    [Congressional Bills 111th Congress]
    [From the U.S. Government Publishing Office]
    [H.R. 3962 Placed on Calendar Senate (PCS)]

                                                           Calendar No. 210
    111th CONGRESS
      1st Session
                                    H. R. 3962

    _______________________________________________________________________

                       IN THE SENATE OF THE UNITED STATES

                               November 10, 2009

                        Received and read the first time

                               November 16, 2009

                Read the second time and placed on the calendar

    _______________________________________________________________________

                                     AN ACT

    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.
    Sec. 264. Performance assessment and accountability: application of
                                GPRA.
    Sec. 265. Limitation on abortion funding.
          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. Repeal of worldwide allocation of interest.
    Sec. 555. Exclusion of unprocessed fuels from the cellulosic biofuel
                                producer credit.
                      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. For a State without a high-risk pool program, the
    Secretary may work with the State to coordinate with other forms of
    coverage expansions, such as State public-private partnerships.
        (c) Eligibility.--For purposes of this section, the term ``eligible
    individual'' means an individual who meets the requirements of
    subsection (i)(1)--
                (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);
                (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; or
                (4) who on or after October 29, 2009, had employment-based
            retiree health coverage (as defined in subsection (i)) and the
            annual increase in premiums for such individual under such
            coverage (for any coverage period beginning on or after such
            date) exceeds such excessive percentage as the Secretary shall
            specify.
    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, consistent with subsection (i)(2), 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.
        (i) Application and Verification of Requirement of Citizenship or
    Lawful Presence in the United States.--
                (1) Requirement.--No individual shall be an eligible
            individual under this section 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).
                (2) Application of verification process for affordability
            credits.--The provisions of paragraphs (4) (other than
            subparagraphs (F) and (H)(i)) and (5)(A) of section 341(b), and
            of subsections (v) (other than paragraph (3)) and (x) of
            section 205 of the Social Security Act, shall apply to the
            verification of eligibility of an eligible individual by the
            Secretary (or by a State agency approved by the Secretary) for
            benefits under this section in the same manner as such
            provisions apply to the verification of eligibility of an
            affordable credit eligible individual for affordability credits
            by the Commissioner under section 341(b). The agreement
            referred to in section 205(v)(2)(A) of the Social Security Act
            (as applied under this paragraph) shall also provide for
            funding, to be payable from the amount made available under
            subsection (h)(1), to the Commissioner of Social Security in
            such amount as is agreed to by such Commissioner and the
            Secretary.
        (j) Employment-based Retiree Health Coverage.--In this section, the
    term ``employment-based retiree health coverage'' means health
    insurance or other coverage of health care costs (whether provided by
    voluntary insurance coverage or pursuant to statutory or contractual
    obligation) for individuals (or for such individuals and their spouses
    and dependents) under a group health plan based on their status as
    retired participants in such plan.

    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.

        (a) Initial Premium Review Process.--
                (1) In general.--The Secretary of Health and Human
            Services, in conjunction with States, shall establish a process
            for the annual review, beginning with 2010 and subject to
            subsection (c)(3)(A), of increases in premiums for health
            insurance coverage.
                (2) Justification and disclosure.-- Such process shall
            require health insurance issuers to submit a justification for
            any premium increase prior to implementation of the increase.
            Such issuers shall prominently post such information on their
            websites. The Secretary shall ensure the public disclosure of
            information on such increases and justifications for all health
            insurance issuers.
        (b) Continuing Premium Review Process.--
                (1) Informing commissioner of premium increase patterns.--
            As a condition of receiving a grant under subsection (c)(1), a
            State, through its Commissioner of Insurance, shall--
                        (A) provide the Health Choices Commissioner with
                    information about trends in premium increases in health
                    insurance coverage in premium rating areas in the
                    State; and
                        (B) make recommendations, as appropriate, to such
                    Commissioner about whether particular health insurance
                    issuers should be excluded from participation in the
                    Health Insurance Exchange based on a pattern of
                    excessive or unjustified premium increases.
                (2) Commissioner authority regarding exchange
            participation.--In making determinations concerning entering
            into contracts with QHBP offering entities for the offering of
            Exchange-participating health plans under section 304, the
            Commissioner shall take into account the information and
            recommendations provided under paragraph (1).
                (3) Monitoring by commissioner of premium increases.--
                        (A) In general.--Beginning in 2014, the
                    Commissioner, in conjunction with the States and in
                    place of the monitoring by the Secretary under
                    subsection (a)(1) and consistent with the provisions of
                    subsection (a)(2), shall monitor premium increases of
                    health insurance coverage offered inside the Health
                    Insurance Exchange under section 304 and outside of the
                    Exchange.
                        (B) Consideration in opening exchange.--In
                    determining under section 302(e)(4) whether to make
                    additional larger employers eligible to participate in
                    the Health Insurance Exchange, the Commissioner shall
                    take into account any excess of premium growth outside
                    the Exchange as compared to the rate of such growth
                    inside the Exchange, including information reported by
                    the States.
        (c) Grants in Support of Process.--
                (1) Premium review grants during 2010 through 2014.--The
            Secretary shall carry out a program of grants to States during
            the 5-year period beginning with 2010 to assist them in
            carrying out subsection (a), including--
                        (A) in reviewing and, if appropriate under State
                    law, approving premium increases for health insurance
                    coverage; and
                        (B) in providing information and recommendations to
                    the Commissioner under subsection (b)(1).
                (2) Funding.--
                        (A) In general.--Out of any funds in the Treasury
                    not otherwise appropriated, there are appropriated to
                    the Secretary $1,000,000,000, to be available for
                    expenditure for grants under paragraph (1) and
                    subparagraph (B).
                        (B) Further availability for insurance reform and
                    consumer protection grants.--If the amounts
                    appropriated under subparagraph (A) are not fully
                    obligated under grants under paragraph (1) by the end
                    of 2014, any remaining funds shall remain available to
                    the Secretary for grants to States for planning and
                    implementing the insurance reforms and consumer
                    protections under title II.
                        (C) Allocation.--The Secretary shall establish a
                    formula for determining the amount of any grant to a
                    State under this subsection. Under such formula--
                                (i) the Secretary shall consider the number
                            of plans of health insurance coverage offered
                            in each State and the population of the State;
                            and
                                (ii) no State qualifying for a grant under
                            paragraph (1) shall receive less than
                            $1,000,000, or more than $5,000,000 for a grant
                            year.

    SEC. 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 Affordable Health Care for America
    Act (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 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 8905a 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.--Not-for-profit 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''.
        (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.
        (d) Treatment of Qualified Direct Primary Care Medical Home
    Plans.--The Commissioner may permit a qualified health benefits plan to
    provide coverage through a qualified direct primary care medical home
    plan so long as the qualified health benefits plan meets all
    requirements that are otherwise applicable and the services covered by
    the medical home plan are coordinated with the QHBP offering entity.

    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) 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) 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; 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 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 insurance.
    Notwithstanding section 4, the Commission's authority shall include the
    authority to conduct studies and prepare reports, and to share
    information under clauses (f) and (k), relating to insurance, without
    regard to whether the subject of such studies, reports, or information
    is for-profit or not-for-profit.''.

    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.
        (c) Savings Clause for State Medical Malpractice Laws.--Nothing in
    this Act or the amendments made by this Act shall be construed to
    modify or impair State law governing legal standards or procedures used
    in medical malpractice cases, including the authority of a State to
    make or implement such law.

    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 the business of health insurance or the
    business of 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; or
                ``(C) performing actuarial services if doing so does not
            involve a restraint of trade.
        ``(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.

    SEC. 264. PERFORMANCE ASSESSMENT AND ACCOUNTABILITY: APPLICATION OF
                  GPRA.

        (a) Application of GPRA.--Section 306 of title 5, United States
    Code, and sections 1115, 1116, 1117, and 9703 of title 31 of such Code
    (originally enacted by the Government Performance and Results Act of
    1993, Public Law 103-62) apply to the executive agencies established by
    this Act, including the Health Choices Administration. Under such
    section 306, each such executive agency is required to provide for a
    strategic plan every 3 years.
        (b) Improving Consumer Service and Streamlining Procedures.--Every
    3 years each such executive agency shall--
                (1)(A) assess the quality of customer service provided, (B)
            develop a strategy for improving such service, and (C)
            establish standards for high-quality customer service; and
                (2)(A) identify redundant rules, regulations, and
            procedures, and (B) develop and implement a plan for
            eliminating or streamlining such redundancies.

    SEC. 265. LIMITATION ON ABORTION FUNDING.

        (a) In General.--No funds authorized or appropriated by this Act
    (or an amendment made by this Act) may be used to pay for any abortion
    or to cover any part of the costs of any health plan that includes
    coverage of abortion, except in the case where a woman suffers from a
    physical disorder, physical injury, or physical illness that would, as
    certified by a physician, place the woman in danger of death unless an
    abortion is performed, including a life-endangering physical condition
    caused by or arising from the pregnancy itself, or unless the pregnancy
    is the result of an act of rape or incest.
        (b) Option to Purchase Separate Supplemental Coverage or Plan.--
    Nothing in this section shall be construed as prohibiting any
    nonfederal entity (including an individual or a State or local
    government) from purchasing separate supplemental coverage for
    abortions for which funding is prohibited under this section, or a plan
    that includes such abortions, so long as--
                (1) such coverage or plan is paid for entirely using only
            funds not authorized or appropriated by this Act; and
                (2) such coverage or plan is not purchased using--
                        (A) individual premium payments required for a
                    Exchange-participating health benefits plan towards
                    which an affordability credit is applied; or
                        (B) other nonfederal funds required to receive a
                    federal payment, including a State's or locality's
                    contribution of Medicaid matching funds.
        (c) Option to Offer Separate Supplemental Coverage or Plan.--
    Notwithstanding section 303(b), nothing in this section shall restrict
    any nonfederal QHBP offering entity from offering separate supplemental
    coverage for abortions for which funding is prohibited under this
    section, or a plan that includes such abortions, so long as--
                (1) premiums for such separate supplemental coverage or
            plan are paid for entirely with funds not authorized or
            appropriated by this Act;
                (2) administrative costs and all services offered through
            such supplemental coverage or plan are paid for using only
            premiums collected for such coverage or plan; and
                (3) any nonfederal QHBP offering entity that offers an
            Exchange-participating health benefits plan that includes
            coverage for abortions for which funding is prohibited under
            this section also offers an Exchange-participating health
            benefits plan that is identical in every respect except that it
            does not cover abortions for which funding is prohibited under
            this section.

          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 certain 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), (aa), or (hh) 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.

    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 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 consult with
    the National Association of Insurance Commissioners (in this section
    referred to as ``NAIC'') to develop not later than January 1, 2014,
    model guidelines for the creation of compacts. In developing such
    guidelines, the Secretary shall consult with consumers, health
    insurance issuers, 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 compacting
            States;
                (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 enforce law relating to--
                        (A) market conduct;
                        (B) unfair trade practices;
                        (C) network adequacy;
                        (D) consumer protection standards;
                        (E) grievance and appeals;
                        (F) fair claims payment requirements;
                        (G) prompt payment of claims;
                        (H) rate review; and
                        (I) fraud.
                (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) No Requirement to Compact.--Nothing in this section shall be
    construed to require a State to join a compact.
        (d) 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.
        (e) 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.
        (f) 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.
                (4) Treatment of certain state waivers.--In the case of any
            State operating a cost-containment waiver for health care
            providers in accordance with section 1814(b)(3) of the Social
            Security Act, the Secretary shall provide for payment to such
            providers under the public health insurance option consistent
            with the provisions and requirements of that waiver.
        (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 program.--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 United States 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 through 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.
        (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)(4), 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 Affordable Health Care for America Act; 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 Affordable Health Care for America Act. 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 Affordable Health Care for America Act, 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 Affordable
            Health Care for America Act, 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 Affordable Health
    Care for America Act. 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 Affordable Health Care
                    for America Act).
                        ``(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 Affordable Health Care for America Act) 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 Affordable Health Care for America Act.
                ``(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 Affordable Health
            Care for America Act, 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, 2012.

         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
                    Affordable Health Care for America Act, 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 Affordable Health Care for America Act. Such
                    return information shall be limited to--
                                ``(i) taxpayer identity information with
                            respect to such taxpayer,
                                ``(ii) the filing status of such taxpayer,
                                ``(iii) the 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 Affordable Health Care for America Act
                    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
                    Affordable Health Care for America Act).
                        ``(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
                    Affordable Health Care for America Act).''.
        (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, and
                                ``(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. REPEAL OF WORLDWIDE ALLOCATION OF INTEREST.

        (a) In General.--Section 864 of the Internal Revenue Code of 1986
    is amended by striking subsection (f) and by redesignating subsection
    (g) as subsection (f).
        (b) Effective Date.--The amendments made by this section shall
    apply to taxable years beginning after December 31, 2010.

    SEC. 555. EXCLUSION OF UNPROCESSED FUELS FROM THE CELLULOSIC BIOFUEL
                  PRODUCER CREDIT.

        (a) In General.--Subparagraph (E) of section 40(b)(6) of the
    Internal Revenue Code of 1986 is amended by adding at the end the
    following new clause:
                                ``(iii) Exclusion of unprocessed fuels.--
                            The term `cellulosic biofuel' shall not include
                            any fuel if--
                                        ``(I) more than 4 percent of such
                                    fuel (determined by weight) is any
                                    combination of water and sediment, or
                                        ``(II) the ash content of such fuel
                                    is more than 1 percent (determined by
                                    weight).''.
        (b) Effective Date.--The amendment made by this section shall apply
    to fuels sold or used after the date of the enactment of this Act.

                      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.
    Sec. 1446. Quality indicators for care of people with Alzheimer's
                                Disease.
               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.
    Sec. 1654. Disclosure of Medicare fraud and abuse hotline number on
                                explanation of benefits.
                          TITLE VII--MEDICAID AND CHIP

                     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).
    Sec. 1739A. Sense of Congress regarding Community First Choice Option
                                to provide medicaid coverage of community-
                                based attendant services and supports.
                             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 final rule for Medicare skilled nursing
            facilities issued by such Secretary on August 11, 2009 (74 Fed.
            Reg. 40287 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
                    Fed. Reg. 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 April 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 U.S.C.
            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.
                                        ``(VII) 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, 3-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 described in subparagraph (F) or
                    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) Special rule for a high medicaid facility.--A
                    hospital described in this subparagraph is a hospital
                    that--
                                ``(i) with respect to each of the 3 most
                            recent cost reporting periods for which data
                            are available, has an annual percent of total
                            inpatient admissions that represent inpatient
                            admissions under the program under title XIX
                            that is determined by the Secretary to be
                            greater than such percent with respect to such
                            admissions for any other hospital located in
                            the county in which the hospital is located;
                            and
                                ``(ii) meets the conditions described in
                            clauses (iii) and (vi) of subparagraph (E).
                        ``(G) 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).
                        ``(H) 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.
                        ``(I) 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 1 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; United States
                                    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 subsection (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. Under
                            such an agreement a State may agree to cover
                            and reimburse each long-term care facility or
                            provider for all costs attributable to
                            conducting background checks and screening
                            described in this subsection that were not
                            otherwise required to be conducted by such
                            long-term care facility or provider before the
                            enactment of this subsection, except that
                            Federal funding with respect to such
                            reimbursement shall be limited to the amount
                            made available to the State from funds under
                            subsection (b)(1).
                        (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. Under
                            such an agreement a State may agree to cover
                            and reimburse each long-term care facility or
                            provider for all costs attributable to
                            conducting background checks and screening
                            described in this subsection that were not
                            otherwise required to be conducted by such
                            long-term care facility or provider before the
                            enactment of this subsection, except that
                            Federal funding with respect to such
                            reimbursement shall be limited to the amount
                            made available to the State from funds under
                            subsection (b)(1).
                (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 subclauses (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 $3,050.
                                ``(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 2-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''.

    SEC. 1446. QUALITY INDICATORS FOR CARE OF PEOPLE WITH ALZHEIMER'S
                  DISEASE.

        (a) Quality Indicators.--The Secretary of Health and Human Services
    shall develop quality indicators for the provision of medical services
    to people with Alzheimer's disease and other dementias and a plan for
    implementing the indicators to measure the quality of care provided for
    people with these conditions by physicians, hospitals, and other
    appropriate providers of services and suppliers.
        (b) Report.--The Secretary shall submit a report to the Committees
    on Energy and Commerce and Ways and Means of the United States House of
    Representatives and to the Committees on Finance and Health, Education,
    Labor, and Pensions of the United States Senate not later than 24
    months after the date of the enactment of this Act setting forth the
    status of their efforts to implement the requirements of subsection
    (a).

               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) 90-day period of enhanced oversight for initial
            claims of dme suppliers.--For periods beginning after January
            1, 2011, if the Secretary determines under paragraph (1) that
            there is a significant risk of fraudulent activity among
            suppliers of durable medical equipment, in the case of a
            supplier of durable medical equipment who is within a category
            or geographic area under title XVIII identified pursuant to
            such determination and who is initially enrolling under such
            title, the Secretary shall, notwithstanding section 1842(c)(2),
            withhold payment under such title with respect to durable
            medical equipment furnished by such supplier during the 90-day
            period beginning on the date of the first submission of a claim
            under such title for durable medical equipment furnished by
            such supplier.
                ``(6) 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.

    SEC. 1654. DISCLOSURE OF MEDICARE FRAUD AND ABUSE HOTLINE NUMBER ON
                  EXPLANATION OF BENEFITS.

        (a) In General.--Section 1804 of the Social Security Act (42 U.S.C.
    1395b-2) is amended by adding at the end the following new subsection:
        ``(d) Any statement or notice containing an explanation of the
    benefits available under this title, including the notice required by
    subsection (a), distributed for periods after July 1, 2011, shall
    prominently display in a manner prescribed by the Secretary a separate
    toll-free telephone number maintained by the Secretary for the receipt
    of complaints and information about waste, fraud, and abuse in the
    provision or billing of services under this title.''.
        (b) Conforming Amendments.--Section 1804(c) of the Social Security
    Act (42 U.S.C. 1395b-2(c)) is amended--
                (1) in paragraph (2), by adding ``and'' at the end;
                (2) in paragraph (3), by striking ``; and'' and inserting a
            period; and
                (3) by striking paragraph (4).

                          TITLE VII--MEDICAID AND CHIP

                     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
                    subclauses:
                                        ``(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
                                    under 19, years of age, who would be
                                    eligible for medical assistance under
                                    the State plan under subclause (I),
                                    (IV) (insofar as it relates to
                                    subsection (l)(1)(B)), (VI), 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 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 and shall not apply,
                    at the option of the Governor of Puerto Rico, the
                    Virgin Islands, Guam, the Northern Mariana Islands, or
                    American Samoa as communicated to the Secretary of
                    Health and Human Services in writing, to any individual
                    who lawfully resides in the respective territory in
                    accordance with such Compacts.''.
        (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. 1396d(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 (United States 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.

    SEC. 1739A. SENSE OF CONGRESS REGARDING COMMUNITY FIRST CHOICE OPTION
                  TO PROVIDE MEDICAID COVERAGE OF COMMUNITY-BASED ATTENDANT
                  SERVICES AND SUPPORTS.

        It is the sense of Congress that States should be allowed to elect
    under their Medicaid State plans under title XIX of the Social Security
    Act to implement a Community First Choice Option under which--
                (1) coverage of community-based attendant services and
            supports furnished in homes and communities is available, at an
            individual's option, to individuals who would otherwise qualify
            for Medicaid institutional coverage under the respective State
            plan;
                (2) such supports and services include assistance to
            individuals with disabilities in accomplishing activities of
            daily living, instrumental activities of daily living, and
            health-related tasks;
                (3) the Federal matching assistance percentage (FMAP) under
            such title for medical assistance for such supports and
            services is enhanced;
                (4) States, consistent with minimum Federal standards,
            ensure quality of such supports and services; and
                (5) States collect and provide data to the Secretary of
            Health and Human Services on the cost and effectiveness and
            quality of supports and services provided through such option.

                             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 make
            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.
    Sec. 2538. Screening, brief intervention, referral, and treatment for
                                mental health and substance abuse
                                disorders.
    Sec. 2539. Grants to assist in developing medical schools in federally-
                                designated health professional shortage
                                areas.
                    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. 2588A. Offices of Minority 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.
    Sec. 2593. Duplicative grant programs.
    Sec. 2594. Diabetes screening collaboration and outreach program.
    Sec. 2595. Improvement of vital statistics collection.
    Sec. 2596. National Health Services Corps demonstration on incentive
                                payments.
        (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) 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.
                        (B) Amounts specified.--The amounts specified in
                    this subparagraph, with respect to a fiscal year, are
                    the amounts appropriated (excluding any amounts in or
                    appropriated from the Fund) 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 made available
                            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,
    out of any monies in the Public Health Investment Fund--
                ``(1) for fiscal year 2011, $2,400,000,000;
                ``(2) for fiscal year 2012, $2,845,000,000;
                ``(3) for fiscal year 2013, $3,100,000,000;
                ``(4) for fiscal year 2014, $3,455,000,000; and
                ``(5) 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), 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.
                (5) No limitation on other state laws.--Nothing in this
            section shall be construed to--
                        (A) preempt or modify the application of any
                    existing State law that limits attorneys' fees or
                    imposes caps on damages;
                        (B) impair the authority of a State to establish or
                    implement a law limiting attorneys' fees or imposing
                    caps on damages; or
                        (C) restrict the eligibility of a State for an
                    incentive payment under this section on the basis of a
                    law described in subparagraph (A) or (B) so long as any
                    such law is not established or implemented as part of
                    the law described in paragraph (4), as determined by
                    the Secretary.
        (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.

    SEC. 2538. SCREENING, BRIEF INTERVENTION, REFERRAL, AND TREATMENT FOR
                  MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS.

        Part D of title V (42 U.S.C. 290dd et seq.) is amended by adding at
    the end the following:

    ``SEC. 544. SCREENING, BRIEF INTERVENTION, REFERRAL, AND TREATMENT FOR
                  MENTAL HEALTH AND SUBSTANCE ABUSE DISORDERS.

        ``(a) Program.--The Secretary, acting through the Administrator,
    shall establish a program (consisting of awarding grants, contracts,
    and cooperative agreements under subsection (b)) on mental health and
    substance abuse screening, brief intervention, referral, and recovery
    services for individuals in primary health care settings.
        ``(b) Use of Funds.--The Secretary may award grants to, or enter
    into contracts or cooperative agreements with, entities--
                ``(1) to provide mental health and substance abuse
            screening, brief interventions, referral, and recovery
            services;
                ``(2) to coordinate these services with primary health care
            services in the same program and setting;
                ``(3) to develop a network of facilities to which patients
            may be referred if needed;
                ``(4) to purchase needed screening and other tools that
            are--
                        ``(A) necessary for providing these services; and
                        ``(B) supported by evidence-based research; and
                ``(5) to maintain communication with appropriate State
            mental health and substance abuse agencies.
        ``(c) Eligibility.--To be eligible for a grant, contract, or
    cooperative agreement under this section, an entity shall be a public
    or private nonprofit entity that--
                ``(1) provides primary health services;
                ``(2) seeks to integrate mental health and substance abuse
            services into its service system;
                ``(3) has developed a working relationship with providers
            of mental health and substance abuse services;
                ``(4) demonstrates a need for the inclusion of mental
            health and substance abuse services in its service system; and
                ``(5) agrees--
                        ``(A) to prepare and submit to the Secretary at the
                    end of the grant, contract, or cooperative agreement
                    period an evaluation of all activities funded through
                    the grant, contract, or cooperative agreement; and
                        ``(B) to use such performance measures as may be
                    stipulated by the Secretary for purposes of such
                    evaluation.
        ``(d) Preference.--In awarding grants, contracts, and cooperative
    agreements under this section, the Secretary shall give preference to
    entities that--
                ``(1) provide services in rural or frontier areas of the
            Nation;
                ``(2) provide services to special needs populations,
            including American Indian or Alaska Native populations; or
                ``(3) provide services in school-based health clinics or on
            university and college campuses.
        ``(e) Duration.--The period of a grant, contract, or cooperative
    agreement under this section may not exceed 5 years.
        ``(f) Report.--Not later than 4 years after the first appropriation
    of funds to carry out this section, the Secretary shall submit a report
    to the Congress on the program under this section--
                ``(1) including an evaluation of the benefits of
            integrating mental health and substance abuse care within
            primary health care; and
                ``(2) focusing on the performance measures stipulated by
            the Secretary under subsection (c)(5).
        ``(g) Authorization of Appropriations.--
                ``(1) In general.--To carry out this section, there are
            authorized to be appropriated $30,000,000 for fiscal year 2011
            and such sums as may be necessary for each of fiscal years 2012
            through 2015.
                ``(2) Program management.--Of the funds appropriated to
            carry out this section for a fiscal year, the Secretary may use
            not more than 5 percent to manage the program under this
            section.''.

    SEC. 2539. GRANTS TO ASSIST IN DEVELOPING MEDICAL SCHOOLS IN FEDERALLY-
                  DESIGNATED HEALTH PROFESSIONAL SHORTAGE AREAS.

        (a) Grants Authorized.--The Secretary of Health and Human Services
    may make grants to nonprofit organizations or institutions of higher
    education for the purpose of assisting the organization or institution
    involved to develop a medical school if--
                (1) the medical school will be located in an area that is
            designated (under section 332 of the Public Health Service Act
            (42 U.S.C. 254e)) as a health professional shortage area;
                (2) the organization or institution provides assurances
            satisfactory to the Secretary of substantial private or public
            funding from non-Federal sources for the development of the
            medical school; and
                (3) the organization or institution provides assurances
            satisfactory to the Secretary that accreditation will be
            achieved for the medical school.
        (b) Use of Grant Funds.--Grants awarded under this section may be
    used for the acquisition and building of the medical school campus in a
    health professional shortage area and the purchase of equipment,
    curriculum and faculty development, and general operations related to
    the development and establishment of the medical school.
        (c) Authorization of Appropriations.--For the purpose of carrying
    out this section, there is authorized to be appropriated $100,000,000
    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 (Public Law 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 subject to
                            enforcement by the Federal Trade Commission in
                            the same manner, by the same means, and with
                            the same jurisdiction as would an unfair and
                            deceptive act or practice in or affecting
                            interstate commerce or an unfair method of
                            competition in or affecting interstate commerce
                            prohibited under section 5 of the Federal Trade
                            Commission Act, 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 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 (United States 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.
        ``(e) References.--Except as otherwise specified, any reference in
    Federal law to an Office on Women's Health (in the Department of Health
    and Human Services) is deemed to be a reference to the Office on
    Women's Health in the Office of the Secretary.''.
                (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. 2588A. OFFICES OF MINORITY HEALTH.

        (a) Existing Office.--Section 1707(a) (42 U.S.C. 300u-6(a)) is
    amended by striking ``within the Office of Public Health and Science''
    and inserting ``within the Office of the Secretary''.
        (b) Additional Offices.--Title XVII (42 U.S.C. 300u et seq.) is
    amended by inserting after section 1707 the following:

    ``SEC. 1707A. ADDITIONAL OFFICES OF MINORITY HEALTH.

        ``(a) Establishment.--In addition to the Office of Minority Health
    established within the Office of the Secretary under section 1707, the
    Secretary shall establish an Office of Minority Health in each of the
    following agencies:
                ``(1) The Centers for Disease Control and Prevention.
                ``(2) The Substance Abuse and Mental Health Services
            Administration.
                ``(3) The Agency for Healthcare Research and Quality.
                ``(4) The Health Resources and Services Administration.
                ``(5) The Food and Drug Administration.
        ``(b) Director; Appointment.--Each Office of Minority Health
    established in an agency listed in subsection (a) shall be headed by a
    director, who shall be appointed by and report directly to the head of
    such agency.
        ``(c) References.--Except as otherwise specified, any reference in
    Federal law to an Office of Minority Health (in the Department of
    Health and Human Services) is deemed to be a reference to the Office of
    Minority Health in the Office of the Secretary.''.
        (c) 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.
        (d) Limitation on Termination.--Notwithstanding any other provision
    of law, a Federal office of minority health or Federal appointive
    position with primary responsibility over minority health issues that
    is in existence in an office or agency of the Department of Health and
    Human Services on the date of enactment of this section shall not be
    terminated, reorganized, or have any of its powers or duties
    transferred unless such termination, reorganization, or transfer is
    approved by an Act of Congress.

    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).''.

    SEC. 2593. DUPLICATIVE GRANT PROGRAMS.

        (a) Study.--The Secretary of Health and Human Services (in this
    section referred to as the ``Secretary'') shall conduct a study to
    determine if any new division C grant program is duplicative of one or
    more other grant programs of the Department of Health and Human
    Services that--
                (1) are specifically authorized in the Public Health
            Service Act (42 U.S.C. 201 et seq.); or
                (2) are receiving appropriations.
        (b) Duplicative Programs.--If the Secretary determines under
    subsection (a) that a new division C grant program is duplicative of
    one or more other grant programs described in such subsection, the
    Secretary shall--
                (1) attempt to integrate the new division C grant program
            with the duplicative programs; and
                (2) if the Secretary determines that such integration is
            not appropriate or has not been successful, promulgate a rule
            eliminating the duplication, including, if appropriate, by
            terminating one or more programs.
        (c) Continued Availability of Funds.--Any funds appropriated to
    carry out a program that is terminated under subsection (b)(2) shall
    remain available for obligation for the one or more programs that--
                (1) were determined under subsection (a) to be duplicative
            of such program; and
                (2) remain in effect.
        (d) Report.--Not later than 1 year after the date of the enactment
    of this Act, the Secretary shall submit to the Congress and make
    available to the public a report that contains the results of the study
    required under subsection (a).
        (e) Congressional Review.--Any rule under subsection (b)(2)
    terminating a program is deemed to be a major rule for purposes of
    chapter 8 of title 5, United States Code.
        (f) Definition.--In this section, the term ``new division C grant
    program''--
                (1) means a grant program first established by this
            division; and
                (2) excludes any program whose statutory authorization was
            in existence before the enactment of this division.

    SEC. 2594. DIABETES SCREENING COLLABORATION AND OUTREACH PROGRAM.

        (a) Establishment.--With respect to diabetes screening tests and
    for the purposes of reducing the number of undiagnosed seniors with
    diabetes or prediabetes, the Secretary of Health and Human Services
    (referred to in this section as the ``Secretary''), in collaboration
    with the Director of the Centers for Disease Control and Prevention
    (referred to in this section as the ``Director''), shall--
                (1) review uptake and utilization of diabetes screening
            benefits, consistent with recommendations of the Task Force on
            Clinical Preventive Services (established under section 3131 of
            the Public Health Service Act, as added by section 2301 of this
            Act), to identify and address any existing problems with regard
            to uptake and utilization and related data collection
            mechanisms; and
                (2) establish an outreach program to identify existing
            efforts by agencies of the Department of Health and Human
            Services and by the private and nonprofit sectors to increase
            awareness among seniors and providers of diabetes screening
            benefits.
        (b) Consultation.--The Secretary shall carry out this section in
    consultation with--
                (1) the heads of appropriate health agencies and offices in
            the Department of Health and Human Services, including the
            Office of Minority Health; and
                (2) entities with an interest in diabetes, including
            industry, voluntary health organizations, trade associations,
            and professional societies.
        (c) Report.--The Secretary shall submit an annual report to the
    Congress on the activities carried out under this section.

    SEC. 2595. IMPROVEMENT OF VITAL STATISTICS COLLECTION.

        (a) In General.--The Secretary of Health and Human Services (in
    this section referred to as the ``Secretary''), acting through the
    Director of the Centers for Disease Control and Prevention and in
    collaboration with appropriate agencies and States, shall--
                (1) promote the education and training of physicians on the
            importance of birth and death certificate data and how to
            properly complete these documents in accordance with State law,
            including the collection of such data for diabetes and other
            chronic diseases as appropriate;
                (2) encourage State adoption of the latest standard
            revisions of birth and death certificates; and
                (3) work with States to re-engineer their vital statistics
            systems in order to provide cost-effective, timely, and
            accurate vital systems data.
        (b) Death Certificate Additional Language.--In carrying out this
    section, the Secretary may promote improvements to the collection of
    diabetes mortality data, including, as appropriate, the addition by
    States of a question for the individual certifying the cause of death
    regarding whether the deceased had diabetes.

    SEC. 2596. NATIONAL HEALTH SERVICES CORPS DEMONSTRATION ON INCENTIVE
                  PAYMENTS.

        (a) In General.--The Secretary of Health and Human Services may
    establish a demonstration program under which, in addition to the
    salary and benefits otherwise owed to a member of the National Health
    Services Corps, incentive payments are awarded to any such member who
    is assigned to a health professional shortage area with extreme need.
        (b) Report.--The Secretary shall submit to the Congress an annual
    report on the demonstration program under subsection (a).
        (c) Definitions.--In this section:
                (1) The term ``health professional shortage area with
            extreme need'' means a health professional shortage area that--
                        (A) is described in section 333A(a)(1)(A) of the
                    Public Health Service Act (42 U.S.C. 254f-1(a)(1)(A));
                        (B) is described in section 333(a)(1)(D)(ii)(IV) of
                    such Act (42 U.S.C. 254f(a)(1)(D)(ii)(IV)); and
                        (C) has high rates of untreated disease, including
                    chronic conditions.
                (3) The term ``Secretary'' means the Secretary of Health
            and Human Services.
        (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.

                   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:

    Sec. 3001. Short title; table of contents.
                       TITLE I--AMENDMENTS TO INDIAN LAWS

    Sec. 3101.  Indian Health Care Improvement Act amended.
    Sec. 3102. Native American Health and Wellness Foundation.
    Sec. 3103. 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 ACT AMENDED.

        (a) In General.--The Indian Health Care Improvement Act (25 U.S.C.
    1601 et seq.) is amended to read as follows:

    ``SEC. 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. Moratorium.
    ``Sec. 810. Severability provisions.
    ``Sec. 811. Use of patient safety organizations.
    ``Sec. 812. Confidentiality of medical quality assurance records;
                                qualified immunity for participants.
    ``Sec. 813. Claremore Indian Hospital.
    ``Sec. 814. Sense of Congress regarding law enforcement and
                                methamphetamine issues in Indian country.
    ``Sec. 815. Permitting implementation through contracts with Tribal
                                Health Programs.
    ``Sec. 816. 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, 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 an intertribal consortium 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 intertribal consortium to reimburse the intertribal
    consortium 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 intertribal consortium under this section for
    any fiscal year may be for reimbursement for administrative expenses
    incurred by the intertribal consortium 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 intertribal consortium in carrying out this section.
    The advisory board shall be composed of representatives, selected by
    the intertribal consortium, from not less than 8 Tribal Health Programs
    serving California Indians covered under this section at least \1/2\ of
    whom are not affiliated with the intertribal consortium.

    ``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. 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. 810. 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. 811. 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. 812. 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. 813. 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. 814. 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. 815. 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. 816. 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. 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. 3103. 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).

                Passed the House of Representatives November 7, 2009.

                Attest:

                                                LORRAINE C. MILLER,

                                                                     Clerk.
                                                           Calendar No. 210

    111th CONGRESS

      1st Session

                                   H. R. 3962

    _______________________________________________________________________

                                     AN ACT

    To provide affordable, quality health care for all Americans and reduce
          the growth in health care spending, and for other purposes.

    _______________________________________________________________________

                               November 16, 2009

                Read the second time and placed on the calendar