committees or other services funded
under the Indian Child Welfare Act of 1978 (25 U.S.C.
1901 et seq.), if any;
``(B) the capability and expertise demonstrated by
the urban Indian organization to address the complex
problem of child sexual abuse in the community; and
``(C) the assessment required under paragraph (2).
``(g) Other Grants.--The Secretary, acting through the Service, may
enter into a contract with or make grants to an urban Indian
organization that provides or arranges for the provision of health care
services (through satellite facilities, provider networks, or
otherwise) to Urban Indians in more than 1 Urban Center.
``SEC. 504. USE OF FEDERAL GOVERNMENT FACILITIES AND SOURCES OF SUPPLY.
``(a) In General.--The Secretary may permit an urban Indian
organization that has entered into a contract or received a grant
pursuant to this title, in carrying out such contract or grant, to use
existing facilities and all equipment therein or pertaining thereto and
other personal property owned by the Federal Government within the
Secretary's jurisdiction under such terms and conditions as may be
agreed upon for their use and maintenance.
``(b) Donations.--Subject to subsection (d), the Secretary may
donate to an urban Indian organization that has entered into a contract
or received a grant pursuant to this title any personal or real
property determined to be excess to the needs of the Indian Health
Service or the General Services Administration for the purposes of
carrying out the contract or grant.
``(c) Acquisition of Property.--The Secretary may acquire excess or
surplus government personal or real property for donation, subject to
subsection (d) to an urban Indian organization that has entered into a
contract or received a grant pursuant to this title if the Secretary
determines that the property is appropriate for use by the urban Indian
organization for a purpose for which a contract or grant is authorized
under this title.
``(d) Priority.--In the event that the Secretary receives a request
for a specific item of personal or real property described in
subsections (b) or (c) from an urban Indian organization and from an
Indian Tribe or Tribal Organization, the Secretary shall give priority
to the request for donation to the Indian Tribe or Tribal Organization
if the Secretary receives the request from the Indian Tribe or Tribal
Organization before the date the Secretary transfers title to the
property or, if earlier, the date the Secretary transfers the property
physically, to the urban Indian organization.
``(e) Executive Agency Status.--For purposes of section 201(a) of
the Federal Property and Administrative Services Act of 1949 (40 U.S.C.
481(a)) (relating to Federal sources of supply), an urban Indian
organization that has entered into a contract or received a grant
pursuant to this title may be deemed to be an executive agency when
carrying out such contract or grant.
``SEC. 505. CONTRACTS AND GRANTS FOR THE DETERMINATION OF UNMET HEALTH
CARE NEEDS.
``(a) Grants and Contracts Authorized.--Under authority of the Act
of November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder
Act'), the Secretary, acting through the Service, may enter into
contracts with or make grants to urban Indian organizations situated in
Urban Centers for which contracts have not been entered into or grants
have not been made under section 503.
``(b) Purpose.--The purpose of a contract or grant made under this
section shall be the determination of the matters described in
subsection (c)(1) in order to assist the Secretary in assessing the
health status and health care needs of Urban Indians in the Urban
Center involved and determining whether the Secretary should enter into
a contract or make a grant under section 503 with respect to the urban
Indian organization which the Secretary has entered into a contract
with, or made a grant to, under this section.
``(c) Grant and Contract Requirements.--Any contract entered into,
or grant made, by the Secretary under this section shall include
requirements that--
``(1) the urban Indian organization successfully undertakes
to--
``(A) document the health care status and unmet
health care needs of urban Indians in the Urban Center
involved; and
``(B) with respect to urban Indians in the Urban
Center involved, determine the matters described in
paragraphs (2), (3), (4), and (7) of section 503(b);
and
``(2) the urban Indian organization complete performance of
the contract, or carry out the requirements of the grant,
within 1 year after the date on which the Secretary and such
organization enter into such contract, or within 1 year after
such organization receives such grant, whichever is applicable.
``(d) No Renewals.--The Secretary may not renew any contract
entered into or grant made under this section.
``SEC. 506. EVALUATIONS; RENEWALS.
``(a) Procedures for Evaluations.--The Secretary, acting through
the Service, shall develop procedures to evaluate compliance with grant
requirements and compliance with and performance of contracts entered
into by urban Indian organizations under this title. Such procedures
shall include provisions for carrying out the requirements of this
section.
``(b) Evaluations.--The Secretary, acting through the Service,
shall evaluate the compliance of each Urban Indian Organization which
has entered into a contract or received a grant under section 503 with
the terms of such contract or grant. For purposes of this evaluation,
the Secretary shall--
``(1) acting through the Service, conduct an annual onsite
evaluation of the organization; or
``(2) accept in lieu of such onsite evaluation evidence of
the organization's provisional or full accreditation by a
private independent entity recognized by the Secretary for
purposes of conducting quality reviews of providers
participating in the Medicare program under title XVIII of the
Social Security Act.
``(c) Noncompliance; Unsatisfactory Performance.--If, as a result
of the evaluations conducted under this section, the Secretary
determines that an urban Indian organization has not complied with the
requirements of a grant or complied with or satisfactorily performed a
contract under section 503, the Secretary shall, prior to renewing such
contract or grant, attempt to resolve with the organization the areas
of noncompliance or unsatisfactory performance and modify the contract
or grant to prevent future occurrences of noncompliance or
unsatisfactory performance. If the Secretary determines that the
noncompliance or unsatisfactory performance cannot be resolved and
prevented in the future, the Secretary shall not renew the contract or
grant with the organization and is authorized to enter into a contract
or make a grant under section 503 with another urban Indian
organization which is situated in the same Urban Center as the urban
Indian organization whose contract or grant is not renewed under this
section.
``(d) Considerations for Renewals.--In determining whether to renew
a contract or grant with an urban Indian organization under section 503
which has completed performance of a contract or grant under section
504, the Secretary shall review the records of the urban Indian
organization, the reports submitted under section 507, and shall
consider the results of the onsite evaluations or accreditations under
subsection (b).
``SEC. 507. OTHER CONTRACT AND GRANT REQUIREMENTS.
``(a) Procurement.--Contracts with urban Indian organizations
entered into pursuant to this title shall be in accordance with all
Federal contracting laws and regulations relating to procurement except
that in the discretion of the Secretary, such contracts may be
negotiated without advertising and need not conform to the provisions
of sections 1304 and 3131 through 3133 of title 40, United States Code.
``(b) Payments Under Contracts or Grants.--
``(1) In general.--Payments under any contracts or grants
pursuant to this title, notwithstanding any term or condition
of such contract or grant--
``(A) may be made in a single advance payment by
the Secretary to the urban Indian organization by no
later than the end of the first 30 days of the funding
period with respect to which the payments apply, unless
the Secretary determines through an evaluation under
section 505 that the organization is not capable of
administering such a single advance payment; and
``(B) if any portion thereof is unexpended by the
urban Indian organization during the funding period
with respect to which the payments initially apply,
shall be carried forward for expenditure with respect
to allowable or reimbursable costs incurred by the
organization during 1 or more subsequent funding
periods without additional justification or
documentation by the organization as a condition of
carrying forward the availability for expenditure of
such funds.
``(2) Semiannual and quarterly payments and
reimbursements.--If the Secretary determines under paragraph
(1)(A) that an urban Indian organization is not capable of
administering an entire single advance payment, on request of
the urban Indian organization, the payments may be made--
``(A) in semiannual or quarterly payments by not
later than 30 days after the date on which the funding
period with respect to which the payments apply begins;
or
``(B) by way of reimbursement.
``(c) Revision or Amendment of Contracts.--Notwithstanding any
provision of law to the contrary, the Secretary may, at the request and
consent of an urban Indian organization, revise or amend any contract
entered into by the Secretary with such organization under this title
as necessary to carry out the purposes of this title.
``(d) Fair and Uniform Services and Assistance.--Contracts with or
grants to urban Indian organizations and regulations adopted pursuant
to this title shall include provisions to assure the fair and uniform
provision to urban Indians of services and assistance under such
contracts or grants by such organizations.
``SEC. 508. REPORTS AND RECORDS.
``(a) Reports.--
``(1) In general.--For each fiscal year during which an
urban Indian organization receives or expends funds pursuant to
a contract entered into or a grant received pursuant to this
title, such urban Indian organization shall submit to the
Secretary not more frequently than every 6 months, a report
that includes the following:
``(A) In the case of a contract or grant under
section 503, recommendations pursuant to section
503(a)(5).
``(B) Information on activities conducted by the
organization pursuant to the contract or grant.
``(C) An accounting of the amounts and purpose for
which Federal funds were expended.
``(D) A minimum set of data, using uniformly
defined elements, as specified by the Secretary after
consultation with urban Indian organizations.
``(2) Health status and services.--
``(A) In general.--Not later than 18 months after
the date of enactment of the Indian Health Care
Improvement Act Amendments of 2009, the Secretary,
acting through the Service, shall submit to Congress a
report evaluating--
``(i) the health status of urban Indians;
``(ii) the services provided to Indians
pursuant to this title; and
``(iii) areas of unmet needs in the
delivery of health services to urban Indians.
``(B) Consultation and contracts.--In preparing the
report under paragraph (1), the Secretary--
``(i) shall consult with urban Indian
organizations; and
``(ii) may enter into a contract with a
national organization representing urban Indian
organizations to conduct any aspect of the
report.
``(b) Audit.--The reports and records of the urban Indian
organization with respect to a contract or grant under this title shall
be subject to audit by the Secretary and the Comptroller General of the
United States.
``(c) Costs of Audits.--The Secretary shall allow as a cost of any
contract or grant entered into or awarded under section 502 or 503 the
cost of an annual independent financial audit conducted by--
``(1) a certified public accountant; or
``(2) a certified public accounting firm qualified to
conduct Federal compliance audits.
``SEC. 509. LIMITATION ON CONTRACT AUTHORITY.
``The authority of the Secretary to enter into contracts or to
award grants under this title shall be to the extent, and in an amount,
provided for in appropriation Acts.
``SEC. 510. FACILITIES.
``(a) Grants.--The Secretary, acting through the Service, may make
grants to contractors or grant recipients under this title for the
lease, purchase, renovation, construction, or expansion of facilities,
including leased facilities, in order to assist such contractors or
grant recipients in complying with applicable licensure or
certification requirements.
``(b) Loan Fund Study.--The Secretary, acting through the Service,
may carry out a study to determine the feasibility of establishing a
loan fund to provide to urban Indian organizations direct loans or
guarantees for loans for the construction of health care facilities in
a manner consistent with section 309, including by submitting a report
in accordance with subsection (c) of that section.
``SEC. 511. DIVISION OF URBAN INDIAN HEALTH.
``There is established within the Service a Division of Urban
Indian Health, which shall be responsible for--
``(1) carrying out the provisions of this title;
``(2) providing central oversight of the programs and
services authorized under this title; and
``(3) providing technical assistance to urban Indian
organizations.
``SEC. 512. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE-RELATED SERVICES.
``(a) Grants Authorized.--The Secretary, acting through the
Service, may make grants for the provision of health-related services
in prevention of, treatment of, rehabilitation of, or school- and
community-based education regarding, alcohol and substance abuse in
Urban Centers to those urban Indian organizations with which the
Secretary has entered into a contract under this title or under section
201.
``(b) Goals.--Each grant made pursuant to subsection (a) shall set
forth the goals to be accomplished pursuant to the grant. The goals
shall be specific to each grant as agreed to between the Secretary and
the grantee.
``(c) Criteria.--The Secretary shall establish criteria for the
grants made under subsection (a), including criteria relating to the
following:
``(1) The size of the urban Indian population.
``(2) Capability of the organization to adequately perform
the activities required under the grant.
``(3) Satisfactory performance standards for the
organization in meeting the goals set forth in such grant. The
standards shall be negotiated and agreed to between the
Secretary and the grantee on a grant-by-grant basis.
``(4) Identification of the need for services.
``(d) Allocation of Grants.--The Secretary shall develop a
methodology for allocating grants made pursuant to this section based
on the criteria established pursuant to subsection (c).
``(e) Grants Subject to Criteria.--Any grant received by an urban
Indian organization under this Act for substance abuse prevention,
treatment, and rehabilitation shall be subject to the criteria set
forth in subsection (c).
``SEC. 513. TREATMENT OF CERTAIN DEMONSTRATION PROJECTS.
``Notwithstanding any other provision of law, the Tulsa Clinic and
Oklahoma City Clinic demonstration projects shall--
``(1) be permanent programs within the Service's direct
care program;
``(2) continue to be treated as Service Units and Operating
Units in the allocation of resources and coordination of care;
and
``(3) continue to meet the requirements and definitions of
an urban Indian organization in this Act, and shall not be
subject to the provisions of the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.).
``SEC. 514. URBAN NIAAA TRANSFERRED PROGRAMS.
``(a) Grants and Contracts.--The Secretary, through the Division of
Urban Indian Health, shall make grants or enter into contracts with
urban Indian organizations, to take effect not later than September 30,
2010, for the administration of urban Indian alcohol programs that were
originally established under the National Institute on Alcoholism and
Alcohol Abuse (hereafter in this section referred to as `NIAAA') and
transferred to the Service.
``(b) Use of Funds.--Grants provided or contracts entered into
under this section shall be used to provide support for the
continuation of alcohol prevention and treatment services for urban
Indian populations and such other objectives as are agreed upon between
the Service and a recipient of a grant or contract under this section.
``(c) Eligibility.--Urban Indian organizations that operate Indian
alcohol programs originally funded under the NIAAA and subsequently
transferred to the Service are eligible for grants or contracts under
this section.
``(d) Report.--The Secretary shall evaluate and report to Congress
on the activities of programs funded under this section not less than
every 5 years.
``SEC. 515. CONFERRING WITH URBAN INDIAN ORGANIZATIONS.
``(a) In General.--The Secretary shall ensure that the Service
confers or conferences, to the greatest extent practicable, with Urban
Indian Organizations.
``(b) Definition of Confer; Conference.--In this section, the terms
`confer' and `conference' mean an open and free exchange of information
and opinions that--
``(1) leads to mutual understanding and comprehension; and
``(2) emphasizes trust, respect, and shared responsibility.
``SEC. 516. URBAN YOUTH TREATMENT CENTER DEMONSTRATION.
``(a) Construction and Operation.--
``(1) In general.--The Secretary, acting through the
Service, through grant or contract, shall fund the construction
and operation of at least 1 residential treatment center in
each Service Area that meets the eligibility requirements set
forth in subsection (b) to demonstrate the provision of alcohol
and substance abuse treatment services to Urban Indian youth in
a culturally competent residential setting.
``(2) Treatment.--Each residential treatment center
described in paragraph (1) shall be in addition to any
facilities constructed under section 707(b).
``(b) Eligibility Requirements.--To be eligible to obtain a
facility under subsection (a)(1), a Service Area shall meet the
following requirements:
``(1) There is an Urban Indian Organization in the Service
Area.
``(2) There reside in the Service Area Urban Indian youth
with need for alcohol and substance abuse treatment services in
a residential setting.
``(3) There is a significant shortage of culturally
competent residential treatment services for Urban Indian youth
in the Service Area.
``SEC. 517. GRANTS FOR DIABETES PREVENTION, TREATMENT, AND CONTROL.
``(a) Grants Authorized.--The Secretary may make grants to those
urban Indian organizations that have entered into a contract or have
received a grant under this title for the provision of services for the
prevention and treatment of, and control of the complications resulting
from, diabetes among urban Indians.
``(b) Goals.--Each grant made pursuant to subsection (a) shall set
forth the goals to be accomplished under the grant. The goals shall be
specific to each grant as agreed to between the Secretary and the
grantee.
``(c) Establishment of Criteria.--The Secretary shall establish
criteria for the grants made under subsection (a) relating to--
``(1) the size and location of the urban Indian population
to be served;
``(2) the need for prevention of and treatment of, and
control of the complications resulting from, diabetes among the
urban Indian population to be served;
``(3) performance standards for the organization in meeting
the goals set forth in such grant that are negotiated and
agreed to by the Secretary and the grantee;
``(4) the capability of the organization to adequately
perform the activities required under the grant; and
``(5) the willingness of the organization to collaborate
with the registry, if any, established by the Secretary under
section 203(e)(1)(B) in the Area Office of the Service in which
the organization is located.
``(d) Funds Subject to Criteria.--Any funds received by an urban
Indian organization under this Act for the prevention, treatment, and
control of diabetes among urban Indians shall be subject to the
criteria developed by the Secretary under subsection (c).
``SEC. 518. COMMUNITY HEALTH REPRESENTATIVES.
``The Secretary, acting through the Service, may enter into
contracts with, and make grants to, urban Indian organizations for the
employment of Indians trained as health service providers through the
Community Health Representatives Program under section 109 in the
provision of health care, health promotion, and disease prevention
services to urban Indians.
``SEC. 519. EFFECTIVE DATE.
``The amendments made by the Indian Health Care Improvement Act
Amendments of 2009 to this title shall take effect beginning on the
date of enactment of that Act, regardless of whether the Secretary has
promulgated regulations implementing such amendments.
``SEC. 520. ELIGIBILITY FOR SERVICES.
``Urban Indians shall be eligible for, and the ultimate
beneficiaries of, health care or referral services provided pursuant to
this title.
``SEC. 521. AUTHORIZATION OF APPROPRIATIONS.
``(a) In General.--There are authorized to be appropriated such
sums as may be necessary to carry out this title.
``(b) Urban Indian Organizations.--The Secretary, acting through
the Service, is authorized to establish programs, including programs
for the awarding of grants, for urban Indian organizations that are
identical to any programs established pursuant to section 126
(behavioral health training), section 209 (school health education),
section 211 (prevention of communicable diseases), section 701
(behavioral health prevention and treatment services), and section
707(g) (multidrug abuse program).
``SEC. 522. HEALTH INFORMATION TECHNOLOGY.
``The Secretary, acting through the Service, may make grants to
urban Indian organizations under this title for the development,
adoption, and implementation of health information technology (as
defined in section 3000(5) of the American Recovery and Reinvestment
Act), telemedicine services development, and related infrastructure.
``TITLE VI--ORGANIZATIONAL IMPROVEMENTS
``SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERVICE AS AN AGENCY OF
THE PUBLIC HEALTH SERVICE.
``(a) Establishment.--
``(1) In general.--In order to more effectively and
efficiently carry out the responsibilities, authorities, and
functions of the United States to provide health care services
to Indians and Indian Tribes, as are or may be hereafter
provided by Federal statute or treaties, there is established
within the Public Health Service of the Department the Indian
Health Service.
``(2) Assistant secretary of indian health.--The Service
shall be administered by an Assistant Secretary of Indian
Health, who shall be appointed by the President, by and with
the advice and consent of the Senate. The Assistant Secretary
shall report to the Secretary. Effective with respect to an
individual appointed by the President, by and with the advice
and consent of the Senate, after January 1, 2010, the term of
service of the Assistant Secretary shall be 4 years. An
Assistant Secretary may serve more than 1 term.
``(3) Incumbent.--The individual serving in the position of
Director of the Service on the day before the date of enactment
of the Indian Health Care Improvement Act Amendments of 2009
shall serve as Assistant Secretary.
``(4) Advocacy and consultation.--The position of Assistant
Secretary is established to, in a manner consistent with the
government-to-government relationship between the United States
and Indian Tribes--
``(A) facilitate advocacy for the development of
appropriate Indian health policy; and
``(B) promote consultation on matters relating to
Indian health.
``(b) Agency.--The Service shall be an agency within the Public
Health Service of the Department, and shall not be an office,
component, or unit of any other agency of the Department.
``(c) Duties.--The Assistant Secretary shall--
``(1) perform all functions that were, on the day before
the date of enactment of the Indian Health Care Improvement Act
Amendments of 2009, carried out by or under the direction of
the individual serving as Director of the Service on that day;
``(2) perform all functions of the Secretary relating to
the maintenance and operation of hospital and health facilities
for Indians and the planning for, and provision and utilization
of, health services for Indians;
``(3) administer all health programs under which health
care is provided to Indians based upon their status as Indians
which are administered by the Secretary, including programs
under--
``(A) this Act;
``(B) the Act of November 2, 1921 (25 U.S.C. 13);
``(C) the Act of August 5, 1954 (42 U.S.C. 2001 et
seq.);
``(D) the Act of August 16, 1957 (42 U.S.C. 2005 et
seq.); and
``(E) the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.);
``(4) administer all scholarship and loan functions carried
out under title I;
``(5) report directly to the Secretary concerning all
policy- and budget-related matters affecting Indian health;
``(6) collaborate with the Assistant Secretary for Health
concerning appropriate matters of Indian health that affect the
agencies of the Public Health Service;
``(7) advise each Assistant Secretary of the Department
concerning matters of Indian health with respect to which that
Assistant Secretary has authority and responsibility;
``(8) advise the heads of other agencies and programs of
the Department concerning matters of Indian health with respect
to which those heads have authority and responsibility;
``(9) coordinate the activities of the Department
concerning matters of Indian health; and
``(10) perform such other functions as the Secretary may
designate.
``(d) Authority.--
``(1) In general.--The Secretary, acting through the
Assistant Secretary, shall have the authority--
``(A) except to the extent provided for in
paragraph (2), to appoint and compensate employees for
the Service in accordance with title 5, United States
Code;
``(B) to enter into contracts for the procurement
of goods and services to carry out the functions of the
Service; and
``(C) to manage, expend, and obligate all funds
appropriated for the Service.
``(2) Personnel actions.--Notwithstanding any other
provision of law, the provisions of section 12 of the Act of
June 18, 1934 (48 Stat. 986; 25 U.S.C. 472), shall apply to all
personnel actions taken with respect to new positions created
within the Service as a result of its establishment under
subsection (a).
``(e) References.--Any reference to the Director of the Indian
Health Service in any other Federal law, Executive order, rule,
regulation, or delegation of authority, or in any document of or
relating to the Director of the Indian Health Service, shall be deemed
to refer to the Assistant Secretary.
``SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYSTEM.
``(a) Establishment.--
``(1) In general.--The Secretary shall establish an
automated management information system for the Service.
``(2) Requirements of system.--The information system
established under paragraph (1) shall include--
``(A) a financial management system;
``(B) a patient care information system for each
area served by the Service;
``(C) privacy protections consistent with the
regulations promulgated under section 264(c) of the
Health Insurance Portability and Accountability Act of
1996 or, to the extent consistent with such
regulations, other Federal rules applicable to privacy
of automated management information systems of a
Federal agency;
``(D) a services-based cost accounting component
that provides estimates of the costs associated with
the provision of specific medical treatments or
services in each Area office of the Service;
``(E) an interface mechanism for patient billing
and accounts receivable system; and
``(F) a training component.
``(b) Provision of Systems to Tribes and Organizations.--The
Secretary shall provide each Tribal Health Program automated management
information systems which--
``(1) meet the management information needs of such Tribal
Health Program with respect to the treatment by the Tribal
Health Program of patients of the Service; and
``(2) meet the management information needs of the Service.
``(c) Access to Records.--The Service shall provide access of
patients to their medical or health records which are held by, or on
behalf of, the Service in accordance with the regulations promulgated
under section 264(c) of the Health Insurance Portability and
Accountability Act of 1996 or, to the extent consistent with such
regulations, other Federal rules applicable to access to health care
records.
``(d) Authority To Enhance Information Technology.--The Secretary,
acting through the Assistant Secretary, shall have the authority to
enter into contracts, agreements, or joint ventures with other Federal
agencies, States, private and nonprofit organizations, for the purpose
of enhancing information technology in Indian Health Programs and
facilities.
``SEC. 603. AUTHORIZATION OF APPROPRIATIONS.
``There is authorized to be appropriated such sums as may be
necessary to carry out this title.
``TITLE VII--BEHAVIORAL HEALTH PROGRAMS
``SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREATMENT SERVICES.
``(a) Purposes.--The purposes of this section are as follows:
``(1) To authorize and direct the Secretary, acting through
the Service, to develop a comprehensive behavioral health
prevention and treatment program which emphasizes collaboration
among alcohol and substance abuse, social services, and mental
health programs.
``(2) To provide information, direction, and guidance
relating to mental illness and dysfunction and self-destructive
behavior, including child abuse and family violence, to those
Federal, tribal, State, and local agencies responsible for
programs in Indian communities in areas of health care,
education, social services, child and family welfare, alcohol
and substance abuse, law enforcement, and judicial services.
``(3) To assist Indian Tribes to identify services and
resources available to address mental illness and dysfunctional
and self-destructive behavior.
``(4) To provide authority and opportunities for Indian
Tribes and Tribal Organizations to develop, implement, and
coordinate with community-based programs which include
identification, prevention, education, referral, and treatment
services, including through multidisciplinary resource teams.
``(5) To ensure that Indians, as citizens of the United
States and of the States in which they reside, have the same
access to behavioral health services to which all citizens have
access.
``(6) To modify or supplement existing programs and
authorities in the areas identified in paragraph (2).
``(b) Plans.--
``(1) Development.--The Secretary, acting through the
Service, shall encourage Indian Tribes and Tribal Organizations
to develop tribal plans, and urban Indian organizations to
develop local plans, and for all such groups to participate in
developing areawide plans for Indian Behavioral Health
Services. The plans shall include, to the extent feasible, the
following components:
``(A) An assessment of the scope of alcohol or
other substance abuse, mental illness, and
dysfunctional and self-destructive behavior, including
suicide, child abuse, and family violence, among
Indians, including--
``(i) the number of Indians served who are
directly or indirectly affected by such illness
or behavior; or
``(ii) an estimate of the financial and
human cost attributable to such illness or
behavior.
``(B) An assessment of the existing and additional
resources necessary for the prevention and treatment of
such illness and behavior, including an assessment of
the progress toward achieving the availability of the
full continuum of care described in subsection (c).
``(C) An estimate of the additional funding needed
by the Service, Indian Tribes, Tribal Organizations,
and urban Indian organizations to meet their
responsibilities under the plans.
``(2) National clearinghouse.--The Secretary, acting
through the Service, shall coordinate with existing national
clearinghouses and information centers to include at the
clearinghouses and centers plans and reports on the outcomes of
such plans developed by Indian Tribes, Tribal Organizations,
urban Indian organizations, and Service Areas relating to
behavioral health. The Secretary shall ensure access to these
plans and outcomes by any Indian Tribe, Tribal Organization,
urban Indian organization, or the Service.
``(3) Technical assistance.--The Secretary shall provide
technical assistance to Indian Tribes, Tribal Organizations,
and urban Indian organizations in preparation of plans under
this section and in developing standards of care that may be
used and adopted locally.
``(c) Programs.--The Secretary, acting through the Service, shall
provide, to the extent feasible and if funding is available, programs
including the following:
``(1) Comprehensive care.--A comprehensive continuum of
behavioral health care which provides--
``(A) community-based prevention, intervention,
outpatient, and behavioral health aftercare;
``(B) detoxification (social and medical);
``(C) acute hospitalization;
``(D) intensive outpatient/day treatment;
``(E) residential treatment;
``(F) transitional living for those needing a
temporary, stable living environment that is supportive
of treatment and recovery goals;
``(G) emergency shelter;
``(H) intensive case management; and
``(I) diagnostic services.
``(2) Child care.--Behavioral health services for Indians
from birth through age 17, including--
``(A) preschool and school age fetal alcohol
disorder services, including assessment and behavioral
intervention;
``(B) mental health and substance abuse services
(emotional, organic, alcohol, drug, inhalant, and
tobacco);
``(C) identification and treatment of co-occurring
disorders and comorbidity;
``(D) prevention of alcohol, drug, inhalant, and
tobacco use;
``(E) early intervention, treatment, and aftercare;
``(F) promotion of healthy approaches to risk and
safety issues; and
``(G) identification and treatment of neglect and
physical, mental, and sexual abuse.
``(3) Adult care.--Behavioral health services for Indians
from age 18 through 55, including--
``(A) early intervention, treatment, and aftercare;
``(B) mental health and substance abuse services
(emotional, alcohol, drug, inhalant, and tobacco),
including sex specific services;
``(C) identification and treatment of co-occurring
disorders (dual diagnosis) and comorbidity;
``(D) promotion of healthy approaches for risk-
related behavior;
``(E) treatment services for women at risk of
giving birth to a child with a fetal alcohol disorder;
and
``(F) sex specific treatment for sexual assault and
domestic violence.
``(4) Family care.--Behavioral health services for
families, including--
``(A) early intervention, treatment, and aftercare
for affected families;
``(B) treatment for sexual assault and domestic
violence; and
``(C) promotion of healthy approaches relating to
parenting, domestic violence, and other abuse issues.
``(5) Elder care.--Behavioral health services for Indians
56 years of age and older, including--
``(A) early intervention, treatment, and aftercare;
``(B) mental health and substance abuse services
(emotional, alcohol, drug, inhalant, and tobacco),
including sex specific services;
``(C) identification and treatment of co-occurring
disorders (dual diagnosis) and comorbidity;
``(D) promotion of healthy approaches to managing
conditions related to aging;
``(E) sex specific treatment for sexual assault,
domestic violence, neglect, physical and mental abuse
and exploitation; and
``(F) identification and treatment of dementias
regardless of cause.
``(d) Community Behavioral Health Plan.--
``(1) Establishment.--The governing body of any Indian
Tribe, Tribal Organization, or urban Indian organization may
adopt a resolution for the establishment of a community
behavioral health plan providing for the identification and
coordination of available resources and programs to identify,
prevent, or treat substance abuse, mental illness, or
dysfunctional and self-destructive behavior, including child
abuse and family violence, among its members or its service
population. This plan should include behavioral health
services, social services, intensive outpatient services, and
continuing aftercare.
``(2) Technical assistance.--At the request of an Indian
Tribe, Tribal Organization, or urban Indian organization, the
Bureau of Indian Affairs and the Service shall cooperate with
and provide technical assistance to the Indian Tribe, Tribal
Organization, or urban Indian organization in the development
and implementation of such plan.
``(3) Funding.--The Secretary, acting through the Service,
may make funding available to Indian Tribes and Tribal
Organizations which adopt a resolution pursuant to paragraph
(1) to obtain technical assistance for the development of a
community behavioral health plan and to provide administrative
support in the implementation of such plan.
``(e) Coordination for Availability of Services.--The Secretary,
acting through the Service, shall coordinate behavioral health
planning, to the extent feasible, with other Federal agencies and with
State agencies, to encourage comprehensive behavioral health services
for Indians regardless of their place of residence.
``(f) Mental Health Care Need Assessment.--Not later than 1 year
after the date of enactment of the Indian Health Care Improvement Act
Amendments of 2009, the Secretary, acting through the Service, shall
make an assessment of the need for inpatient mental health care among
Indians and the availability and cost of inpatient mental health
facilities which can meet such need. In making such assessment, the
Secretary shall consider the possible conversion of existing, underused
Service hospital beds into psychiatric units to meet such need.
``SEC. 702. MEMORANDA OF AGREEMENT WITH THE DEPARTMENT OF THE INTERIOR.
``(a) Contents.--Not later than 12 months after the date of
enactment of the Indian Health Care Improvement Act Amendments of 2009,
the Secretary, acting through the Service, and the Secretary of the
Interior shall develop and enter into a memoranda of agreement, or
review and update any existing memoranda of agreement, as required by
section 4205 of the Indian Alcohol and Substance Abuse Prevention and
Treatment Act of 1986 (25 U.S.C. 2411) under which the Secretaries
address the following:
``(1) The scope and nature of mental illness and
dysfunctional and self-destructive behavior, including child
abuse and family violence, among Indians.
``(2) The existing Federal, tribal, State, local, and
private services, resources, and programs available to provide
behavioral health services for Indians.
``(3) The unmet need for additional services, resources,
and programs necessary to meet the needs identified pursuant to
paragraph (1).
``(4)(A) The right of Indians, as citizens of the United
States and of the States in which they reside, to have access
to behavioral health services to which all citizens have
access.
``(B) The right of Indians to participate in, and receive
the benefit of, such services.
``(C) The actions necessary to protect the exercise of such
right.
``(5) The responsibilities of the Bureau of Indian Affairs
and the Service, including mental illness identification,
prevention, education, referral, and treatment services
(including services through multidisciplinary resource teams),
at the central, area, and agency and Service Unit, Service
Area, and headquarters levels to address the problems
identified in paragraph (1).
``(6) A strategy for the comprehensive coordination of the
behavioral health services provided by the Bureau of Indian
Affairs and the Service to meet the problems identified
pursuant to paragraph (1), including--
``(A) the coordination of alcohol and substance
abuse programs of the Service, the Bureau of Indian
Affairs, and Indian Tribes and Tribal Organizations
(developed under the Indian Alcohol and Substance Abuse
Prevention and Treatment Act of 1986 (25 U.S.C. 2401 et
seq.)) with behavioral health initiatives pursuant to
this Act, particularly with respect to the referral and
treatment of dually diagnosed individuals requiring
behavioral health and substance abuse treatment; and
``(B) ensuring that the Bureau of Indian Affairs
and Service programs and services (including
multidisciplinary resource teams) addressing child
abuse and family violence are coordinated with such
non-Federal programs and services.
``(7) Directing appropriate officials of the Bureau of
Indian Affairs and the Service, particularly at the agency and
Service Unit levels, to cooperate fully with tribal requests
made pursuant to community behavioral health plans adopted
under section 701(c) and section 4206 of the Indian Alcohol and
Substance Abuse Prevention and Treatment Act of 1986 (25 U.S.C.
2412).
``(8) Providing for an annual review of such agreement by
the Secretaries which shall be provided to Congress and Indian
Tribes and Tribal Organizations.
``(b) Specific Provisions Required.--The memoranda of agreement
updated or entered into pursuant to subsection (a) shall include
specific provisions pursuant to which the Service shall assume
responsibility for--
``(1) the determination of the scope of the problem of
alcohol and substance abuse among Indians, including the number
of Indians within the jurisdiction of the Service who are
directly or indirectly affected by alcohol and substance abuse
and the financial and human cost;
``(2) an assessment of the existing and needed resources
necessary for the prevention of alcohol and substance abuse and
the treatment of Indians affected by alcohol and substance
abuse; and
``(3) an estimate of the funding necessary to adequately
support a program of prevention of alcohol and substance abuse
and treatment of Indians affected by alcohol and substance
abuse.
``(c) Publication.--Each memorandum of agreement entered into or
renewed (and amendments or modifications thereto) under subsection (a)
shall be published in the Federal Register. At the same time as
publication in the Federal Register, the Secretary shall provide a copy
of such memoranda, amendment, or modification to each Indian Tribe,
Tribal Organization, and urban Indian organization.
``SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PREVENTION AND TREATMENT
PROGRAM.
``(a) Establishment.--
``(1) In general.--The Secretary, acting through the
Service, shall provide a program of comprehensive behavioral
health, prevention, treatment, and aftercare, including Systems
of Care, which shall include--
``(A) prevention, through educational intervention,
in Indian communities;
``(B) acute detoxification, psychiatric
hospitalization, residential, and intensive outpatient
treatment;
``(C) community-based rehabilitation and aftercare;
``(D) community education and involvement,
including extensive training of health care,
educational, and community-based personnel;
``(E) specialized residential treatment programs
for high-risk populations, including pregnant and
postpartum women and their children; and
``(F) diagnostic services.
``(2) Target populations.--The target population of such
programs shall be members of Indian Tribes. Efforts to train
and educate key members of the Indian community shall also
target employees of health, education, judicial, law
enforcement, legal, and social service programs.
``(b) Contract Health Services.--
``(1) In general.--The Secretary, acting through the
Service, may enter into contracts with public or private
providers of behavioral health treatment services for the
purpose of carrying out the program required under subsection
(a).
``(2) Provision of assistance.--In carrying out this
subsection, the Secretary shall provide assistance to Indian
Tribes and Tribal Organizations to develop criteria for the
certification of behavioral health service providers and
accreditation of service facilities which meet minimum
standards for such services and facilities.
``SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM.
``(a) In General.--Under the authority of the Act of November 2,
1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), the Secretary
shall establish and maintain a mental health technician program within
the Service which--
``(1) provides for the training of Indians as mental health
technicians; and
``(2) employs such technicians in the provision of
community-based mental health care that includes
identification, prevention, education, referral, and treatment
services.
``(b) Paraprofessional Training.--In carrying out subsection (a),
the Secretary, acting through the Service, shall provide high-standard
paraprofessional training in mental health care necessary to provide
quality care to the Indian communities to be served. Such training
shall be based upon a curriculum developed or approved by the Secretary
which combines education in the theory of mental health care with
supervised practical experience in the provision of such care.
``(c) Supervision and Evaluation of Technicians.--The Secretary,
acting through the Service, shall supervise and evaluate the mental
health technicians in the training program.
``(d) Traditional Health Care Practices.--The Secretary, acting
through the Service, shall ensure that the program established pursuant
to this subsection involves the use and promotion of the traditional
health care practices of the Indian Tribes to be served.
``SEC. 705. LICENSING REQUIREMENT FOR MENTAL HEALTH CARE WORKERS.
``(a) In General.--Subject to the provisions of section 221, and
except as provided in subsection (b), any individual employed as a
psychologist, social worker, or marriage and family therapist for the
purpose of providing mental health care services to Indians in a
clinical setting under this Act is required to be licensed as a
psychologist, social worker, or marriage and family therapist,
respectively.
``(b) Trainees.--An individual may be employed as a trainee in
psychology, social work, or marriage and family therapy to provide
mental health care services described in subsection (a) if such
individual--
``(1) works under the direct supervision of a licensed
psychologist, social worker, or marriage and family therapist,
respectively;
``(2) is enrolled in or has completed at least 2 years of
course work at a post-secondary, accredited education program
for psychology, social work, marriage and family therapy, or
counseling; and
``(3) meets such other training, supervision, and quality
review requirements as the Secretary may establish.
``SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS.
``(a) Grants.--The Secretary, consistent with section 701, may make
grants to Indian Tribes, Tribal Organizations, and urban Indian
organizations to develop and implement a comprehensive behavioral
health program of prevention, intervention, treatment, and relapse
prevention services that specifically addresses the cultural,
historical, social, and child care needs of Indian women, regardless of
age.
``(b) Use of Grant Funds.--A grant made pursuant to this section
may be used to--
``(1) develop and provide community training, education,
and prevention programs for Indian women relating to behavioral
health issues, including fetal alcohol disorders;
``(2) identify and provide psychological services,
counseling, advocacy, support, and relapse prevention to Indian
women and their families; and
``(3) develop prevention and intervention models for Indian
women which incorporate traditional health care practices,
cultural values, and community and family involvement.
``(c) Criteria.--The Secretary, in consultation with Indian Tribes
and Tribal Organizations, shall establish criteria for the review and
approval of applications and proposals for funding under this section.
``(d) Allocation of Funds for Urban Indian Organizations.--Twenty
percent of the funds appropriated pursuant to this section shall be
used to make grants to urban Indian organizations.
``SEC. 707. INDIAN YOUTH PROGRAM.
``(a) Detoxification and Rehabilitation.--The Secretary, acting
through the Service, consistent with section 701, shall develop and
implement a program for acute detoxification and treatment for Indian
youths, including behavioral health services. The program shall include
regional treatment centers designed to include detoxification and
rehabilitation for both sexes on a referral basis and programs
developed and implemented by Indian Tribes or Tribal Organizations at
the local level under the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.). Regional centers shall be
integrated with the intake and rehabilitation programs based in the
referring Indian community.
``(b) Alcohol and Substance Abuse Treatment Centers or
Facilities.--
``(1) Establishment.--
``(A) In general.--The Secretary, acting through
the Service, shall construct, renovate, or, as
necessary, purchase, and appropriately staff and
operate, at least 1 youth regional treatment center or
treatment network in each area under the jurisdiction
of an Area Office.
``(B) Area office in california.--For the purposes
of this subsection, the Area Office in California shall
be considered to be 2 Area Offices, 1 office whose
jurisdiction shall be considered to encompass the
northern area of the State of California, and 1 office
whose jurisdiction shall be considered to encompass the
remainder of the State of California for the purpose of
implementing California treatment networks.
``(2) Funding.--For the purpose of staffing and operating
such centers or facilities, funding shall be pursuant to the
Act of November 2, 1921 (25 U.S.C. 13).
``(3) Location.--A youth treatment center constructed or
purchased under this subsection shall be constructed or
purchased at a location within the area described in paragraph
(1) agreed upon (by appropriate tribal resolution) by a
majority of the Indian Tribes to be served by such center.
``(4) Specific provision of funds.--
``(A) In general.--Notwithstanding any other
provision of this title, the Secretary may, from
amounts authorized to be appropriated for the purposes
of carrying out this section, make funds available to--
``(i) the Tanana Chiefs Conference,
Incorporated, for the purpose of leasing,
constructing, renovating, operating, and
maintaining a residential youth treatment
facility in Fairbanks, Alaska; and
``(ii) the Southeast Alaska Regional Health
Corporation to staff and operate a residential
youth treatment facility without regard to the
proviso set forth in section 4(l) of the Indian
Self-Determination and Education Assistance Act
(25 U.S.C. 450b(l)).
``(B) Provision of services to eligible youths.--
Until additional residential youth treatment facilities
are established in Alaska pursuant to this section, the
facilities specified in subparagraph (A) shall make
every effort to provide services to all eligible Indian
youths residing in Alaska.
``(c) Intermediate Adolescent Behavioral Health Services.--
``(1) In general.--The Secretary, acting through the
Service, may provide intermediate behavioral health services,
which may incorporate Systems of Care, to Indian children and
adolescents, including--
``(A) pretreatment assistance;
``(B) inpatient, outpatient, and aftercare
services;
``(C) emergency care;
``(D) suicide prevention and crisis intervention;
and
``(E) prevention and treatment of mental illness
and dysfunctional and self-destructive behavior,
including child abuse and family violence.
``(2) Use of funds.--Funds provided under this subsection
may be used--
``(A) to construct or renovate an existing health
facility to provide intermediate behavioral health
services;
``(B) to hire behavioral health professionals;
``(C) to staff, operate, and maintain an
intermediate mental health facility, group home, sober
housing, transitional housing or similar facilities, or
youth shelter where intermediate behavioral health
services are being provided;
``(D) to make renovations and hire appropriate
staff to convert existing hospital beds into adolescent
psychiatric units; and
``(E) for intensive home- and community-based
services.
``(3) Criteria.--The Secretary, acting through the Service,
shall, in consultation with Indian Tribes and Tribal
Organizations, establish criteria for the review and approval
of applications or proposals for funding made available
pursuant to this subsection.
``(d) Federally Owned Structures.--
``(1) In general.--The Secretary, in consultation with
Indian Tribes and Tribal Organizations, shall--
``(A) identify and use, where appropriate,
federally owned structures suitable for local
residential or regional behavioral health treatment for
Indian youths; and
``(B) establish guidelines for determining the
suitability of any such federally owned structure to be
used for local residential or regional behavioral
health treatment for Indian youths.
``(2) Terms and conditions for use of structure.--Any
structure described in paragraph (1) may be used under such
terms and conditions as may be agreed upon by the Secretary and
the agency having responsibility for the structure and any
Indian Tribe or Tribal Organization operating the program.
``(e) Rehabilitation and Aftercare Services.--
``(1) In general.--The Secretary, Indian Tribes, or Tribal
Organizations, in cooperation with the Secretary of the
Interior, shall develop and implement within each Service Unit,
community-based rehabilitation and follow-up services for
Indian youths who are having significant behavioral health
problems, and require long-term treatment, community
reintegration, and monitoring to support the Indian youths
after their return to their home community.
``(2) Administration.--Services under paragraph (1) shall
be provided by trained staff within the community who can
assist the Indian youths in their continuing development of
self-image, positive problem-solving skills, and nonalcohol or
substance abusing behaviors. Such staff may include alcohol and
substance abuse counselors, mental health professionals, and
other health professionals and paraprofessionals, including
community health representatives.
``(f) Inclusion of Family in Youth Treatment Program.--In providing
the treatment and other services to Indian youths authorized by this
section, the Secretary, acting through the Service, shall provide for
the inclusion of family members of such youths in the treatment
programs or other services as may be appropriate. Not less than 10
percent of the funds appropriated for the purposes of carrying out
subsection (e) shall be used for outpatient care of adult family
members related to the treatment of an Indian youth under that
subsection.
``(g) Multidrug Abuse Program.--The Secretary, acting through the
Service, shall provide, consistent with section 701, programs and
services to prevent and treat the abuse of multiple forms of
substances, including alcohol, drugs, inhalants, and tobacco, among
Indian youths residing in Indian communities, on or near reservations,
and in urban areas and provide appropriate mental health services to
address the incidence of mental illness among such youths.
``(h) Indian Youth Mental Health.--The Secretary, acting through
the Service, shall collect data for the report under section 801 with
respect to--
``(1) the number of Indian youth who are being provided
mental health services through the Service and Tribal Health
Programs;
``(2) a description of, and costs associated with, the
mental health services provided for Indian youth through the
Service and Tribal Health Programs;
``(3) the number of youth referred to the Service or Tribal
Health Programs for mental health services;
``(4) the number of Indian youth provided residential
treatment for mental health and behavioral problems through the
Service and Tribal Health Programs, reported separately for on-
and off-reservation facilities; and
``(5) the costs of the services described in paragraph (4).
``SEC. 708. INDIAN YOUTH TELEMENTAL HEALTH DEMONSTRATION PROJECT.
``(a) Purpose.--The purpose of this section is to authorize the
Secretary to carry out a demonstration project to test the use of
telemental health services in suicide prevention, intervention and
treatment of Indian youth, including through--
``(1) the use of psychotherapy, psychiatric assessments,
diagnostic interviews, therapies for mental health conditions
predisposing to suicide, and alcohol and substance abuse
treatment;
``(2) the provision of clinical expertise to, consultation
services with, and medical advice and training for frontline
health care providers working with Indian youth;
``(3) training and related support for community leaders,
family members and health and education workers who work with
Indian youth;
``(4) the development of culturally relevant educational
materials on suicide; and
``(5) data collection and reporting.
``(b) Definitions.--For the purpose of this section, the following
definitions shall apply:
``(1) Demonstration project.--The term `demonstration
project' means the Indian youth telemental health demonstration
project authorized under subsection (c).
``(2) Telemental health.--The term `telemental health'
means the use of electronic information and telecommunications
technologies to support long distance mental health care,
patient and professional-related education, public health, and
health administration.
``(c) Authorization.--
``(1) In general.--The Secretary is authorized to award
grants under the demonstration project for the provision of
telemental health services to Indian youth who--
``(A) have expressed suicidal ideas;
``(B) have attempted suicide; or
``(C) have mental health conditions that increase
or could increase the risk of suicide.
``(2) Eligibility for grants.--Such grants shall be awarded
to Indian Tribes and Tribal Organizations that operate 1 or
more facilities--
``(A) located in Alaska and part of the Alaska
Federal Health Care Access Network;
``(B) reporting active clinical telehealth
capabilities; or
``(C) offering school-based telemental health
services relating to psychiatry to Indian youth.
``(3) Grant period.--The Secretary shall award grants under
this section for a period of up to 4 years.
``(4) Awarding of grants.--Not more than 5 grants shall be
provided under paragraph (1), with priority consideration given
to Indian Tribes and Tribal Organizations that--
``(A) serve a particular community or geographic
area where there is a demonstrated need to address
Indian youth suicide;
``(B) enter in to collaborative partnerships with
Indian Health Service or Tribal Health Programs or
facilities to provide services under this demonstration
project;
``(C) serve an isolated community or geographic
area which has limited or no access to behavioral
health services; or
``(D) operate a detention facility at which Indian
youth are detained.
``(d) Use of Funds.--
``(1) In general.--An Indian Tribe or Tribal Organization
shall use a grant received under subsection (c) for the
following purposes:
``(A) To provide telemental health services to
Indian youth, including the provision of--
``(i) psychotherapy;
``(ii) psychiatric assessments and
diagnostic interviews, therapies for mental
health conditions predisposing to suicide, and
treatment; and
``(iii) alcohol and substance abuse
treatment.
``(B) To provide clinician-interactive medical
advice, guidance and training, assistance in diagnosis
and interpretation, crisis counseling and intervention,
and related assistance to Service, tribal, or urban
clinicians and health services providers working with
youth being served under this demonstration project.
``(C) To assist, educate and train community
leaders, health education professionals and
paraprofessionals, tribal outreach workers, and family
members who work with the youth receiving telemental
health services under this demonstration project,
including with identification of suicidal tendencies,
crisis intervention and suicide prevention, emergency
skill development, and building and expanding networks
among these individuals and with State and local health
services providers.
``(D) To develop and distribute culturally
appropriate community educational materials on--
``(i) suicide prevention;
``(ii) suicide education;
``(iii) suicide screening;
``(iv) suicide intervention; and
``(v) ways to mobilize communities with
respect to the identification of risk factors
for suicide.
``(E) For data collection and reporting related to
Indian youth suicide prevention efforts.
``(2) Traditional health care practices.--In carrying out
the purposes described in paragraph (1), an Indian Tribe or
Tribal Organization may use and promote the traditional health
care practices of the Indian Tribes of the youth to be served.
``(e) Applications.--To be eligible to receive a grant under
subsection (c), an Indian Tribe or Tribal Organization shall prepare
and submit to the Secretary an application, at such time, in such
manner, and containing such information as the Secretary may require,
including--
``(1) a description of the project that the Indian Tribe or
Tribal Organization will carry out using the funds provided
under the grant;
``(2) a description of the manner in which the project
funded under the grant would--
``(A) meet the telemental health care needs of the
Indian youth population to be served by the project; or
``(B) improve the access of the Indian youth
population to be served to suicide prevention and
treatment services;
``(3) evidence of support for the project from the local
community to be served by the project;
``(4) a description of how the families and leadership of
the communities or populations to be served by the project
would be involved in the development and ongoing operations of
the project;
``(5) a plan to involve the tribal community of the youth
who are provided services by the project in planning and
evaluating the mental health care and suicide prevention
efforts provided, in order to ensure the integration of
community, clinical, environmental, and cultural components of
the treatment; and
``(6) a plan for sustaining the project after Federal
assistance for the demonstration project has terminated.
``(f) Collaboration; Reporting to National Clearinghouse.--
``(1) Collaboration.--The Secretary, acting through the
Service, shall encourage Indian Tribes and Tribal Organizations
receiving grants under this section to collaborate to enable
comparisons about best practices across projects.
``(2) Reporting to national clearinghouse.--The Secretary,
acting through the Service, shall also encourage Indian Tribes
and Tribal Organizations receiving grants under this section to
submit relevant, declassified project information to the
national clearinghouse authorized under section 701(b)(2) in
order to better facilitate program performance and improve
suicide prevention, intervention, and treatment services.
``(g) Annual Report.--Each grant recipient shall submit to the
Secretary an annual report that--
``(1) describes the number of telemental health services
provided; and
``(2) includes any other information that the Secretary may
require.
``(h) Report to Congress.--Not later than 270 days after the
termination of the demonstration project, the Secretary shall submit to
the Committee on Indian Affairs of the Senate and the Committee on
Natural Resources and Committee on Energy and Commerce of the House of
Representatives a final report, based on the annual reports provided by
grant recipients under subsection (h), that--
``(1) describes the results of the projects funded by
grants awarded under this section, including any data available
which indicates the number of attempted suicides;
``(2) evaluates the impact of the telemental health
services funded by the grants in reducing the number of
completed suicides among Indian youth;
``(3) evaluates whether the demonstration project should
be--
``(A) expanded to provide more than 5 grants; and
``(B) designated a permanent program; and
``(4) evaluates the benefits of expanding the demonstration
project to include urban Indian organizations.
``(i) Authorization of Appropriations.--There is authorized to be
appropriated such sums as may be necessary to carry out this section.
``SEC. 709. INPATIENT AND COMMUNITY-BASED MENTAL HEALTH FACILITIES
DESIGN, CONSTRUCTION, AND STAFFING.
``Not later than 1 year after the date of enactment of the Indian
Health Care Improvement Act Amendments of 2009, the Secretary, acting
through the Service, may provide, in each area of the Service, not less
than 1 inpatient mental health care facility, or the equivalent, for
Indians with behavioral health problems. For the purposes of this
subsection, California shall be considered to be 2 Area Offices, 1
office whose location shall be considered to encompass the northern
area of the State of California and 1 office whose jurisdiction shall
be considered to encompass the remainder of the State of California.
The Secretary shall consider the possible conversion of existing,
underused Service hospital beds into psychiatric units to meet such
need.
``SEC. 710. TRAINING AND COMMUNITY EDUCATION.
``(a) Program.--The Secretary, in cooperation with the Secretary of
the Interior, shall develop and implement or assist Indian Tribes and
Tribal Organizations to develop and implement, within each Service Unit
or tribal program, a program of community education and involvement
which shall be designed to provide concise and timely information to
the community leadership of each tribal community. Such program shall
include education about behavioral health issues to political leaders,
Tribal judges, law enforcement personnel, members of tribal health and
education boards, health care providers including traditional
practitioners, and other critical members of each tribal community.
Such program may also include community-based training to develop local
capacity and tribal community provider training for prevention,
intervention, treatment, and aftercare.
``(b) Instruction.--The Secretary, acting through the Service,
shall provide instruction in the area of behavioral health issues,
including instruction in crisis intervention and family relations in
the context of alcohol and substance abuse, child sexual abuse, youth
alcohol and substance abuse, and the causes and effects of fetal
alcohol disorders to appropriate employees of the Bureau of Indian
Affairs and the Service, and to personnel in schools or programs
operated under any contract with the Bureau of Indian Affairs or the
Service, including supervisors of emergency shelters and halfway houses
described in section 4213 of the Indian Alcohol and Substance Abuse
Prevention and Treatment Act of 1986 (25 U.S.C. 2433).
``(c) Training Models.--In carrying out the education and training
programs required by this section, the Secretary, in consultation with
Indian Tribes, Tribal Organizations, Indian behavioral health experts,
and Indian alcohol and substance abuse prevention experts, shall
develop and provide community-based training models. Such models shall
address--
``(1) the elevated risk of alcohol and behavioral health
problems faced by children of alcoholics;
``(2) the cultural, spiritual, and multigenerational
aspects of behavioral health problem prevention and recovery;
and
``(3) community-based and multidisciplinary strategies,
including Systems of Care, for preventing and treating
behavioral health problems.
``SEC. 711. BEHAVIORAL HEALTH PROGRAM.
``(a) Innovative Programs.--The Secretary, acting through the
Service, consistent with section 701, may plan, develop, implement, and
carry out programs to deliver innovative community-based behavioral
health services to Indians.
``(b) Awards; Criteria.--The Secretary may award a grant for a
project under subsection (a) to an Indian Tribe or Tribal Organization
and may consider the following criteria:
``(1) The project will address significant unmet behavioral
health needs among Indians.
``(2) The project will serve a significant number of
Indians.
``(3) The project has the potential to deliver services in
an efficient and effective manner.
``(4) The Indian Tribe or Tribal Organization has the
administrative and financial capability to administer the
project.
``(5) The project may deliver services in a manner
consistent with traditional health care practices.
``(6) The project is coordinated with, and avoids
duplication of, existing services.
``(c) Equitable Treatment.--For purposes of this subsection, the
Secretary shall, in evaluating project applications or proposals, use
the same criteria that the Secretary uses in evaluating any other
application or proposal for such funding.
``SEC. 712. FETAL ALCOHOL DISORDER PROGRAMS.
``(a) Programs.--
``(1) Establishment.--The Secretary, consistent with
section 701 and acting through the Service, is authorized to
establish and operate fetal alcohol disorder programs as
provided in this section for the purposes of meeting the health
status objectives specified in section 3.
``(2) Use of funds.--
``(A) In general.--Funding provided pursuant to
this section shall be used for the following:
``(i) To develop and provide for Indians
community and in-school training, education,
and prevention programs relating to fetal
alcohol disorders.
``(ii) To identify and provide behavioral
health treatment to high-risk Indian women and
high-risk women pregnant with an Indian's
child.
``(iii) To identify and provide appropriate
psychological services, educational and
vocational support, counseling, advocacy, and
information to fetal alcohol disorder affected
Indians and their families or caretakers.
``(iv) To develop and implement counseling
and support programs in schools for fetal
alcohol disorder affected Indian children.
``(v) To develop prevention and
intervention models which incorporate
practitioners of traditional health care
practices, cultural values, and community
involvement.
``(vi) To develop, print, and disseminate
education and prevention materials on fetal
alcohol disorder.
``(vii) To develop and implement, in
consultation with Indian Tribes, Tribal
Organizations, and urban Indian organizations,
culturally sensitive assessment and diagnostic
tools including dysmorphology clinics and
multidisciplinary fetal alcohol disorder
clinics for use in Indian communities and Urban
Centers.
``(B) Additional uses.--In addition to any purpose
under subparagraph (A), funding provided pursuant to
this section may be used for 1 or more of the
following:
``(i) Early childhood intervention projects
from birth on to mitigate the effects of fetal
alcohol disorder among Indians.
``(ii) Community-based support services for
Indians and women pregnant with Indian
children.
``(iii) Community-based housing for adult
Indians with fetal alcohol disorder.
``(3) Criteria for applications.--The Secretary shall
establish criteria for the review and approval of applications
for funding under this section.
``(b) Services.--The Secretary, acting through the Service, shall--
``(1) develop and provide services for the prevention,
intervention, treatment, and aftercare for those affected by
fetal alcohol disorder in Indian communities; and
``(2) provide supportive services, including services to
meet the special educational, vocational, school-to-work
transition, and independent living needs of adolescent and
adult Indians with fetal alcohol disorder.
``(c) Task Force.--The Secretary shall establish a task force to be
known as the Fetal Alcohol Disorder Task Force to advise the Secretary
in carrying out subsection (b). Such task force shall be composed of
representatives from the following:
``(1) The National Institute on Drug Abuse.
``(2) The National Institute on Alcohol and Alcoholism.
``(3) The Office of Substance Abuse Prevention.
``(4) The National Institute of Mental Health.
``(5) The Service.
``(6) The Office of Minority Health of the Department of
Health and Human Services.
``(7) The Administration for Native Americans.
``(8) The National Institute of Child Health and Human
Development (NICHD).
``(9) The Centers for Disease Control and Prevention.
``(10) The Bureau of Indian Affairs.
``(11) Indian Tribes.
``(12) Tribal Organizations.
``(13) urban Indian organizations.
``(14) Indian fetal alcohol spectrum disorders experts.
``(d) Applied Research Projects.--The Secretary, acting through the
Substance Abuse and Mental Health Services Administration, shall make
grants to Indian Tribes, Tribal Organizations, and urban Indian
organizations for applied research projects which propose to elevate
the understanding of methods to prevent, intervene, treat, or provide
rehabilitation and behavioral health aftercare for Indians and urban
Indians affected by fetal alcohol spectrum disorders.
``(e) Funding for Urban Indian Organizations.--Ten percent of the
funds appropriated pursuant to this section shall be used to make
grants to urban Indian organizations funded under title V.
``SEC. 713. CHILD SEXUAL ABUSE AND PREVENTION TREATMENT PROGRAMS.
``(a) Establishment.--The Secretary, acting through the Service,
shall establish, consistent with section 701, in every Service Area,
programs involving treatment for--
``(1) victims of sexual abuse who are Indian children or
children in an Indian household; and
``(2) perpetrators of child sexual abuse who are Indian or
members of an Indian household.
``(b) Use of Funds.--Funding provided pursuant to this section
shall be used for the following:
``(1) To develop and provide community education and
prevention programs related to sexual abuse of Indian children
or children in an Indian household.
``(2) To identify and provide behavioral health treatment
to victims of sexual abuse who are Indian children or children
in an Indian household, and to their family members who are
affected by sexual abuse.
``(3) To develop prevention and intervention models which
incorporate traditional health care practices, cultural values,
and community involvement.
``(4) To develop and implement culturally sensitive
assessment and diagnostic tools for use in Indian communities
and Urban Centers.
``(5) To identify and provide behavioral health treatment
to Indian perpetrators and perpetrators who are members of an
Indian household--
``(A) making efforts to begin offender and
behavioral health treatment while the perpetrator is
incarcerated or at the earliest possible date if the
perpetrator is not incarcerated; and
``(B) providing treatment after the perpetrator is
released, until it is determined that the perpetrator
is not a threat to children.
``(c) Coordination.--The programs established under subsection (a)
shall be carried out in coordination with programs and services
authorized under the Indian Child Protection and Family Violence
Prevention Act (25 U.S.C. 3201 et seq.).
``SEC. 714. DOMESTIC AND SEXUAL VIOLENCE PREVENTION AND TREATMENT.
``(a) In General.--The Secretary, in accordance with section 701,
is authorized to establish in each Service Area programs involving the
prevention and treatment of--
``(1) Indian victims of domestic violence or sexual abuse;
and
``(2) perpetrators of domestic violence or sexual abuse who
are Indian or members of an Indian household.
``(b) Use of Funds.--Funds made available to carry out this section
shall be used--
``(1) to develop and implement prevention programs and
community education programs relating to domestic violence and
sexual abuse;
``(2) to provide behavioral health services, including
victim support services, and medical treatment (including
examinations performed by sexual assault nurse examiners) to
Indian victims of domestic violence or sexual abuse;
``(3) to purchase rape kits;
``(4) to develop prevention and intervention models, which
may incorporate traditional health care practices; and
``(5) to identify and provide behavioral health treatment
to perpetrators who are Indian or members of an Indian
household.
``(c) Training and Certification.--
``(1) In general.--Not later than 1 year after the date of
enactment of the Indian Health Care Improvement Act Amendments
of 2009, the Secretary shall establish appropriate protocols,
policies, procedures, standards of practice, and, if not
available elsewhere, training curricula and training and
certification requirements for services for victims of domestic
violence and sexual abuse.
``(2) Report.--Not later than 18 months after the date of
enactment of the Indian Health Care Improvement Act Amendments
of 2008, the Secretary shall submit to the Committee on Indian
Affairs of the Senate and the Committee on Natural Resources of
the House of Representatives a report that describes the means
and extent to which the Secretary has carried out paragraph
(1).
``(d) Coordination.--
``(1) In general.--The Secretary, in coordination with the
Attorney General, Federal and tribal law enforcement agencies,
Indian Health Programs, and domestic violence or sexual assault
victim organizations, shall develop appropriate victim services
and victim advocate training programs--
``(A) to improve domestic violence or sexual abuse
responses;
``(B) to improve forensic examinations and
collection;
``(C) to identify problems or obstacles in the
prosecution of domestic violence or sexual abuse; and
``(D) to meet other needs or carry out other
activities required to prevent, treat, and improve
prosecutions of domestic violence and sexual abuse.
``(2) Report.--Not later than 2 years after the date of
enactment of the Indian Health Care Improvement Act Amendments
of 2008, the Secretary shall submit to the Committee on Indian
Affairs of the Senate and the Committee on Natural Resources of
the House of Representatives a report that describes, with
respect to the matters described in paragraph (1), the
improvements made and needed, problems or obstacles identified,
and costs necessary to address the problems or obstacles, and
any other recommendations that the Secretary determines to be
appropriate.
``SEC. 715. BEHAVIORAL HEALTH RESEARCH.
``The Secretary, in consultation with appropriate Federal agencies,
shall make grants to, or enter into contracts with, Indian Tribes,
Tribal Organizations, and urban Indian organizations or enter into
contracts with, or make grants to appropriate institutions for, the
conduct of research on the incidence and prevalence of behavioral
health problems among Indians served by the Service, Indian Tribes, or
Tribal Organizations and among Indians in urban areas. Research
priorities under this section shall include--
``(1) the multifactorial causes of Indian youth suicide,
including--
``(A) protective and risk factors and scientific
data that identifies those factors; and
``(B) the effects of loss of cultural identity and
the development of scientific data on those effects;
``(2) the interrelationship and interdependence of
behavioral health problems with alcoholism and other substance
abuse, suicide, homicides, other injuries, and the incidence of
family violence; and
``(3) the development of models of prevention techniques.
The effect of the interrelationships and interdependencies referred to
in paragraph (2) on children, and the development of prevention
techniques under paragraph (3) applicable to children, shall be
emphasized.
``SEC. 716. DEFINITIONS.
``For the purpose of this title, the following definitions shall
apply:
``(1) Assessment.--The term `assessment' means the
systematic collection, analysis, and dissemination of
information on health status, health needs, and health
problems.
``(2) Alcohol-related neurodevelopmental disorders or
arnd.--The term `alcohol-related neurodevelopmental disorders'
or `ARND' means, with a history of maternal alcohol consumption
during pregnancy, central nervous system involvement such as
developmental delay, intellectual deficit, or neurologic
abnormalities. Behaviorally, there can be problems with
irritability, and failure to thrive as infants. As children
become older there will likely be hyperactivity, attention
deficit, language dysfunction, and perceptual and judgment
problems.
``(3) Behavioral health aftercare.--The term `behavioral
health aftercare' includes those activities and resources used
to support recovery following inpatient, residential, intensive
substance abuse, or mental health outpatient or outpatient
treatment. The purpose is to help prevent or deal with relapse
by ensuring that by the time a client or patient is discharged
from a level of care, such as outpatient treatment, an
aftercare plan has been developed with the client. An aftercare
plan may use such resources as a community-based therapeutic
group, transitional living facilities, a 12-step sponsor, a
local 12-step or other related support group, and other
community-based providers.
``(4) Dual diagnosis.--The term `dual diagnosis' means
coexisting substance abuse and mental illness conditions or
diagnosis. Such clients are sometimes referred to as mentally
ill chemical abusers (MICAs).
``(5) Fetal alcohol spectrum disorders.--
``(A) In general.--The term `fetal alcohol spectrum
disorders' includes a range of effects that can occur
in an individual whose mother drank alcohol during
pregnancy, including physical, mental, behavioral, and/
or learning disabilities with possible lifelong
implications.
``(B) Inclusions.--The term `fetal alcohol spectrum
disorders' may include--
``(i) fetal alcohol syndrome (FAS);
``(ii) fetal alcohol effect (FAE);
``(iii) alcohol-related birth defects; and
``(iv) alcohol-related neurodevelopmental
disorders (ARND).
``(6) Fetal alcohol syndrome or fas.--The term `fetal
alcohol syndrome' or `FAS' means any 1 of a spectrum of effects
that may occur when a woman drinks alcohol during pregnancy,
the diagnosis of which involves the confirmed presence of the
following 3 criteria:
``(A) Craniofacial abnormalities.
``(B) Growth deficits.
``(C) Central nervous system abnormalities.
``(7) Rehabilitation.--The term `rehabilitation' means
medical and health care services that--
``(A) are recommended by a physician or licensed
practitioner of the healing arts within the scope of
their practice under applicable law;
``(B) are furnished in a facility, home, or other
setting in accordance with applicable standards; and
``(C) have as their purpose any of the following:
``(i) The maximum attainment of physical,
mental, and developmental functioning.
``(ii) Averting deterioration in physical
or mental functional status.
``(iii) The maintenance of physical or
mental health functional status.
``(8) Substance abuse.--The term `substance abuse' includes
inhalant abuse.
``(9) Systems of care.--The term `Systems of Care' means a
system for delivering services to children and their families
that is child-centered, family-focused and family-driven,
community-based, and culturally competent and responsive to the
needs of the children and families being served. The systems of
care approach values prevention and early identification,
smooth transitions for children and families, child and family
participation and advocacy, comprehensive array of services,
individualized service planning, services in the least
restrictive environment, and integrated services with
coordinated planning across the child-serving systems.
``SEC. 717. AUTHORIZATION OF APPROPRIATIONS.
``There is authorized to be appropriated such sums as may be
necessary to carry out the provisions of this title.
``TITLE VIII--MISCELLANEOUS
``SEC. 801. REPORTS.
``For each fiscal year following the date of enactment of the
Indian Health Care Improvement Act Amendments of 2009, the Secretary
shall transmit to Congress a report containing the following:
``(1) A report on the progress made in meeting the
objectives of this Act, including a review of programs
established or assisted pursuant to this Act and assessments
and recommendations of additional programs or additional
assistance necessary to, at a minimum, provide health services
to Indians and ensure a health status for Indians, which are at
a parity with the health services available to and the health
status of the general population.
``(2) A report on whether, and to what extent, new national
health care programs, benefits, initiatives, or financing
systems have had an impact on the purposes of this Act and any
steps that the Secretary may have taken to consult with Indian
Tribes, Tribal Organizations, and urban Indian organizations to
address such impact, including a report on proposed changes in
allocation of funding pursuant to section 807.
``(3) A report on the use of health services by Indians--
``(A) on a national and area or other relevant
geographical basis;
``(B) by gender and age;
``(C) by source of payment and type of service;
``(D) comparing such rates of use with rates of use
among comparable non-Indian populations; and
``(E) provided under contracts.
``(4) A report of contractors to the Secretary on Health
Care Educational Loan Repayments every 6 months required by
section 110.
``(5) A general audit report of the Secretary on the Health
Care Educational Loan Repayment Program as required by section
110(m).
``(6) A report of the findings and conclusions of
demonstration programs on development of educational curricula
for substance abuse counseling as required in section 125(f).
``(7) A separate statement which specifies the amount of
funds requested to carry out the provisions of section 201.
``(8) A report of the evaluations of health promotion and
disease prevention as required in section 203(c).
``(9) A biennial report to Congress on infectious diseases
as required by section 212.
``(10) A report on environmental and nuclear health hazards
as required by section 215.
``(11) An annual report on the status of all health care
facilities needs as required by section 301(c)(2)(B) and
301(d).
``(12) Reports on safe water and sanitary waste disposal
facilities as required by section 302(h).
``(13) An annual report on the expenditure of non-Service
funds for renovation as required by sections 304(b)(2).
``(14) A report identifying the backlog of maintenance and
repair required at Service and tribal facilities required by
section 313(a).
``(15) A report providing an accounting of reimbursement
funds made available to the Secretary under titles XVIII, XIX,
and XXI of the Social Security Act.
``(16) A report on any arrangements for the sharing of
medical facilities or services, as authorized by section 406.
``(17) A report on evaluation and renewal of urban Indian
programs under section 505.
``(18) A report on the evaluation of programs as required
by section 513(d).
``(19) A report on alcohol and substance abuse as required
by section 701(f).
``(20) A report on Indian youth mental health services as
required by section 707(h).
``(21) A report on the reallocation of base resources if
required by section 807.
``(22) A report on the movement of patients between Service
Units, including--
``(A) a list of those Service Units that have a net
increase and those that have a net decrease of patients
due to patients assigned to one Service Unit
voluntarily choosing to receive service at another
Service Unit;
``(B) an analysis of the effect of patient movement
on the quality of services for those Service Units
experiencing an increase in the number of patients
served; and
``(C) what funding changes are necessary to
maintain a consistent quality of service at Service
Units that have an increase in the number of patients
served.
``(23) A report on the extent to which health care
facilities of the Service, Indian Tribes, Tribal Organizations,
and urban Indian organizations comply with credentialing
requirements of the Service or licensure requirements of
States.
``SEC. 802. REGULATIONS.
``(a) Deadlines.--
``(1) Procedures.--Not later than 90 days after the date of
enactment of the Indian Health Care Improvement Act Amendments
of 2009, the Secretary shall initiate procedures under
subchapter III of chapter 5 of title 5, United States Code, to
negotiate and promulgate such regulations or amendments thereto
that are necessary to carry out this Act, except sections 105,
115, 117, 202, and 409 through 414. The Secretary may
promulgate regulations to carry out such sections using the
procedures required by chapter 5 of title 5, United States Code
(commonly known as the `Administrative Procedure Act').
``(2) Proposed regulations.--Proposed regulations to
implement this Act shall be published in the Federal Register
by the Secretary no later than 2 years after the date of
enactment of the Indian Health Care Improvement Act Amendments
of 2009 and shall have no less than a 120-day comment period.
``(3) Final regulations.--The Secretary shall publish in
the Federal Register final regulations to implement this Act by
not later than 3 years after the date of enactment of the
Indian Health Care Improvement Act Amendments of 2009.
``(b) Committee.--A negotiated rulemaking committee established
pursuant to section 565 of title 5, United States Code, to carry out
this section shall have as its members only representatives of the
Federal Government and representatives of Indian Tribes, and Tribal
Organizations, a majority of whom shall be nominated by and be
representatives of Indian Tribes and Tribal Organizations from each
Service Area.
``(c) Adaptation of Procedures.--The Secretary shall adapt the
negotiated rulemaking procedures to the unique context of self-
governance and the government-to-government relationship between the
United States and Indian Tribes.
``(d) Lack of Regulations.--The lack of promulgated regulations
shall not limit the effect of this Act.
``SEC. 803. PLAN OF IMPLEMENTATION.
``(a) In General.--Not later than 1 year after the date of
enactment of the Indian Health Care Improvement Act Amendments of 2009,
the Secretary, in consultation with Indian Tribes, Tribal
Organizations, and urban Indian organizations, shall submit to Congress
a plan explaining the manner and schedule, by title and section, by
which the Secretary will implement the provisions of this Act. This
consultation may be conducted jointly with the annual budget
consultation pursuant to the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.).
``(b) Lack of Plan.--The lack of (or failure to submit) such a plan
shall not limit the effect, or prevent the implementation, of this Act.
``SEC. 804. LIMITATION ON USE OF FUNDS APPROPRIATED TO INDIAN HEALTH
SERVICE.
``Any limitation on the use of funds contained in an Act providing
appropriations for the Department for a period with respect to the
performance of abortions shall apply for that period with respect to
the performance of abortions using funds contained in an Act providing
appropriations for the Service.
``SEC. 805. ELIGIBILITY OF CALIFORNIA INDIANS.
``(a) In General.--The following California Indians shall be
eligible for health services provided by the Service:
``(1) Any member of a federally recognized Indian Tribe.
``(2) Any descendant of an Indian who was residing in
California on June 1, 1852, if such descendant--
``(A) is a member of the Indian community served by
a local program of the Service; and
``(B) is regarded as an Indian by the community in
which such descendant lives.
``(3) Any Indian who holds trust interests in public
domain, national forest, or reservation allotments in
California.
``(4) Any Indian in California who is listed on the plans
for distribution of the assets of rancherias and reservations
located within the State of California under the Act of August
18, 1958 (72 Stat. 619), and any descendant of such an Indian.
``(b) Clarification.--Nothing in this section may be construed as
expanding the eligibility of California Indians for health services
provided by the Service beyond the scope of eligibility for such health
services that applied on May 1, 1986.
``SEC. 806. HEALTH SERVICES FOR INELIGIBLE PERSONS.
``(a) Children.--Any individual who--
``(1) has not attained 19 years of age;
``(2) is the natural or adopted child, stepchild, foster
child, legal ward, or orphan of an eligible Indian; and
``(3) is not otherwise eligible for health services
provided by the Service,
shall be eligible for all health services provided by the Service on
the same basis and subject to the same rules that apply to eligible
Indians until such individual attains 19 years of age. The existing and
potential health needs of all such individuals shall be taken into
consideration by the Service in determining the need for, or the
allocation of, the health resources of the Service. If such an
individual has been determined to be legally incompetent prior to
attaining 19 years of age, such individual shall remain eligible for
such services until 1 year after the date of a determination of
competency.
``(b) Spouses.--Any spouse of an eligible Indian who is not an
Indian, or who is of Indian descent but is not otherwise eligible for
the health services provided by the Service, shall be eligible for such
health services if all such spouses or spouses who are married to
members of each Indian Tribe being served are made eligible, as a
class, by an appropriate resolution of the governing body of the Indian
Tribe or Tribal Organization providing such services. The health needs
of persons made eligible under this paragraph shall not be taken into
consideration by the Service in determining the need for, or allocation
of, its health resources.
``(c) Provision of Services to Other Individuals.--
``(1) In general.--The Secretary is authorized to provide
health services under this subsection through health programs
operated directly by the Service to individuals who reside
within the Service area of the Service Unit and who are not
otherwise eligible for such health services if--
``(A) the Indian Tribes served by such Service Unit
request such provision of health services to such
individuals; and
``(B) the Secretary and the served Indian Tribes
have jointly determined that--
``(i) the provision of such health services
will not result in a denial or diminution of
health services to eligible Indians; and
``(ii) there is no reasonable alternative
health facilities or services, within or
without the Service Unit, available to meet the
health needs of such individuals.
``(2) ISDEAA programs.--In the case of health programs and
facilities operated under a contract or compact entered into
under the Indian Self-Determination and Education Assistance
Act (25 U.S.C. 450 et seq.), the governing body of the Indian
Tribe or Tribal Organization providing health services under
such contract or compact is authorized to determine whether
health services should be provided under such contract to
individuals who are not eligible for such health services under
any other subsection of this section or under any other
provision of law. In making such determinations, the governing
body of the Indian Tribe or Tribal Organization shall take into
account the considerations described in paragraph (1)(B).
``(3) Payment for services.--
``(A) In general.--Persons receiving health
services provided by the Service under this subsection
shall be liable for payment of such health services
under a schedule of charges prescribed by the Secretary
which, in the judgment of the Secretary, results in
reimbursement in an amount not less than the actual
cost of providing the health services. Notwithstanding
section 404 of this Act or any other provision of law,
amounts collected under this subsection, including
Medicare, Medicaid, or SCHIP reimbursements under
titles XVIII, XIX, and XXI of the Social Security Act,
shall be credited to the account of the program
providing the service and shall be used for the
purposes listed in section 401(d)(2) and amounts
collected under this subsection shall be available for
expenditure within such program.
``(B) Indigent people.--Health services may be
provided by the Secretary through the Service under
this subsection to an indigent individual who would not
be otherwise eligible for such health services but for
the provisions of paragraph (1) only if an agreement
has been entered into with a State or local government
under which the State or local government agrees to
reimburse the Service for the expenses incurred by the
Service in providing such health services to such
indigent individual.
``(4) Revocation of consent for services.--
``(A) Single tribe service area.--In the case of a
Service Area which serves only 1 Indian Tribe, the
authority of the Secretary to provide health services
under paragraph (1) shall terminate at the end of the
fiscal year succeeding the fiscal year in which the
governing body of the Indian Tribe revokes its
concurrence to the provision of such health services.
``(B) Multitribal service area.--In the case of a
multitribal Service Area, the authority of the
Secretary to provide health services under paragraph
(1) shall terminate at the end of the fiscal year
succeeding the fiscal year in which at least 51 percent
of the number of Indian Tribes in the Service Area
revoke their concurrence to the provisions of such
health services.
``(d) Other Services.--The Service may provide health services
under this subsection to individuals who are not eligible for health
services provided by the Service under any other provision of law in
order to--
``(1) achieve stability in a medical emergency;
``(2) prevent the spread of a communicable disease or
otherwise deal with a public health hazard;
``(3) provide care to non-Indian women pregnant with an
eligible Indian's child for the duration of the pregnancy
through postpartum; or
``(4) provide care to immediate family members of an
eligible individual if such care is directly related to the
treatment of the eligible individual.
``(e) Hospital Privileges for Practitioners.--
``(1) In general.--Hospital privileges in health facilities
operated and maintained by the Service or operated under a
contract or compact pursuant to the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.) may be
extended to non-Service health care practitioners who provide
services to individuals described in subsection (a), (b), (c),
or (d). Such non-Service health care practitioners may, as part
of the privileging process, be designated as employees of the
Federal Government for purposes of section 1346(b) and chapter
171 of title 28, United States Code (relating to Federal tort
claims) only with respect to acts or omissions which occur in
the course of providing services to eligible individuals as a
part of the conditions under which such hospital privileges are
extended.
``(2) Definition.--For purposes of this subsection, the
term `non-Service health care practitioner' means a
practitioner who is not--
``(A) an employee of the Service; or
``(B) an employee of an Indian tribe or tribal
organization operating a contract or compact under the
Indian Self-Determination and Education Assistance Act
or an individual who provides health care services
pursuant to a personal services contract with such
Indian tribe or tribal organization.
``(f) Eligible Indian.--For purposes of this section, the term
`eligible Indian' means any Indian who is eligible for health services
provided by the Service without regard to the provisions of this
section.
``SEC. 807. REALLOCATION OF BASE RESOURCES.
``(a) Report Required.--Notwithstanding any other provision of law,
any allocation of Service funds for a fiscal year that reduces by 5
percent or more from the previous fiscal year the funding for any
recurring program, project, or activity of a Service Unit may be
implemented only after the Secretary has submitted to Congress, under
section 801, a report on the proposed change in allocation of funding,
including the reasons for the change and its likely effects.
``(b) Exception.--Subsection (a) shall not apply if the total
amount appropriated to the Service for a fiscal year is at least 5
percent less than the amount appropriated to the Service for the
previous fiscal year.
``SEC. 808. RESULTS OF DEMONSTRATION PROJECTS.
``The Secretary shall provide for the dissemination to Indian
Tribes, Tribal Organizations, and urban Indian organizations of the
findings and results of demonstration projects conducted under this
Act.
``SEC. 809. PROVISION OF SERVICES IN MONTANA.
``(a) Consistent With Court Decision.--The Secretary, acting
through the Service, shall provide services and benefits for Indians in
Montana in a manner consistent with the decision of the United States
Court of Appeals for the Ninth Circuit in McNabb for McNabb v. Bowen,
829 F.2d 787 (9th Cir. 1987).
``(b) Clarification.--The provisions of subsection (a) shall not be
construed to be an expression of the sense of Congress on the
application of the decision described in subsection (a) with respect to
the provision of services or benefits for Indians living in any State
other than Montana.
``SEC. 810. MORATORIUM.
``During the period of the moratorium imposed on implementation of
the final rule published in the Federal Register on September 16, 1987,
by the Department of Health and Human Services, relating to eligibility
for the health care services of the Indian Health Service, the Indian
Health Service shall provide services pursuant to the criteria for
eligibility for such services that were in effect on September 15,
1987, subject to the provisions of sections 805 and 806, until the
Service has submitted to the Committees on Appropriations of the Senate
and the House of Representatives a budget request reflecting the
increased costs associated with the proposed final rule, and the
request has been included in an appropriations Act and enacted into
law.
``SEC. 811. SEVERABILITY PROVISIONS.
``If any provision of this Act, any amendment made by the Act, or
the application of such provision or amendment to any person or
circumstances is held to be invalid, the remainder of this Act, the
remaining amendments made by this Act, and the application of such
provisions to persons or circumstances other than those to which it is
held invalid, shall not be affected thereby.
``SEC. 812. USE OF PATIENT SAFETY ORGANIZATIONS.
``The Service, an Indian Tribe, Tribal Organization, or urban
Indian organization may provide for quality assurance activities
through the use of a patient safety organization in accordance with
title IX of the Public Health Service Act.
``SEC. 813. CONFIDENTIALITY OF MEDICAL QUALITY ASSURANCE RECORDS;
QUALIFIED IMMUNITY FOR PARTICIPANTS.
``(a) Confidentiality of Records.--Medical quality assurance
records created by or for any Indian Health Program or a health program
of an Urban Indian Organization as part of a medical quality assurance
program are confidential and privileged. Such records may not be
disclosed to any person or entity, except as provided in subsection
(c).
``(b) Prohibition on Disclosure and Testimony.--
``(1) In general.--No part of any medical quality assurance
record described in subsection (a) may be subject to discovery
or admitted into evidence in any judicial or administrative
proceeding, except as provided in subsection (c).
``(2) Testimony.--A person who reviews or creates medical
quality assurance records for any Indian Health Program or
Urban Indian Organization who participates in any proceeding
that reviews or creates such records may not be permitted or
required to testify in any judicial or administrative
proceeding with respect to such records or with respect to any
finding, recommendation, evaluation, opinion, or action taken
by such person or body in connection with such records except
as provided in this section.
``(c) Authorized Disclosure and Testimony.--
``(1) In general.--Subject to paragraph (2), a medical
quality assurance record described in subsection (a) may be
disclosed, and a person referred to in subsection (b) may give
testimony in connection with such a record, only as follows:
``(A) To a Federal executive agency or private
organization, if such medical quality assurance record
or testimony is needed by such agency or organization
to perform licensing or accreditation functions related
to any Indian Health Program or to a health program of
an Urban Indian Organization to perform monitoring,
required by law, of such program or organization.
``(B) To an administrative or judicial proceeding
commenced by a present or former Indian Health Program
or Urban Indian Organization provider concerning the
termination, suspension, or limitation of clinical
privileges of such health care provider.
``(C) To a governmental board or agency or to a
professional health care society or organization, if
such medical quality assurance record or testimony is
needed by such board, agency, society, or organization
to perform licensing, credentialing, or the monitoring
of professional standards with respect to any health
care provider who is or was an employee of any Indian
Health Program or Urban Indian Organization.
``(D) To a hospital, medical center, or other
institution that provides health care services, if such
medical quality assurance record or testimony is needed
by such institution to assess the professional
qualifications of any health care provider who is or
was an employee of any Indian Health Program or Urban
Indian Organization and who has applied for or been
granted authority or employment to provide health care
services in or on behalf of such program or
organization.
``(E) To an officer, employee, or contractor of the
Indian Health Program or Urban Indian Organization that
created the records or for which the records were
created. If that officer, employee, or contractor has a
need for such record or testimony to perform official
duties.
``(F) To a criminal or civil law enforcement agency
or instrumentality charged under applicable law with
the protection of the public health or safety, if a
qualified representative of such agency or
instrumentality makes a written request that such
record or testimony be provided for a purpose
authorized by law.
``(G) In an administrative or judicial proceeding
commenced by a criminal or civil law enforcement agency
or instrumentality referred to in subparagraph (F), but
only with respect to the subject of such proceeding.
``(2) Identity of participants.--With the exception of the
subject of a quality assurance action, the identity of any
person receiving health care services from any Indian Health
Program or Urban Indian Organization or the identity of any
other person associated with such program or organization for
purposes of a medical quality assurance program that is
disclosed in a medical quality assurance record described in
subsection (a) shall be deleted from that record or document
before any disclosure of such record is made outside such
program or organization.
``(d) Disclosure for Certain Purposes.--
``(1) In general.--Nothing in this section shall be
construed as authorizing or requiring the withholding from any
person or entity aggregate statistical information regarding
the results of any Indian Health Program or Urban Indian
Organizations's medical quality assurance programs.
``(2) Withholding from congress.--Nothing in this section
shall be construed as authority to withhold any medical quality
assurance record from a committee of either House of Congress,
any joint committee of Congress, or the Government
Accountability Office if such record pertains to any matter
within their respective jurisdictions.
``(e) Prohibition on Disclosure of Record or Testimony.--A person
or entity having possession of or access to a record or testimony
described by this section may not disclose the contents of such record
or testimony in any manner or for any purpose except as provided in
this section.
``(f) Exemption From Freedom of Information Act.--Medical quality
assurance records described in subsection (a) may not be made available
to any person under section 552 of title 5, United States Code.
``(g) Limitation on Civil Liability.--A person who participates in
or provides information to a person or body that reviews or creates
medical quality assurance records described in subsection (a) shall not
be civilly liable for such participation or for providing such
information if the participation or provision of information was in
good faith based on prevailing professional standards at the time the
medical quality assurance program activity took place.
``(h) Application to Information in Certain Other Records.--Nothing
in this section shall be construed as limiting access to the
information in a record created and maintained outside a medical
quality assurance program, including a patient's medical records, on
the grounds that the information was presented during meetings of a
review body that are part of a medical quality assurance program.
``(i) Regulations.--The Secretary, acting through the Service,
shall promulgate regulations pursuant to section 802.
``(j) Definitions.--In this section:
``(1) The term `health care provider' means any health care
professional, including community health aides and
practitioners certified under section 121, who are granted
clinical practice privileges or employed to provide health care
services in an Indian Health Program or health program of an
Urban Indian Organization, who is licensed or certified to
perform health care services by a governmental board or agency
or professional health care society or organization.
``(2) The term `medical quality assurance program' means
any activity carried out before, on, or after the date of
enactment of this Act by or for any Indian Health Program or
Urban Indian Organization to assess the quality of medical
care, including activities conducted by or on behalf of
individuals, Indian Health Program or Urban Indian Organization
medical or dental treatment review committees, or other review
bodies responsible for quality assurance, credentials,
infection control, patient safety, patient care assessment
(including treatment procedures, blood, drugs, and
therapeutics), medical records, health resources management
review and identification and prevention of medical or dental
incidents and risks.
``(3) The term `medical quality assurance record' means the
proceedings, records, minutes, and reports that emanate from
quality assurance program activities described in paragraph (2)
and are produced or compiled by or for an Indian Health Program
or Urban Indian Organization as part of a medical quality
assurance program.
``(k) Continued Protection.--Disclosure under subsection (c) does
not permit redisclosure except to the extent such further disclosure is
authorized under subsection (c) or is otherwise authorized to be
disclosed under this section.
``(l) Inconsistencies.--To the extent that the protections under
the Patient Safety and Quality Improvement Act of 2005 and this section
are inconsistent, the provisions of whichever is more protective shall
control.
``(m) Relationship to Other Law.--This section shall continue in
force and effect, except as otherwise specifically provided in any
Federal law enacted after the date of enactment of the Indian Health
Care Improvement Act Amendments of 2009.
``SEC. 814. CLAREMORE INDIAN HOSPITAL.
``The Claremore Indian Hospital shall be deemed to be a dependant
Indian community for the purposes of section 1151 of title 18, United
States Code.
``SEC. 815. SENSE OF CONGRESS REGARDING LAW ENFORCEMENT AND
METHAMPHETAMINE ISSUES IN INDIAN COUNTRY.
``It is the sense of Congress that Congress encourages State,
local, and Indian tribal law enforcement agencies to enter into
memoranda of agreement between and among those agencies for purposes of
streamlining law enforcement activities and maximizing the use of
limited resources--
``(1) to improve law enforcement services provided to
Indian tribal communities; and
``(2) to increase the effectiveness of measures to address
problems relating to methamphetamine use in Indian country (as
defined in section 1151 of title 18, United States Code).
``SEC. 816. PERMITTING IMPLEMENTATION THROUGH CONTRACTS WITH TRIBAL
HEALTH PROGRAMS.
``Nothing in this Act shall be construed as preventing the
Secretary from--
``(1) carrying out any section of this Act through
contracts with Tribal Health Programs; and
``(2) carrying out sections through 214, 701(a)(1),
701(b)(1), 701(c), 707(g), and 712(b), through contracts with
urban Indian organizations.
The previous sentence shall not affect the authority the Secretary may
otherwise have to carry out other provisions of this Act through such
contracts.
``SEC. 817. AUTHORIZATION OF APPROPRIATIONS; AVAILABILITY.
``(a) Authorization of Appropriations.--There are authorized to be
appropriated such sums as may be necessary to carry out this title.
``(b) Limitation on New Spending Authority.--Any new spending
authority (described in subparagraph (A) or (B) of section 401(c)(2) of
the Congressional Budget Act of 1974 (Public Law 93-344; 88 Stat. 317))
which is provided under this Act shall be effective for any fiscal year
only to such extent or in such amounts as are provided in appropriation
Acts.
``(c) Availability.--The funds appropriated pursuant to this Act
shall remain available until expended.''.
(b) Rate of Pay.--
(1) Positions at level iv.--Section 5315 of title 5, United
States Code, is amended by striking ``Assistant Secretaries of
Health and Human Services (6).'' and inserting ``Assistant
Secretaries of Health and Human Services (7)''.
(2) Positions at level v.--Section 5316 of title 5, United
States Code, is amended by striking ``Director, Indian Health
Service, Department of Health and Human Services''.
(c) Amendments to Other Provisions of Law.--
(1) Section 3307(b)(1)(C) of the Children's Health Act of
2000 (25 U.S.C. 1671 note; Public Law 106-310) is amended by
striking ``Director of the Indian Health Service'' and
inserting ``Assistant Secretary for Indian Health''.
(2) The Indian Lands Open Dump Cleanup Act of 1994 is
amended--
(A) in section 3 (25 U.S.C. 3902)--
(i) by striking paragraph (2);
(ii) by redesignating paragraphs (1), (3),
(4), (5), and (6) as paragraphs (4), (5), (2),
(6), and (1), respectively, and moving those
paragraphs so as to appear in numerical order;
and
(iii) by inserting before paragraph (4) (as
redesignated by subclause (II)) the following:
``(3) Assistant secretary.--The term `Assistant Secretary'
means the Assistant Secretary for Indian Health.'';
(B) in section 5 (25 U.S.C. 3904), by striking the
section designation and heading and inserting the
following:
``SEC. 5. AUTHORITY OF ASSISTANT SECRETARY FOR INDIAN HEALTH.'';
(C) in section 6(a) (25 U.S.C. 3905(a)), in the
subsection heading, by striking ``Director'' and
inserting ``Assistant Secretary'';
(D) in section 9(a) (25 U.S.C. 3908(a)), in the
subsection heading, by striking ``Director'' and
inserting ``Assistant Secretary''; and
(E) by striking ``Director'' each place it appears
and inserting ``Assistant Secretary''.
(3) Section 5504(d)(2) of the Augustus F. Hawkins-Robert T.
Stafford Elementary and Secondary School Improvement Amendments
of 1988 (25 U.S.C. 2001 note; Public Law 100-297) is amended by
striking ``Director of the Indian Health Service'' and
inserting ``Assistant Secretary for Indian Health''.
(4) Section 203(a)(1) of the Rehabilitation Act of 1973 (29
U.S.C. 763(a)(1)) is amended by striking ``Director of the
Indian Health Service'' and inserting ``Assistant Secretary for
Indian Health''.
(5) Subsections (b) and (e) of section 518 of the Federal
Water Pollution Control Act (33 U.S.C. 1377) are amended by
striking ``Director of the Indian Health Service'' each place
it appears and inserting ``Assistant Secretary for Indian
Health''.
(6) Section 317M(b) of the Public Health Service Act (42
U.S.C. 247b-14(b)) is amended--
(A) by striking ``Director of the Indian Health
Service'' each place it appears and inserting
``Assistant Secretary for Indian Health''; and
(B) in paragraph (2)(A), by striking ``the
Directors referred to in such paragraph'' and inserting
``the Director of the Centers for Disease Control and
Prevention and the Assistant Secretary for Indian
Health''.
(7) Section 417C(b) of the Public Health Service Act (42
U.S.C. 285-9(b)) is amended by striking ``Director of the
Indian Health Service'' and inserting ``Assistant Secretary for
Indian Health''.
(8) Section 1452(i) of the Safe Drinking Water Act (42
U.S.C. 300j-12(i)) is amended by striking ``Director of the
Indian Health Service'' each place it appears and inserting
``Assistant Secretary for Indian Health''.
(9) Section 803B(d)(1) of the Native American Programs Act
of 1974 (42 U.S.C. 2991b-2(d)(1)) is amended in the last
sentence by striking ``Director of the Indian Health Service''
and inserting ``Assistant Secretary for Indian Health''.
(10) Section 203(b) of the Michigan Indian Land Claims
Settlement Act (Public Law 105-143; 111 Stat. 2666) is amended
by striking ``Director of the Indian Health Service'' and
inserting ``Assistant Secretary for Indian Health''.
SEC. 3102. SOBOBA SANITATION FACILITIES.
The Act of December 17, 1970 (84 Stat. 1465), is amended by adding
at the end the following:
``Sec. 9. Nothing in this Act shall preclude the Soboba Band of
Mission Indians and the Soboba Indian Reservation from being provided
with sanitation facilities and services under the authority of section
7 of the Act of August 5, 1954 (68 Stat. 674), as amended by the Act of
July 31, 1959 (73 Stat. 267).''.
SEC. 3103. NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION.
(a) In General.--The Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.) is amended by adding at the end
the following:
``TITLE VIII--NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION
``SEC. 801. DEFINITIONS.
``In this title:
``(1) Board.--The term `Board' means the Board of Directors
of the Foundation.
``(2) Committee.--The term `Committee' means the Committee
for the Establishment of Native American Health and Wellness
Foundation established under section 802(f).
``(3) Foundation.--The term `Foundation' means the Native
American Health and Wellness Foundation established under
section 802.
``(4) Secretary.--The term `Secretary' means the Secretary
of Health and Human Services.
``(5) Service.--The term `Service' means the Indian Health
Service of the Department of Health and Human Services.
``SEC. 802. NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION.
``(a) Establishment.--
``(1) In general.--As soon as practicable after the date of
enactment of this title, the Secretary shall establish, under
the laws of the District of Columbia and in accordance with
this title, the Native American Health and Wellness Foundation.
``(2) Funding determinations.--No funds, gift, property, or
other item of value (including any interest accrued on such an
item) acquired by the Foundation shall--
``(A) be taken into consideration for purposes of
determining Federal appropriations relating to the
provision of health care and services to Indians; or
``(B) otherwise limit, diminish, or affect the
Federal responsibility for the provision of health care
and services to Indians.
``(b) Perpetual Existence.--The Foundation shall have perpetual
existence.
``(c) Nature of Corporation.--The Foundation--
``(1) shall be a charitable and nonprofit federally
chartered corporation; and
``(2) shall not be an agency or instrumentality of the
United States.
``(d) Place of Incorporation and Domicile.--The Foundation shall be
incorporated and domiciled in the District of Columbia.
``(e) Duties.--The Foundation shall--
``(1) encourage, accept, and administer private gifts of
real and personal property, and any income from or interest in
such gifts, for the benefit of, or in support of, the mission
of the Service;
``(2) undertake and conduct such other activities as will
further the health and wellness activities and opportunities of
Native Americans; and
``(3) participate with and assist Federal, State, and
tribal governments, agencies, entities, and individuals in
undertaking and conducting activities that will further the
health and wellness activities and opportunities of Native
Americans.
``(f) Committee for the Establishment of Native American Health and
Wellness Foundation.--
``(1) In general.--The Secretary shall establish the
Committee for the Establishment of Native American Health and
Wellness Foundation to assist the Secretary in establishing the
Foundation.
``(2) Duties.--Not later than 180 days after the date of
enactment of this section, the Committee shall--
``(A) carry out such activities as are necessary to
incorporate the Foundation under the laws of the
District of Columbia, including acting as incorporators
of the Foundation;
``(B) ensure that the Foundation qualifies for and
maintains the status required to carry out this
section, until the Board is established;
``(C) establish the constitution and initial bylaws
of the Foundation;
``(D) provide for the initial operation of the
Foundation, including providing for temporary or
interim quarters, equipment, and staff; and
``(E) appoint the initial members of the Board in
accordance with the constitution and initial bylaws of
the Foundation.
``(g) Board of Directors.--
``(1) In general.--The Board of Directors shall be the
governing body of the Foundation.
``(2) Powers.--The Board may exercise, or provide for the
exercise of, the powers of the Foundation.
``(3) Selection.--
``(A) In general.--Subject to subparagraph (B), the
number of members of the Board, the manner of selection
of the members (including the filling of vacancies),
and the terms of office of the members shall be as
provided in the constitution and bylaws of the
Foundation.
``(B) Requirements.--
``(i) Number of members.--The Board shall
have at least 11 members, who shall have
staggered terms.
``(ii) Initial voting members.--The initial
voting members of the Board--
``(I) shall be appointed by the
Committee not later than 180 days after
the date on which the Foundation is
established; and
``(II) shall have staggered terms.
``(iii) Qualification.--The members of the
Board shall be United States citizens who are
knowledgeable or experienced in Native American
health care and related matters.
``(C) Compensation.--A member of the Board shall
not receive compensation for service as a member, but
shall be reimbursed for actual and necessary travel and
subsistence expenses incurred in the performance of the
duties of the Foundation.
``(h) Officers.--
``(1) In general.--The officers of the Foundation shall
be--
``(A) a secretary, elected from among the members
of the Board; and
``(B) any other officers provided for in the
constitution and bylaws of the Foundation.
``(2) Chief operating officer.--The secretary of the
Foundation may serve, at the direction of the Board, as the
chief operating officer of the Foundation, or the Board may
appoint a chief operating officer, who shall serve at the
direction of the Board.
``(3) Election.--The manner of election, term of office,
and duties of the officers of the Foundation shall be as
provided in the constitution and bylaws of the Foundation.
``(i) Powers.--The Foundation--
``(1) shall adopt a constitution and bylaws for the
management of the property of the Foundation and the regulation
of the affairs of the Foundation;
``(2) may adopt and alter a corporate seal;
``(3) may enter into contracts;
``(4) may acquire (through a gift or otherwise), own,
lease, encumber, and transfer real or personal property as
necessary or convenient to carry out the purposes of the
Foundation;
``(5) may sue and be sued; and
``(6) may perform any other act necessary and proper to
carry out the purposes of the Foundation.
``(j) Principal Office.--
``(1) In general.--The principal office of the Foundation
shall be in the District of Columbia.
``(2) Activities; offices.--The activities of the
Foundation may be conducted, and offices may be maintained,
throughout the United States in accordance with the
constitution and bylaws of the Foundation.
``(k) Service of Process.--The Foundation shall comply with the law
on service of process of each State in which the Foundation is
incorporated and of each State in which the Foundation carries on
activities.
``(l) Liability of Officers, Employees, and Agents.--
``(1) In general.--The Foundation shall be liable for the
acts of the officers, employees, and agents of the Foundation
acting within the scope of their authority.
``(2) Personal liability.--A member of the Board shall be
personally liable only for gross negligence in the performance
of the duties of the member.
``(m) Restrictions.--
``(1) Limitation on spending.--Beginning with the fiscal
year following the first full fiscal year during which the
Foundation is in operation, the administrative costs of the
Foundation shall not exceed the percentage described in
paragraph (2) of the sum of--
``(A) the amounts transferred to the Foundation
under subsection (o) during the preceding fiscal year;
and
``(B) donations received from private sources
during the preceding fiscal year.
``(2) Percentages.--The percentages referred to in
paragraph (1) are--
``(A) for the first fiscal year described in that
paragraph, 20 percent;
``(B) for the following fiscal year, 15 percent;
and
``(C) for each fiscal year thereafter, 10 percent.
``(3) Appointment and hiring.--The appointment of officers
and employees of the Foundation shall be subject to the
availability of funds.
``(4) Status.--A member of the Board or officer, employee,
or agent of the Foundation shall not by reason of association
with the Foundation be considered to be an officer, employee,
or agent of the United States.
``(n) Audits.--The Foundation shall comply with section 10101 of
title 36, United States Code, as if the Foundation were a corporation
under part B of subtitle II of that title.
``(o) Funding.--
``(1) Authorization of appropriations.--There is authorized
to be appropriated to carry out subsection (e)(1) $500,000 for
each fiscal year, as adjusted to reflect changes in the
Consumer Price Index for all-urban consumers published by the
Department of Labor.
``(2) Transfer of donated funds.--The Secretary shall
transfer to the Foundation funds held by the Department of
Health and Human Services under the Act of August 5, 1954 (42
U.S.C. 2001 et seq.), if the transfer or use of the funds is
not prohibited by any term under which the funds were donated.
``SEC. 803. ADMINISTRATIVE SERVICES AND SUPPORT.
``(a) Provision of Support by Secretary.--Subject to subsection
(b), during the 5-year period beginning on the date on which the
Foundation is established, the Secretary--
``(1) may provide personnel, facilities, and other
administrative support services to the Foundation;
``(2) may provide funds for initial operating costs and to
reimburse the travel expenses of the members of the Board; and
``(3) shall require and accept reimbursements from the
Foundation for--
``(A) services provided under paragraph (1); and
``(B) funds provided under paragraph (2).
``(b) Reimbursement.--Reimbursements accepted under subsection
(a)(3)--
``(1) shall be deposited in the Treasury of the United
States to the credit of the applicable appropriations account;
and
``(2) shall be chargeable for the cost of providing
services described in subsection (a)(1) and travel expenses
described in subsection (a)(2).
``(c) Continuation of Certain Services.--The Secretary may continue
to provide facilities and necessary support services to the Foundation
after the termination of the 5-year period specified in subsection (a)
if the facilities and services--
``(1) are available; and
``(2) are provided on reimbursable cost basis.''.
(b) Technical Amendments.--The Indian Self-Determination and
Education Assistance Act is amended--
(1) by redesignating title V (25 U.S.C. 458bbb et seq.) as
title VII;
(2) by redesignating sections 501, 502, and 503 (25 U.S.C.
458bbb, 458bbb-1, 458bbb-2) as sections 701, 702, and 703,
respectively; and
(3) in subsection (a)(2) of section 702 and paragraph (2)
of section 703 (as redesignated by paragraph (2)), by striking
``section 501'' and inserting ``section 701''.
SEC. 3104. GAO STUDY AND REPORT ON PAYMENTS FOR CONTRACT HEALTH
SERVICES.
(a) Study.--
(1) In general.--The Comptroller General of the United
States (in this section referred to as the ``Comptroller
General'') shall conduct a study on the utilization of health
care furnished by health care providers under the contract
health services program funded by the Indian Health Service and
operated by the Indian Health Service, an Indian Tribe, or a
Tribal Organization (as those terms are defined in section 4 of
the Indian Health Care Improvement Act).
(2) Analysis.--The study conducted under paragraph (1)
shall include an analysis of--
(A) the amounts reimbursed under the contract
health services program described in paragraph (1) for
health care furnished by entities, individual
providers, and suppliers, including a comparison of
reimbursement for such health care through other public
programs and in the private sector;
(B) barriers to accessing care under such contract
health services program, including, but not limited to,
barriers relating to travel distances, cultural
differences, and public and private sector reluctance
to furnish care to patients under such program;
(C) the adequacy of existing Federal funding for
health care under such contract health services
program; and
(D) any other items determined appropriate by the
Comptroller General.
(b) Report.--Not later than 18 months after the date of enactment
of this Act, the Comptroller General shall submit to Congress a report
on the study conducted under subsection (a), together with
recommendations regarding--
(1) the appropriate level of Federal funding that should be
established for health care under the contract health services
program described in subsection (a)(1); and
(2) how to most efficiently utilize such funding.
(c) Consultation.--In conducting the study under subsection (a) and
preparing the report under subsection (b), the Comptroller General
shall consult with the Indian Health Service, Indian Tribes, and Tribal
Organizations.
TITLE II--IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER THE SOCIAL
SECURITY ACT
SEC. 3201. EXPANSION OF PAYMENTS UNDER MEDICARE, MEDICAID, AND SCHIP
FOR ALL COVERED SERVICES FURNISHED BY INDIAN HEALTH
PROGRAMS.
(a) Medicaid.--
(1) Expansion to all covered services.--Section 1911 of the
Social Security Act (42 U.S.C. 1396j) is amended--
(A) by amending the heading to read as follows:
``SEC. 1911. INDIAN HEALTH PROGRAMS.'';
and
(B) by amending subsection (a) to read as follows:
``(a) Eligibility for Payment for Medical Assistance.--An Indian
Health Program shall be eligible for payment for medical assistance
provided under a State plan or under waiver authority with respect to
items and services furnished by the Program if the furnishing of such
services meets all the conditions and requirements which are applicable
generally to the furnishing of items and services under this title and
under such plan or waiver authority.''.
(2) Repeal of obsolete provision.--Subsection (b) of such
section is repealed.
(3) Revision of authority to enter into agreements.--
Subsection (c) of such section is amended to read as follows:
``(c) Authority To Enter Into Agreements.--The Secretary may enter
into an agreement with a State for the purpose of reimbursing the State
for medical assistance provided by the Indian Health Service, an Indian
Tribe, Tribal Organization, or an Urban Indian Organization (as so
defined), directly, through referral, or under contracts or other
arrangements between the Indian Health Service, an Indian Tribe, Tribal
Organization, or an Urban Indian Organization and another health care
provider to Indians who are eligible for medical assistance under the
State plan or under waiver authority. This subsection shall not be
construed to impair the entitlement of a State to reimbursement for
such medical assistance under this title.''.
(4) Cross-references to special fund for improvement of ihs
facilities; direct billing option; definitions.--Such section
is further amended by striking subsection (d) and adding at the
end the following new subsections:
``(c) Special Fund for Improvement of IHS Facilities.--For
provisions relating to the authority of the Secretary to place payments
to which a facility of the Indian Health Service is eligible for
payment under this title into a special fund established under section
401(c)(1) of the Indian Health Care Improvement Act, see subparagraphs
(A) and (B) of section 401(c)(1) of such Act.
``(d) Direct Billing.--For provisions relating to the authority of
an Tribal Health Program to elect to directly bill for, and receive
payment for, health care items and services provided by such Program
for which payment is made under this title, see section 401(d) of the
Indian Health Care Improvement Act.''.
(5) Definitions.--Section 1101(a) of such Act (42 U.S.C.
1301(a)) is amended by adding at the end the following new
paragraph:
``(11) For purposes of this title and titles XVIII, XIX,
and XXI, the terms `Indian Health Program', `Indian Tribe' (and
`Indian tribe'), `Tribal Health Program', `Tribal Organization'
(and `tribal organization'), and `urban Indian organization'
(and `urban Indian organization') have the meanings given those
terms in section 4 of the Indian Health Care Improvement
Act.''.
(b) Medicare.--
(1) Expansion to all covered services.--Section 1880 of
such Act (42 U.S.C. 1395qq) is amended--
(A) by amending the heading to read as follows:
``SEC. 1880. INDIAN HEALTH PROGRAMS.'';
and
(B) by amending subsection (a) to read as follows:
``(a) Eligibility for Payments.--Subject to subsection (e), an
Indian Health Program shall be eligible for payments under this title
with respect to items and services furnished by the Program if the
furnishing of such services meets all the conditions and requirements
which are applicable generally to the furnishing of items and services
under this title.''.
(2) Repeal of obsolete provision.--Subsection (b) of such
section is repealed.
(3) Cross-references to special fund for improvement of ihs
facilities; direct billing option; definitions.--
(A) In general.--Such section is further amended by
striking subsections (c) and (d) and inserting the
following new subsections:
``(b) Special Fund for Improvement of IHS Facilities.--For
provisions relating to the authority of the Secretary to place payments
to which a facility of the Indian Health Service is eligible for
payment under this title into a special fund established under section
401(c)(1) of the Indian Health Care Improvement Act, and the
requirement to use amounts paid from such fund for making improvements
in accordance with subsection (b), see subparagraphs (A) and (B) of
section 401(c)(1) of such Act.
``(c) Direct Billing.--For provisions relating to the authority of
a Tribal Health Program to elect to directly bill for, and receive
payment for, health care items and services provided by such Program
for which payment is made under this title, see section 401(d) of the
Indian Health Care Improvement Act.''.
(B) Conforming amendments.--Such section is further
amended--
(i) in subsection (e)(3), by striking
``Subsection (c)'' and inserting ``Subsection
(b) and section 401(b)(1) of the Indian Health
Care Improvement Act'';
(ii) by redesignating subsection (e) as
subsection (d); and
(iii) by striking subsection (f).
(4) Definitions.--Such section is further amended by
amending adding at the end the following new subsection:
``(e) Definitions.--In this section, the terms `Indian Health
Program', `Indian Tribe', `Service Unit', `Tribal Health Program',
`Tribal Organization', and `Urban Indian Organization' have the
meanings given those terms in section 4 of the Indian Health Care
Improvement Act.''.
(c) Application to SCHIP.--Section 2107(e)(1) of the Social
Security Act (42 U.S.C. 1397gg(e)(1)) is amended--
(1) by redesignating subparagraphs (K) through (M) as
subparagraphs (L) through (N), respectively; and
(2) by inserting after subparagraph (J), the following new
subparagraph:
``(K) Section 1911 (relating to Indian Health
Programs, other than subsection (c) of such
section).''.
SEC. 3202. ADDITIONAL PROVISIONS TO INCREASE OUTREACH TO, AND
ENROLLMENT OF, INDIANS IN SCHIP AND MEDICAID.
(a) Assurance of Payments to Indian Health Care Providers for Child
Health Assistance.--Section 2102(b)(3)(D) of the Social Security Act
(42 U.S.C. 1397bb(b)(3)(D)) is amended by striking ``(as defined in
section 4(c) of the Indian Health Care Improvement Act, 25 U.S.C.
1603(c))'' and inserting ``, including how the State will ensure that
payments are made to Indian Health Programs and urban Indian
organizations operating in the State for the provision of such
assistance''.
(b) Inclusion of Other Indian Financed Health Care Programs in
Exemption From Prohibition on Certain Payments.--Section 2105(c)(6)(B)
of such Act (42 U.S.C. 1397ee(c)(6)(B)) is amended by striking
``insurance program, other than an insurance program operated or
financed by the Indian Health Service'' and inserting ``program, other
than a health care program operated or financed by the Indian Health
Service or by an Indian Tribe, Tribal Organization, or urban Indian
organization''.
(c) Definitions.--Section 2110(c) of such Act (42 U.S.C. 1397jj(c))
is amended by adding at the end the following new paragraph:
``(9) Indian; indian health program; indian tribe; etc.--
The terms `Indian', `Indian Health Program', `Indian Tribe',
`Tribal Organization', and `Urban Indian Organization' have the
meanings given those terms in section 4 of the Indian Health
Care Improvement Act.''.
SEC. 3203. SOLICITATION OF PROPOSALS FOR SAFE HARBORS UNDER THE SOCIAL
SECURITY ACT FOR FACILITIES OF INDIAN HEALTH PROGRAMS AND
URBAN INDIAN ORGANIZATIONS.
The Secretary of Health and Human Services, acting through the
Office of the Inspector General of the Department of Health and Human
Services, shall publish a notice, described in section 1128D(a)(1)(A)
of the Social Security Act (42 U.S.C. 1320a-7d(a)(1)(A)), soliciting a
proposal, not later than July 1, 2010, on the development of safe
harbors described in such section relating to health care items and
services provided by facilities of Indian Health Programs or an urban
Indian organization (as such terms are defined in section 4 of the
Indian Health Care Improvement Act). Such a safe harbor may relate to
areas such as transportation, housing, or cost-sharing, assistance
provided through such facilities or contract health services for
Indians.
SEC. 3204. ANNUAL REPORT ON INDIANS SERVED BY SOCIAL SECURITY ACT
HEALTH BENEFIT PROGRAMS.
Section 1139 of the Social Security Act (42 U.S.C. 1320b-9), as
amended by the sections 3203 and 3204, is amended by redesignating
subsection (e) as subsection (f), and inserting after subsection (d)
the following new subsection:
``(e) Annual Report on Indians Served by Health Benefit Programs
Funded Under This Act.--Beginning January 1, 2011, and annually
thereafter, the Secretary, acting through the Administrator of the
Centers for Medicare & Medicaid Services and the Director of the Indian
Health Service, shall submit a report to Congress regarding the
enrollment and health status of Indians receiving items or services
under health benefit programs funded under this Act during the
preceding year. Each such report shall include the following:
``(1) The total number of Indians enrolled in, or receiving
items or services under, such programs, disaggregated with
respect to each such program.
``(2) The number of Indians described in paragraph (1) that
also received health benefits under programs funded by the
Indian Health Service.
``(3) General information regarding the health status of
the Indians described in paragraph (1), disaggregated with
respect to specific diseases or conditions and presented in a
manner that is consistent with protections for privacy of
individually identifiable health information under section
264(c) of the Health Insurance Portability and Accountability
Act of 1996.
``(4) A detailed statement of the status of facilities of
the Indian Health Service or an Indian Tribe, Tribal
Organization, or an Urban Indian Organization with respect to
such facilities' compliance with the applicable conditions and
requirements of titles XVIII, XIX, and XXI, and, in the case of
title XIX or XXI, under a State plan under such title or under
waiver authority, and of the progress being made by such
facilities (under plans submitted under 1911(b) or otherwise)
toward the achievement and maintenance of such compliance.
``(5) Such other information as the Secretary determines is
appropriate.''.
SEC. 3205. DEVELOPMENT OF RECOMMENDATIONS TO IMPROVE INTERSTATE
COORDINATION OF MEDICAID AND SCHIP COVERAGE OF INDIAN
CHILDREN AND OTHER CHILDREN WHO ARE OUTSIDE OF THEIR
STATE OF RESIDENCY BECAUSE OF EDUCATIONAL OR OTHER NEEDS.
(a) Study.--The Secretary shall conduct a study to identify
barriers to interstate coordination of enrollment and coverage under
the Medicaid program under title XIX of the Social Security Act and the
State Children's Health Insurance Program under title XXI of such Act
of children who are eligible for medical assistance or child health
assistance under such programs and who, because of educational needs,
migration of families, emergency evacuations, or otherwise, frequently
change their State of residency or otherwise are temporarily present
outside of the State of their residency. Such study shall include an
examination of the enrollment and coverage coordination issues faced by
Indian children who are eligible for medical assistance or child health
assistance under such programs in their State of residence and who
temporarily reside in an out-of-State boarding school or peripheral
dormitory funded by the Bureau of Indian Affairs.
(b) Report.--Not later than 18 months after the date of enactment
of this Act, the Secretary, in consultation with directors of State
Medicaid programs under title XIX of the Social Security Act and
directors of State Children's Health Insurance Programs under title XXI
of such Act, shall submit a report to Congress that contains
recommendations for such legislative and administrative actions as the
Secretary determines appropriate to address the enrollment and coverage
coordination barriers identified through the study required under
subsection (a).
<all>